Protocol for Management of Maxillofacial Injuries Caused by Fox Attack: A Case Report

Introduction

Facial injuries caused by animal attack pose complex challenges due to their impact on function and appearance, as well as the risk of polymicrobial infections. They rank third in frequency among bite injuries, following those to limbs, particularly extremities.  Lips and nose are the frequently affected areas on the face.¹ In addition to the significant physical trauma and potential for lasting disfigurement, patients also endure psychological and social distress. Bites also carry the risk of transmitting zoonotic infections, notably rabies and tetanus. Given that a significant proportion of bite wounds occur in the maxillofacial region, maxillofacial surgeons play a vital role in leading the surgical treatment and establishing treatment protocols for these injuries.²

Animal bite injuries to the maxillofacial skeleton are related to a significant rate of morbidity and mortality. A thorough knowledge of the epidemiology, outcomes, therapeutic and surgical management protocols and comprehensive association of multiple specialty departments are essential to manage such injuries.^1,2 Animal bites are rather common and can result in infection, functional impairment, and disfigurement. Moreover, wounds may need to be debrided or treated in the operating room using flaps, skin grafts, microsurgical tissue transfer, primary closure, or even facial transplantation.^1,2 Fox bite injuries to maxillofacial skeleton are rare and fox bite as a single entity lacks detailed evidence in the literature.^3,4 In this article, we present a protocol along with case report for the management of maxillofacial injuries caused by fox attack.

Case Report

A 66 year old male patient presented to the Department of Emergency Medicine with an  alleged history of fox bite four hours prior. On examination, multiple abrasions were noted  on the left side of the face. Also, multiple contused lacerated wounds were noted, one measuring 6x2 cm on the left submental region and another measuring 4x1 cm below the hyoid bone. Patient was admitted under the Department of Oral and Maxillofacial Surgery and was managed according to the protocol mentioned below (Figure 1).

The patient was reviewed after one month and later after six months. Healing of the wounds was uneventful (Figure 3).

Discussion

The approach to managing bite wounds continues to be a subject of debate.^7,8 The treatment of any individual case is affected by various factors, including the location and the nature of the injury, as well as the type of animal involved.⁵

While over 95% of human deaths are attributed to the rabid dog exposure, cases of rabies resulting from bite injuries caused by wild animals, such as jackals, wolves and foxes are reported occasionally. According to the National Guidelines for Rabies Prophylaxis 2019, Category III exposure includes injuries caused by wild animals and all bite injuries in forest areas, and is treated accordingly.

Aerobic species commonly isolated from bite injuries caused by mammals include Staphylococcus & Streptococcus species, while Corynebacterium, Neisseria and Moraxella species are also frequently found in bite wound samples. Among anaerobic organisms, Bacteroides, Propionibacterium, Prevotella, Peptostreptococcus, Fusobacterium and Porphyromonas are commonly identified.⁵

Callaham suggested that wounds with a high risk of infection must be thoroughly irrigated with antiseptic agents and left open to drain. For uncomplicated bite wounds presenting beyond the golden 24-hour period, the decision for closure during the initial visit is debated. In such cases, delayed closure after 4–5 days is recommended. During this time, the wound remains open, typically covered with moist gauze dressings for drainage, allowing the edema to subside. Antibiotics may be administered to reduce the risk of infection. According to recurrent guidelines, Amoxicillin/Clavulanate is the preferred antimicrobial for prophylaxis of bite wounds due to its effectiveness against most animal and human bite wounds. Azithromycin is likely the most suitable choice for penicillin-allergic pregnant women. These antimicrobial agents are considered empirical treatments until specific pathogens are identified through accurate culturing and appropriate antimicrobials are determined through in vitro susceptibility testing.^5,6

Bite injuries carry a risk of tetanus infection, necessitating proper immunization if the patient has not received three tetanus toxoid doses or if more than five years have elapsed since the last dose. In case of bites from dogs or wildlife animals, immediate post- exposure prophylaxis for rabies should be initiated, unless thorough laboratory surveillance and data indicate that the species involved is not a rabies vector.⁹

Medical practitioners in rural areas need increased awareness regarding rabies in wild animals and the appropriate post-exposure prophylactic measures for humans exposed to the virus. Serious injuries involving bones should be managed according to the established protocols. Clinical judgment should guide treatment decisions, with close follow-up recommended to minimize morbidity and future complications.¹⁰

Animal bites represent a significant healthcare concern and are a prevalent cause of maxillofacial trauma worldwide. Fox attack injuries have not been reported prior as a single entity. The management of such an injury becomes challenging owing to its infectious ratio, rabies and associated morbidity, wide extent of injury caused and the risks associated with immediate closure of wound. We conclude that this case requires a standardized protocol to effectively manage polymicrobial infections that arise from viral and bacterial contamination of wound, which can possibly lead to death and life threatening infections.

Acknowledgement

Nil

Conflict of interest

Nil