CEPHALIC TETANUS: A CASE REPORT AND REVIEW OF LITERATURE

Cephalic tetanus (CT) constitutes only 1-3% of total reported tetanus cases. It is marked by flaccid paralysis of one or more cranial nerves (CN) with or without spasticity, typically following craniofacial injuries. The facial nerve is the most frequently paralyzed. Other CNs are rarely involved but mostly alongside facial nerve palsy. Broomstick injury as a portal of entry has been reported in generalized tetanus but not in CT to the best of our knowledge. Here is presented a case of CT with two peculiarities: broomstick penetrating ear trauma as a portal of entry, and an unusual onset with features of isolated glossopharyngeal and/or vagus nerve palsy.

A 30-month-old unimmunized male who one week before presentation developed sudden-onset dysphagia, drooling, nasal regurgitation, and rhinolalia. Two days later, he developed trismus and left-sided rd torticollis; on the 3 day, provoked spasms, initially of the face and neck muscles, and later including the limbs. Three weeks earlier he had accidentally injured his left ear while poking it with a broomstick. This was poorly managed at home without anti-tetanus prophylaxis. Examination revealed a conscious acutely ill child with risus sardonicus and episodic generalized spasms, more intense in the face and neck regions. Trismus/provoked spasms did not permit an objective assessment of glossopharyngeal, vagus, and hypoglossal nerves but other CNs were normal. Managed in a quiet, dark isolation room where he received IM anti-tetanus serum, staggered doses of chlorpromazine, phenobarbitone, diazepam; and metronidazole, his condition gradually improved, and was discharged after 21 days of hospitalization.

The rarity and sometimes unusual presentation of CT delays prompt diagnosis and early treatment leading to secondary generalization with its attendant poor outcomes. A careful history, examination, and heightened suspicion are needed. Furthermore, this report highlights ear poking, particularly with broomsticks, as a risk for CT and should be strongly discouraged.