Dog bites are common and disproportionately affect children. The head, neck, and face (HNF) is the most frequently injured region in the pediatric population. Some have identified a “central target area” (CTA), where the nose, cheeks, and lips are most often injured in dog bites, particularly in children.1 Others have noted increased risk of periorbital injury in this group.2 Past studies have not controlled for higher rates of HNF injury in the pediatric population. Therefore, it is unclear if targeting of specific facial structures by dogs drives higher rates of HNF injury in children, or if increased injuries to these structures are simply a byproduct of the higher rate of overall HNF injury. This study sought to answer the following clinical question: Among individuals sustaining a dog bite injury to the HNF, are children, when compared to adults, at greater risk of injury to the periorbital region and CTA?
A retrospective cohort study was implemented. The trauma registry at Harborview Medical Center, Seattle, Washington was reviewed for patients presenting between 2000-2015 with a HNF dog bite injury. The primary predictor variable was age category with subjects 18 years or older defined as adult. The primary outcome variables were the presence or absence of injury to the periorbital region or CTA. An injury to at least one of the following qualified a patient as having a periorbital injury: eyebrow, eyelid, medial or lateral canthus, canaliculus, or orbit and orbital contents. Injury to the nose, lips, zygomatic, or buccal regions qualified a patient as having an injury to the CTA. Uni- and bivariate statistics including chi-squared tests were computed. P-value <0.05 was considered statistically significant.
Dog bite injuries to the HNF were identified in 313 subjects, 183 (58.5%) pediatric and 130 (41.5%) adults. Periorbital injuries were more common in the pediatric group (50.3%) than in adults (23.8%), relative risk (RR) 2.1 (1.5-3.0 [p < 0.0001]). Within the periorbital region, the pediatric group was at greater risk of injury to the eyelid RR 2.3 (1.6 – 3.4 [p<0.0001]), medial/lateral canthus RR 2.1 (1.2 – 3.4 [p=0.002]), and canaliculus RR 4.9 (1.9 – 12.5 [p<0.0001]). The CTA was the most frequently injured region in both children (61.2%) and adults (66.9%), but there was no significant difference between the groups, RR 0.9 (0.8-1.1 [p = 0.300]). Within the CTA, children were at greater risk of injury to the zygomatic RR 1.9 (1.3-2.9 [p<0.001]) and buccal regions RR 2.2 (1.4-3.2 [p<0.0001]), and at less risk of injury to the lips RR 0.6 (0.35-0.8 [p<0.0001]). No difference in the frequency of nasal injury was observed, RR 1.0 (0.7- 1.5 [p = 0.880]).
Our study found that pediatric patients are two times more likely to incur injury to the periorbital region from dog bites. This could reflect instinctual targeting of the eyes, conceivably contributing to higher rates of HNF injury in this population. These findings have important implications for the management and prevention of dog bite injuries in children. Public health and educational measures should recommend against children being placed at eye level with dogs, even if familiar or under adult supervision. Opportunities for collaboration exist between the ‘National Facial Protection Month’ sponsored by oral and facial health care professional organizations and the ‘National Dog Bite Awareness week’ spearheaded by The American Veterinary Medical Association.
1. Palmer J, Rees M. Dog bites of the face: a fifteen year review. Br J Plast Surg 1983;36:315-8.
2. Prendes MA, Jian-Amadi A, Chang S, Shaftel S. Ocular Trauma From Dog Bites: Characterization, Associations, and Treatment Patterns at a Regional Level I Trauma Center Over 11 Years. Opthal Plast Reconstr Surg. 2016;32:279-283.
Supported by the OMS Foundation