Bite Wounds of the

Head and Neck

Brian H. Weeks, M.D.
June 24, 1999
Bobby R. Alford
Department of
Otolaryngology- Head and
Neck Surgery
V.A. Hospital

Case Report- Holyfield vs.

Tyson
Holyfield vs. TysonSeptember 28, 1997Las Vegas, Nevada
MGM Grand Hotel

Case Report- Holyfield vs.

Tyson
-Segmental auricular
defect after a hungry
Tyson bites a piece of
his ear off and spits it
out.

Case Report- Holyfield vs.

Tyson

Chunk of Holyfields ear on floorfound by hotel employee

Case Report- Hoylfield vs.

Tyson
-Skin edges cleaned,
reapproximated after fight
-Antibiotic therapy
-Delayed secondary
reconstruction 6-weeks
after injury with graft
-Excellent cosmetic result

Bite Wounds- Introduction

aDefinition- Inflicted on a person by another
person.
aNot self inflicted
aUsually young individuals involved in quarrels
aChildren at play
aMental institutions
aSexual relations / assaults- throes of
passion

Bite Wounds- Introduction

aSome 80% involve upper extremities
aPredominately closed fist injuries (CFI)
aAbout 10% involve head and neck
aHead and neck bite wounds- should be
treated emergently or urgently
aPotential for gross disfigurement great

Bite Wounds- Introduction

aMismanagement- high morbidity
a...Exemplary treatment and management
mandatory

Bite Wounds-Outline
aIntroduction
aHistory
aClassification
aAnatomic site
-Ear, lip, nose, eyelid
aBacteriology
aManagement
aNon-human bites

Bite Wounds- History

aTeeth- natural weapons
aSign of dominanceanimal kingdom
aLowry (1936)-the
dirtiest of all mouths.
aMason (1941)- Of all
animal bites, that of the
human animal is the
worst.

Bite Wounds- History

aWeinstein (1973)- .a bacterial sewer.
aBoland (1941)- Treated facial bites like other
facial wounds
aEarly treatments- unbelievable!
-No wound closure
-Electrocautery
-Nitric acid
-Radiation therapy

Bite wounds- History

aCrickelair and Bates (1950)-Series of 52 pts. with facial bite wounds
-Treated with combination antimicrobial Rx.PCN & sulfonamides
-Tx. not based on CFI data
-Facial blood supply, anatomy- less infection
prone than hand

Bite Wounds- Classification

aBased on type and extent of injury
aLaskin, Jour Oral Surgery, 1989aType I- puncture or simple linear wound
aType II- separation of pedunculated flap of
tissue
aType III- complete tissue avulsion
aUsed for prognosis and managementcontroversial

Bite wounds- Incidence

aOverall approx. 12/100,000 population
a1/600 pediatric ER visits
a>50% of day care children bitten once or
more- other kids
aHighest freq. in toddlers, then age 11-16
aShelter children- 1.5/100

Bite Wounds- Incidence

aAbused, retarded children
aMales >> females in western world
aFemales >> males in Africa

Bite Wounds- Topography

Sites:
-Ear>Lip>nose>eyelid
-Lower lip>Upper lip
-Forehead, cheek, chin,
brow common sites
-Eyelid bites rare

Bite wounds- Ear

aMajority of avulsions 2o bites
aPartial vs. complete avulsion
-Complete- No delay in reattachment
-Non-vascular vs. microvascular
-Pocket principle
aEar metabolic factors, congestion
aPoor overall results
aMicrovascular- best aesthetic results

Bite wounds- Ear

aPartial avulsion-Only small pedicle needed for survival
-OK to repair
aSegmental avulsion-Many authors warn against attaching any avulsed
part- delayed 2o closure
-Stucker (1990)- never a good result with
autograft.
-Cartilage infection- serious problem

-Reconstruction with graft, local flap

Bite wounds- Ear

-Primary closure
of segmental
defect with graft
necrosis

- Resultant
auricular
defect 6-mos
later

Bite wounds- Ear

-After bite
injury

-Wound closure-no reconstruction

Bite wounds- Ear

aPocket principle- Mladick, et al., 1971-Avulsed tissue debrided, dermabraded
-anatomically reattached
-buried in post-auricular pocket
-10-14d--> pocket opened, helical rim out
-7-10d--> remainder of ear out
-Re-epithelialization

Bite wounds- Ear

Near-total
avulsion of
auricle from bite
injury

Bite wounds- Ear

Reattached ear
buried in pocket

After partial
removal- 10-14d

Complete removal- 3
weeks

Bite wounds- Ear

Final result- 6
weeks

Bite wounds- Ear

1-year after
injury

Bite wounds- Ear

aPros-Provides extra, immediate blood supply
-Preserves skin/cartilage relationship
aCons-Aesthetic results variable- poor if left buried
too long- granulation

Bite wounds- Lip

aLosken, Clin Plas Surg, 1984-Most bites involve lower lip, tissue loss
-After loss- unrestrained orbicularis m.-->
defect appears larger (50%)
-Vermillion border!!
-Clean wounds- <10mm--> local care
- >10mm--> close +/- flap
-Infected wounds- debride, wound care 3-4d
-Close with flap (Estlander, Abbe, Karapanzic)

Bite wounds- Lip

Wedge excision with

Abbe flap closure

Bite wounds- Lip

-Large lower lip/chin

bite with ST loss

-After wedge excision,

primary closure

Bite wounds- Lip

aUchendu, Plas & Recon Surg, 1992-37 pts.- human bite losses of lip
-24/37 lower lip
-From 1-hour-->2-week delay from injury
- >1/2 wounds infected, draining pus
-Defects from 25-75% loss of lip

Bite wounds- Lip

aPts. started on Ampicillin/Flagyl 250mg q8 x
7d- wounds cleaned, closed with local
aDiamond wedge ex. /mucosal adv. in 10 pts.
aMultiple Z-plasty in skin suture
aNo infections, no scar revision, no flaps
aOthers argue- standard closure equivalent

Bite wounds- Lip

-Diamond wedge
excision
-Multiple Z-plasty

Bite wounds- Lip

After lip bite injuries- large soft

tissue losses

After closure with diamond

wedge excision, Z-plasty

Bite wounds- Nose

aUsually complex wounds- tissue loss
aExposed, missing cartilage- infection serious
aMost favor delayed primary closure
-Wound care, Abx.
aReconstruct with graft from ear (chondro vs.
perichondrocutaneous)
aConsider FTSG
aLocal care, granulation- cosmesis OK

Bite wounds- Nose

-Soft tissue
loss

-FTSG to nose

Final result-->
1-year later

Bite wounds- Eyelid

aExtremely uncommon
aSpinelli, et al., Plas & Recon Surg, 1986-5 pts. with eyelid human bite injury- full thickness
-3/5 pts. With missing lid, 2/5 sent back for tissue
retrieval- all upper lid injuries
-Reconstruction with pt. autograft within 24 hrs.
-Meticulous layered closure
-Upper lid sutured inferiorly for 4-7d due to levator
apo. retraction superiorly

Bite wounds- Eyelid

aOpthalmology consult
aComplications:
-2/5 pts. with mild upper lid retraction
-2/5 pts. With mild loss of cilia- prevented if autograft
replaced within 14 hrs. of injury
-Overall cosmesis quite acceptable
-Many authors still favor delayed reconstruction with
full-thickness graft

Bite wounds- Eyelid

Bite wounds- Eyelid

Bite wounds- Eyelid

Bite wounds- Eyelid

Bite wounds- Forehead,

cheek, chin
aSame principles apply
aNo cartilage invoved
aPrimary closure if clean
aDelayed primary closure with flaps, skin grafts
as necessary

Bite wounds- Forehead,

cheek, chin

-Primary closure

-Excellent cosmetic
result

Bite wounds- Forehead,

cheek, chin

-Full thickness skin

graft of facial
wound

-Acceptable
cosmetic result at
6-months

Microbiology- Prior studies

aHuman bites-Staph aureus in 62-80% of wounds
-Not oral flora, ie. few anaerobes
-Staph sp. by far most frequent pathogen

Microbiology- Human bites

aGoldstein, et al., J Clin Micro, 1978
-34 human bite wounds
-33/34 wounds- strep
-18/34 wounds staph species
-9/34 wounds- Group A -hemolytic Strep
flesh-eating bacteria
-14/34 wounds- anaerobes

Microbiology- Human bites

aConclusions:
- >50% mixed infections
- Anaerobes-> less favorable prognosis
- Oral flora frequently present

Microbiology- Human bites

-5/34 wounds- Eikenella corrodens
-Capnophilic, facultative GNR
-Normal oral flora
-Problematic- variable sens. (to PCN, Amp)
-Some species resist oxacil, meth, nafcillin
-24-43% PCN resistant
-Also resist clinda, flagyl, 1st gen. cephs.
-Cx. with sensitivities

Bite Wounds- Microbiology

aOnly 4% of facial bites lead to infection
a28% of hand bites (CFI)- infected

Microbiology- Human and

Animal bites
aBrook, Pedi ID, 1987-Prospective eval., 39 children
-21 animal, 18 human bites
-18% wounds- aerobes only (Staph, Strep,

Eikenella)

-8% anaerobic (Bacteroides, Fusobac, GPC)

-74% mixed infections

Microbiology- Human and

Animal bites
aMost common both- Staph aureus, Anaerobic
cocci, Bacteroides sp.
aOnly in animal bites- Pasturella multocida
aOnly in human bites- Group A -hemolytic

strep

aBoth- large percent -lactamase orgs.

Bite wounds- Treatment

goals
aPrevention of infection
aAesthetic, functional closure

Bite wounds- Factors

aFactors increasing infection:
-Age >50
-Contamination of oral flora
-Delay in tx. ( >12 hrs.)
-Tissue necrosis
-Excessive debridement
-Pt. factors

Management- Primary
closure
aFactors favoring decision:
-Rich vascularity
-Minimal debridement
-Appropriate Abx.
-Exposure to open air- less anaerobes
-Must consider wound type, pt. factors

Management- Primary
closure
aDonkor, et al., J Oral Max Surg., 1997-Prospective, 30 pts.
-Teaching hosp., Ghana- limited facilities
-Facial bite wounds (human)- 1o closure
-21 males, 9 females- ages 17-55 yo
-Location- lips>>nose, ear, eyelid, brow
-15-40 mm in size

Management- Primary
closure
aMean 1.6 d duration before presentation
a21/30 pts.- before 48 hrs.
aTx: local anesthetic, irrigation, antiseptic
-only non-vital tissue debrided
-1o closure- suturing, local flap or skin graft
-Wound open, dry

Management- Primary
closure
aAntibiotics- po Amoxil, Flagyl x 7d
aSutures out 5-7d (skin graft 10d)
aResults:
-27/30 pts.- wound healing complete at suture
removal
-3/30- infection, 2/30 healed with Abx,
dressings
-1/30- hot water soak- complications

Management- Primary
closure
aConclusions:
-Primary closure is safe, acceptable tx.
-Infection rates comparable to delayed
closure
-Wound care principles important

Bite Wounds- Management

aClosure of wounds if appropriate
aAntimicrobial therapy
aTetanus IG vs. toxoid
aFollow-up / reconstruction as needed

Bite Wounds- Management

aPertinent history- details of injury, tetanus
status, medical hx., medical hx. of attacker
aExam- closely examine wounds, type, missing
tissue, foreign bodies (teeth)
aCopious irrigation
aDebridement- of devascularized/devitalized
tissues

Bite wounds- Management

aMedical therapy-Ampicillin/sulbactam 3.0 g IV q6h
-Timentin- no benefit
-Antibiotics for 10 d- mimimum
-Augmentin is ideal po- good G+, anaerobes
-Tetracycline for PCN allergic pts.
-PCN allergic children- Clindamycin

Bite wounds- Management

aGram stain and cx. if wound infected or no tx.
response
aBeware of unusual bugs
aOK to complete 10d course Abx. as outpt.

Bite wounds- Management

aIs admission to hospital necessary?
-Low risk wounds, <12hr., healthy pt--> d/c
OK with close follow-up
-All high risk wounds, >12hr.--> 24-48o IV
Abx., wound care
-Pt. Factors- Admit to hosp.
-BTGH, VA- poor compliance
-When in doubt- Admit

Bite wounds- Complications

aLeung, et al., Pedi ER, 1992-Human bites- 20% infection-> adults
-10% infection-> children
-Children- more superficial bites
-Cellulitis, lymphangitis, abscess
-Systemic infection transmission-> Hep. B,
actinomycosis, TB, syphilis, poss. HIV

Bite Wounds- Complications

aNon-infectious-> Nerve palsy, hematoma,
disfiguration, psych. trauma
aCase report: Physician bitten on neck by
nurse in sexual act-- accessory n. palsy

Animal bites- Incidence

aDog bites 80-90% of all animal bites
a1% of all ER visits
a52% in pts. < age 20
aApprox. 60% in males
aHead and neck bites--> almost always in kids
< age 15 (90%)

Animal bites- Statistics

aDogs teeth- 200-450 psi. (species depend.)
aTissue edematous, devitalized- crush injury
aPuncture wounds- due to canine teeth
aContamination- dogs oral-feces pred.

Animal bites- Microbiology

aDogs-Predominantly -hemolytic strep, staph sp.
-Aerobic- Corynebact., Pasteurella mult.
-Anaerobic- Bacteroides, peptococcus,

Fusobacterium
-Capnocytophagia canimorsus- GNR,

splenectomy pts.

Animal bites- Management

aSame principles as human bites
aOverall less complications, infections
aVery similar bacteriology (+ Pasteurella)
aSame antimicrobial Rx., can shorten course to
5-7 d for clean wounds <12 hr.
a? Rabies- reporting to animal control
aAnimal-assoc. infections

Bite wounds- Case report

a33 y.o. veteran, African-American male- street
altercation
aHuman bite injury to upper lip- soft tissue loss
aPresented to ER 48 hrs. after injury- wound red,
tender
aStarted on IV Unasyn, wound care, tetanus IG
aOn hosp. D#3--> to OR for flap closure of lip
wound- mucosal advancement

Bite wounds- Case Report

-Large upper lip
defect
-Local fan flap
with mucosal
advancement
-Overall
results
acceptablesmall ST
defect

Bite wounds- Case Report

aPt. discharged on po Abx. POD #1
aMinimal tissue loss at edge of flap
aDefect essentially closed by secondary
intention
aSatisfactory cosmetic, good functional result

Bite wounds- Summary

aBite wounds to the Head and Neck- likely
encountered by most Otolaryngologists
aEarly, definitive tx. most important for good
overall results
aMixed, polymicrobial infections
aIrrigate, debride, Abx., tetanus--> Survey
wound, pt. factors
aPrimary closure is acceptable- consider all
factors, wound location

Bite wounds- Summary

aHospital admission not always necessary
aDelayed closure is safe, conservative tx.
aHigh morbidity if wounds not handled
properly