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Table of Contents
ORIGINAL ARTICLE
Year : 2020  |  Volume : 28  |  Issue : 1  |  Page : 51-54

Pediatric dog bite injuries of head and neck: An algorithm for the treatment of our clinic


1 Department of Plastic, Reconstructive and Aesthetic Surgery, Faculty of Medicine, Kirikkale University, Kirikkale, Turkey
2 Department of Oral and Maxillofacial Surgery, Faculty of Dentistry, Kirikkale University, Kirikkale, Turkey

Date of Submission04-Mar-2019
Date of Acceptance22-May-2019
Date of Web Publication31-Dec-2019

Correspondence Address:
Dr. Elif Sanli
Department of Plastic, Reconstructive and Aesthetic Surgery, Faculty of Medicine, Kirikkale University, Ankara-Kirikkale Road 7th KM Yahsihan, Kirikkale 71450
Turkey
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/tjps.tjps_24_19

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  Abstract 


Background: Dog bite injuries are more frequent injuries than they are supposed to be in our country. Aims and Objectives: This study presents our pediatric dog bite injuries of head and neck and a simple algorithm of the treatment. Materials and Methods: A retrospective screening was done of the cases, and data was collected. Descriptive statistical analysis was done about age, sex, type of injury, time of injury, type of dog breed, and closure options. Results: A total of ten children were enrolled to the study. The mean age was 6.4 years, and most of the cases were preschool-aged children. Scalp was the most affected region at head and neck. Pit bull was the only known dog breed. The common time of the injuries was morning. Major injuries were more than minor ones, and they were closed with graft or flaps. Conclusion: We think that dog bite injuries are an important problem in our country. Therefore, further detailed multi-centered studies should be done.

Keywords: Children, dog bite, head and neck, pit bull


How to cite this article:
Sanli E, Altay B. Pediatric dog bite injuries of head and neck: An algorithm for the treatment of our clinic. Turk J Plast Surg 2020;28:51-4

How to cite this URL:
Sanli E, Altay B. Pediatric dog bite injuries of head and neck: An algorithm for the treatment of our clinic. Turk J Plast Surg [serial online] 2020 [cited 2020 Feb 28];28:51-4. Available from: http://www.turkjplastsurg.org/text.asp?2020/28/1/51/274438




  Introduction Top


Dog bite injuries are yet a modifiable public health problem. A total of 4.7 million people are bitten by dogs annually, and pediatric cases are 50% of these injuries.[1] Dog bite injuries cause significant psychosocial, esthetic, and functional sequelae, and underreported patients are common. Pit bulls are associated with severe traumas, needing surgical reconstruction. Covering of large tissue defects that involve hair-bearing areas of the head and neck in children is especially difficult. Moreover, reconstruction of the esthetic structures of the face is another challenge in pediatric patients.

The purpose of this study is to present pediatric cases of dog bite injuries of our clinic and report a basic algorithm of our clinic in light of the literature.


  Materials and Methods Top


The retrospective study was performed at University Faculty of Medicine according to the ethical guidelines of Helsinki Declaration. A photo sharing authorization form was signed by the parents. Data were collected with regard to the age and sex of the patients, location, type, and time of the injuries. Moreover, type of the dog breeds and treatment methods were collected [Table 1]. The type of injury was scored according to the scale designed in our clinic [Table 2]. In addition, a simple algorithm was included in the present study [Figure 1].
Table 1: Descriptive table of the patients

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Table 2: Classification of the dog bite injuries according to the surgical repair

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Figure 1: An algorithm of our clinic about dog bite injuries in pediatric population

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Descriptive analysis was performed using SPSS 17.0 program, (Version 17.0, Chicago, IL, USA) and results were reported.


  Results Top


A total of 10 children admitted to our clinic between June 2013 and December 2018 were enrolled in the study. Ages were between 3 and 14 years (mean age: 6.4). A total of 7 children were male (70%) and 3 were female (30%).

The most common ages of the injury were 6 and 7 years. The majority of the cases were preschool-aged children [Table 1].

The location of the injuries was scalp (50%), face (30%), and neck (20%). The common time of the injuries was morning (80%) and afternoon (20%). Most of the injuries were major (60%) and needed a flap or graft. Remaining minor cases were closed primarily (40%). The breed of the dogs was mostly unknown (60%). The others were pit bull (40%) [Figure 2].
Figure 2: Location and time rates of the dog bite injuries, treatment options rates, and dog breed rates were shown in this figure

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Case 1

A 7-year-old girl was referred to our clinic from another hospital with two large scalp defects due to dog bite [Figure 3]a. She and her mother have bitten by pit bull. Emergency treatments have done by another hospital. After a detailed examination, the patient was consulted to infectious diseases clinic and pediatrics. According to the pediatrics' offer, the reconstruction was kept until the 3rd dose of the vaccine, and the two defects were closed with two rotation flaps. No complication was occurred after the operation [Figure 3]b and [Figure 3]c.
Figure 3: A 7-year-old girl was referred to our clinic with large scalp defects due to dog bite (a). Two flaps were designed to ensure the integrity of the hairy skin (b). Six month view of the child could be seen in this photo (c)

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Case 2

A 14-year-old boy presented to our clinic with left eyelid injury [Figure 4]a. There were large crush injury and lacerations at his left eyelid involving the tars and around the orbit. Frontozygomatic fracture was also observed in his computed tomography [Figure 4]b. He has bitten by pit bull. The child was consulted to the ophthalmologist and the other necessary clinics according to our algorithm [Figure 1]. After the first intervention, the patient was operated, and the tissues were closed. No complication was seen after the operation [Figure 4]c.
Figure 4: A 14-year-old boy was admitted to our clinic with severe upper lid injury due to dog bite (a). He had maxillofacial fracture in his computerized tomography sections (b). His wound was closed primarily after tars repair (c)

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  Discussion Top


Dog bites are common injuries in the world.[1] However, they are usually underreported in our country. In addition to injury, the rabies virus and other agents in dog's flora may cause a delay in the time of closure. The delayed closure may cause other different problems such as infections and contraction of the wound edges.

After dog bites, several problems may be observed such as granuloma telengiecticum, lymphangitis, endocarditis, meningitis, abscess, and sepsis. Another complication is immediate wound infections caused by Capnocytophaga canimorsus, Staphylococcusaureus, Staphylococcus intermedius, Pasteurella multocida, Eikenella corrodens, and alpha-hemolytic Streptococcus which are located in dog's flora.[2] The large defects are more prone to these microorganisms. Prophylactic antibiotics could be used in these wounds such as penicillin, cephalexin monohydrate, erythromycin, clindamycin, and ciprofloxacin.[3],[4] We prefer to consult the pediatric patients to the infection diseases clinic for the prophylaxis according to our algorithm. Moreover, tetanus prophylaxis could be done by the emergency clinic.

Rabies virus affects central nervous system (CNS). It reaches to the CNS by peripheral nerves and moves into the salivary glands. The closer the injury site to the brain, the easier and faster the transport of the virus. Therefore, head-and-neck injuries are more susceptible to virus infection. Vaccination on 0, 3, 7, 14, and 28 days of the dog bite and injection of heterologous rabies antiserum are essential in both adults and children.[2]

We want to present ten pediatric dog bite injuries that located at head and neck. According to our study, preschool-aged children were the most common affected population as in the literature.[5],[6] This may be related to the low level of defense and awareness of children.

A total of seven children were male in our study. It was thought that boys act more individually than girls and are independent of their parents in our residential area.

Head and neck is more vulnerable to the dog bites in children.[7] All of the pediatric patients who were admitted to our clinic were injured in the head-and-neck region during our retrospective screening. However, adults were mostly bitten in the body, according to the literature.[8],[9],[10] As the child grows, he became more able to protect himself, and dog bites occur more peripherally.[8] The scalp was the most frequently effected area according to our work. Conversely, the face is the most affected area in children in another study.[9] The neck was rarely injured in the present study. This may be due to the fact that neck is more secret region.

Children are exposed to dog attack, especially in the morning. This result may be associated with the fact that dogs are the most hungry and herd in the morning hours. However, afternoon and evening periods are the most common injury times of the day in the other two studies in the literature.[11],[12]

Pit bulls are the most known type of the breed of the dogs in our study. These types accounted for 82% of 34 dog bite fatalities in the United States.[5] The pit bull population in our country is unknown. In addition, pit bull feeding is forbidden in our country.[13] Moreover, familiarity with a dog does not prevent the incidence of major injuries.[11]

In the present study, we want to classify the dog bite injured wounds as major and minor. There are many classification methods in the literature according to the injured tissues or surgical needs.[11],[14],[15] We thought that classification, according to the surgical method, could be more simple and useful for plastic surgeons. Furthermore, we also tried to design an algorithm to guide the plastic surgeon's approach to the patient. There is a detailed algorithm in Alizadeh et al.'s study in the literature.[7] However, according to our clinical practice, the approvals of the other clinics about wound closure varies from patient to patient. Therefore, we think that the treatment attitude in cooperation with other clinics could be more accurate in our country.

In summary, dog bites constitute inadequately recorded part of the pediatric traumas. Those injuries, especially targeting the head-and-neck region, cause both esthetic and functional and psychosocial sequelae.[16] Thereupon, the doctors should report these injuries more and the state should take stringent measures in this regard.

Consent

The parents were signed an informed consent form about publication of the data and the pictures of their children.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form, the legal guardian has given his consent for images and other clinical information to be reported in the journal. The guardian understands that names and initials will not be published and due efforts will be made to conceal patient identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Beck AM, Jones BA. Unreported dog bites in children. Public Health Rep 1985;100:315-21.  Back to cited text no. 1
    
2.
Kuvat SV, Bozkurt M, Kapi E, Karakol P, Yaçsar Z, Güven E. Our treatment approaches in head-neck injuries caused by animal bites. J Craniofac Surg 2011;22:1507-10.  Back to cited text no. 2
    
3.
Abuabara A. A review of facial injuries due to dog bites. Med Oral Patol Oral Cir Bucal 2006;11:E348-50.  Back to cited text no. 3
    
4.
Zonnevylle ED, van der Waal RI. Diagnostic image (368). A child with facial swelling after a dog bite. Ned Tijdschr Geneeskd 2008;152:874Y875  Back to cited text no. 4
    
5.
Available from: http://www.dogsbite.org/dog-bitestatisticsfatalities-2015.php. [Last accessed on 2016 Dec 13].  Back to cited text no. 5
    
6.
Golinko MS, Arslanian B, Williams JK. Characteristics of 1616 consecutive dog bite injuries at a single institution. Clin Pediatr (Phila) 2017;56:316-25.  Back to cited text no. 6
    
7.
Alizadeh K, Shayesteh A, Xu ML. An algorithmic approach to operative management of complex pediatric dog bites: 3-year review of a level I regional referral pediatric trauma hospital. Plast Reconstr Surg Glob Open 2017;5:e1431.  Back to cited text no. 7
    
8.
Bykowski MR, Shakir S, Naran S, Smith DM, Goldstein JA, Grunwaldt L, et al. Pediatric dog bite prevention: Are we barking up the wrong tree or just not barking loud enough? Pediatr Emerg Care 2017.doi: 10.1097/PEC.0000000000001132.  Back to cited text no. 8
    
9.
Morgan M, Palmer J. Dog bites. BMJ 2007;334:413-7.  Back to cited text no. 9
    
10.
Morales C, Falcón N, Hernández H, Férnandez C. Dog bite accidents in a children hospital at Lima, Peru. Retrospective study from 1995 – 2009. Rev Peru Med Exp Salud Publica 2011;28:639-42.  Back to cited text no. 10
    
11.
Abraham JT, Czerwinski M. Pediatric dog bite injuries in central Texas. J Pediatr Surg 2018. pii: S0022-3468 (18) 30672-9.  Back to cited text no. 11
    
12.
Bernardo LM, Gardner MJ, O'Connor J, Amon N. Dog bites in children treated in a pediatric emergency department. J Soc Pediatr Nurs 2000;5:87-95.  Back to cited text no. 12
    
13.
Available from: http://www.resmigazete.gov.tr/eskiler/2006/05/20060512-7.htm. [Last accessed on 2019 Jan 14].  Back to cited text no. 13
    
14.
Essig GF Jr., Sheehan C, Rikhi S, Elmaraghy CA, Christophel JJ. Dog bite injuries to the face: Is there risk with breed ownership? A systematic review with meta-analysis. Int J Pediatr Otorhinolaryngol 2019;117:182-8.  Back to cited text no. 14
    
15.
Lackmann GM, Draf W, Isselstein G, Töllner U. Surgical treatment of facial dog bite injuries in children. J Craniomaxillofac Surg 1992;20:81-6.  Back to cited text no. 15
    
16.
O'Brien DC, Andre TB, Robinson AD, Squires LD, Tollefson TT. Dog bites of the head and neck: An evaluation of a common pediatric trauma and associated treatment. Am J Otolaryngol 2015;36:32-8.  Back to cited text no. 16
    


    Figures

  [Figure 1], [Figure 2], [Figure 3], [Figure 4]
 
 
    Tables

  [Table 1], [Table 2]



 

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