Tetanus (Cephalic)

Cephalic Tetanus

Cephalic tetanus is a rare variant of localized tetanus (accounting for 1–3% of all tetanus cases) confined to the head and neck, characterized by trismus, dysphagia, and cranial nerve palsies — most commonly CN VII — following head or neck wounds.[1-3] Diagnosis is often delayed and outcomes are poor due to the high risk of progression to generalized tetanus and cardiorespiratory compromise.[2][4]

1. History

• Port of entry: Ask specifically about recent head trauma, facial lacerations, dental procedures, ear infections (otitis media), and eye injuries[1-2]
• Incubation period: Typically 3–21 days from injury to first symptom; shorter incubation (<7 days) portends worse prognosis[1]
• Period of onset: Time from first symptom to first spasm — ≤48 hours suggests severe disease[5]
• Symptom characterization: Jaw stiffness/difficulty opening mouth, facial weakness (unilateral or bilateral), difficulty swallowing, painful spasms of the lower face and neck, voice changes[1-2]
• Vaccination history: Number of tetanus toxoid doses, date of last booster — unknown or incomplete history should be treated as unvaccinated[6]
• Important negatives: Preserved consciousness (lucidity is maintained in tetanus, unlike many neurological infections); no sensory deficits; no altered mental status[2]

2. Alarm Features

• Progression to generalized tetanus: New truncal rigidity, opisthotonus, or limb spasms beyond the head/neck[1-2]
• Airway compromise: Laryngeal or pharyngeal spasm, stridor, apneic spells, dyspnea[1-2]
• Aspiration risk: Severe dysphagia with inability to manage secretions[2]
• Autonomic dysfunction: Labile blood pressure, tachycardia alternating with bradycardia, profuse sweating, fever — most feared complication and leading cause of death in ventilated patients[2]
• Respiratory failure: Can occur rapidly even without generalized tetanus, as toxin spreads among brainstem nuclei affecting respiratory centers[4]

3. Medications

• Antibiotics: Metronidazole 500 mg IV q6–8h for 7–10 days (first-line); penicillin is an alternative but theoretically may potentiate tetanus neurotoxin effects via GABA-A antagonism[1-2]
• Antitoxin: Human tetanus immunoglobulin (HTIG) 500 IU IM (single dose); equine antitoxin if HTIG unavailable[1][7]
• Active immunization: Td or Tdap 0.5 mL IM at a different site from HTIG — tetanus does not confer natural immunity[1-2]
• Spasm control: IV benzodiazepines (diazepam 10–30 mg IV q1–4h PRN); propofol as second-line; neuromuscular blocking agents (vecuronium preferred over pancuronium) for refractory spasms[1]
• Autonomic dysfunction: Magnesium sulfate or labetalol for sympathetic hyperactivity[1]
• Contraindicated/caution: Avoid pancuronium (worsens autonomic instability); use penicillin with awareness of theoretical GABA antagonism[1]

4. Diet

• NPO initially if significant trismus or dysphagia — high aspiration risk
• Enteral feeding via soft, small-bore nasogastric tube or parenteral nutrition via central venous catheter when oral intake is not possible[1]
• Hydration: Aggressive IV fluid management, especially with rhabdomyolysis risk from sustained spasms
• Long-term: Resume oral diet only when swallowing function is confirmed safe

5. Review of Systems

• Neurologic: Jaw stiffness, facial weakness, difficulty speaking, eye deviation, eyelid retraction, neck stiffness[1]
• Respiratory: Dyspnea, stridor, apneic episodes, cough with swallowing (aspiration)
• GI: Dysphagia, reduced oral intake, abdominal rigidity (if generalizing)
• Cardiovascular: Palpitations, chest pain (Takotsubo cardiomyopathy is the most common cardiovascular complication)[1][8]
• GU: Urinary retention (autonomic dysfunction)[2]
• MSK: Back pain, muscle stiffness (signs of generalization)

6. Collateral History and Family History

• Collateral: Witnesses to the injury mechanism; timeline of symptom onset; vaccination records from primary care or military service (military service since 1941 implies at least one dose)[9]
• Social context: Occupation (farming, gardening), rural residence, injection drug use — all increase risk[2][10]
• Immigration/travel: Origin from or travel to regions with low vaccination coverage (South/Southeast Asia, sub-Saharan Africa)[2]
• Family history: Not directly relevant (tetanus is not hereditary), but household vaccination status may reflect shared under-immunization

7. Risk Factors

• Incomplete or absent vaccination — the single most important risk factor; 43.9% of US tetanus cases had received zero doses[10]
• Older age and male sex[2][10]
• Head/neck wounds: Lacerations, penetrating injuries, dental procedures, chronic otitis media, eye injuries[1-2]
• Immunosuppression: HIV, immunosuppressive therapy — these patients should receive HTIG regardless of vaccination history[1][6]
• Rural residence, farming, gardening injuries[2][11]
• Injection drug use[2]
• Wound characteristics: Contamination with dirt/soil/feces, devitalized tissue, puncture wounds, delayed wound care[1]

8. Differential Diagnosis

• The differential for cephalic tetanus specifically includes:[2]
• Bell palsy: Isolated facial weakness without trismus; no history of wound; no spasms
• Brainstem stroke / TIA: Symptoms may fluctuate in cephalic tetanus mimicking TIA; stroke will show imaging abnormalities; tetanus preserves consciousness[2]
• Botulism: Descending flaccid paralysis, bilateral, with pupillary involvement; no trismus or rigidity; rapid onset
• Myasthenia gravis: Fatigable weakness, no trismus, positive antibodies
• Peritonsillar/retropharyngeal abscess: Trismus present but with fever, sore throat, and visible oropharyngeal pathology
• Strychnine poisoning: Virtually indistinguishable from tetanus but rapid onset (<30 min of ingestion), absence of tonic contraction between spasms, positive toxicology[2]
• Neuroleptic malignant syndrome: Altered mental status (unlike tetanus), very high CK, medication history[2]
• Stiff-person syndrome / PERM: Positive GAD/anti-glycine antibodies, altered mental status common[2]
• Hypocalcemic tetany: Low serum calcium, absence of trismus[2]
• Key distinguishing feature of cephalic tetanus: Trismus + ipsilateral cranial nerve palsy (especially CN VII) + history of head/neck wound, with preserved consciousness.[2-3]

9. Past Medical History

• Vaccination history: Most critical element — number of doses, timing of last booster
• Prior tetanus episodes: Natural infection does not confer immunity[2]
• Diabetes, cardiovascular disease, immunosuppression: Associated with worse prognosis[1]
• Chronic otitis media: A recognized portal of entry for cephalic tetanus[1-2]
• Prior dental procedures or head/facial surgery

10. Physical Exam

• Vital signs: Tachycardia, hypertension (or labile BP), fever (if present, consider superinfection or autonomic dysfunction)[2]
• Head/face: Carefully examine the scalp for contaminated wounds (may be occult); look for risus sardonicus, eyelid retraction, eye deviation[1-2]
• CN exam: CN VII palsy (upper and lower face — both flaccid and spastic weakness can coexist); CN III, IV, VI palsies (eye deviation); CN XII (tongue deviation)[2-3]
• Jaw: Trismus — inability to open mouth; spatula test (touching the posterior pharyngeal wall with a spatula induces jaw spasm rather than gag reflex — reported sensitivity 94%, specificity 100%)[2]
• Neck: Rigidity, painful spasms
• Neurologic: Preserved consciousness, normal sensory exam, hyper-reflexia; no cerebellar signs[2]
• Respiratory: Assess for stridor, tachypnea, use of accessory muscles, oxygen saturation

11. Lab Studies

Recommended initial labs

• CBC, electrolytes, BUN, creatinine
• Creatine kinase (CK) — elevated with rhabdomyolysis from sustained spasms
• CRP, procalcitonin — to assess for superinfection
• Calcium, magnesium — rule out hypocalcemic tetany
• Wound culture: Culture and Gram stain of debrided tissue (C. tetani is isolated in a minority of cases; a negative culture does not exclude tetanus)[2]
• Serum tetanus antibody levels: Rapid immunoassays can detect protective antibodies but lack standalone confirmatory utility; subprotective levels support the diagnosis[2][5]
• Toxicology screen: If strychnine poisoning is considered[2]
• Lumbar puncture: CSF is typically normal in tetanus; useful to exclude meningitis/encephalitis if diagnostic uncertainty[1]

12. Imaging

• CT head/face: Unremarkable in cephalic tetanus (no acute parenchymal abnormalities); useful to rule out stroke, abscess, or intracranial pathology[2-3]
• Gas locules: Presence of gas in soft tissue on CT could support a probable diagnosis[2]
• MRI brain: Normal in tetanus; may be needed to exclude brainstem stroke or demyelination
• Chest X-ray: Baseline and to evaluate for aspiration pneumonia
• Imaging is not diagnostic: Tetanus is a clinical diagnosis; imaging serves primarily to exclude mimics[2][7]

13. Special Tests

• Spatula test: Touching the posterior pharyngeal wall with a tongue depressor — a positive test (reflex jaw clamp) is highly specific for tetanus[2]
• Ablett classification: Grades severity from Grade 1 (mild) to Grade 4 (very severe with autonomic disturbance)[5]
• Tetanus Severity Score (TSS): Includes age, dyspnea at admission, time from first symptom to admission, comorbidities, entry site, blood pressure, and fever; sensitivity 77%, specificity 82% — outperforms Phillips and Dakar scores[1]
• Heart rate variability (HRV): Reduced HRV on ECG monitoring may indicate autonomic nervous system dysfunction before clinical signs are apparent[12]
• Electrophysiology: Can demonstrate dual peripheral (neuromuscular junction) and central (brainstem) sites of toxin action in cephalic tetanus[4]

14. ECG

• Indications: All patients with suspected tetanus should have continuous cardiac monitoring

Findings associated with autonomic dysfunction

• Sinus tachycardia (most common)
• Bradycardia (alternating with tachycardia)
• ST-segment and T-wave changes (>93% of patients in one series had ≥1 ECG abnormality despite normal echocardiography)[13]
• QT prolongation
• Arrhythmias — ventricular and supraventricular
• Takotsubo cardiomyopathy: The most common cardiovascular event in tetanus (40% of all cardiovascular events); catecholamine-mediated; may present with ST elevation and wall motion abnormalities[1][8]
• Sudden cardiac arrest: Reported in 16% of cardiovascular events in tetanus[8]

15. Assessment

• Clinical summary: Cephalic tetanus is a rare, frequently misdiagnosed variant of localized tetanus presenting with trismus and cranial nerve palsies after head/neck injury. Both flaccid and spastic paralysis can coexist, reflecting dual peripheral and central toxin action.[2][4]
• Severity stratification: Use the Ablett classification and/or Tetanus Severity Score; however, even "mild" cephalic tetanus warrants ICU-level monitoring given the risk of rapid generalization and cardiorespiratory collapse[1-2]
• Typical vs atypical: Classic presentation is trismus + ipsilateral CN VII palsy after facial wound. Atypical presentations include fluctuating symptoms mimicking TIA, bilateral cranial nerve involvement, or isolated dysphagia[2]
• Complications: Generalization to full-body tetanus, laryngeal spasm, aspiration pneumonia, respiratory failure, autonomic dysfunction, Takotsubo cardiomyopathy, rhabdomyolysis with AKI, PRES, nosocomial infections, VTE[1]

16. Treatment Plan

Initial stabilization (ED)

• Secure the airway — have intubation equipment at bedside; early intubation if any signs of laryngeal spasm or respiratory compromise
• IV benzodiazepines for spasm control (diazepam 10–30 mg IV, titrate to effect)[1]
• Place patient in a quiet, dark, low-stimulation environment[1][7]

Specific therapy (Day 1)

• HTIG 500 IU IM (single dose)
• Td or Tdap 0.5 mL IM (at a different anatomic site from HTIG)
• Metronidazole 500 mg IV q6h for 7–10 days
• Wound debridement — thorough exploration, removal of foreign bodies and devitalized tissue

ICU management

• Titrate benzodiazepines; add propofol or neuromuscular blocking agents (vecuronium) for refractory spasms
• Magnesium sulfate IV infusion for autonomic dysfunction and as adjunctive spasm control[14]
• Labetalol for sympathetic hyperactivity[1]
• Enteral feeding via NG tube or parenteral nutrition
• DVT prophylaxis with heparin[1]
• Bedside physical therapy when spasms allow[1]

Recovery phase

• Taper benzodiazepines over 14–21 days as spasms diminish
• Intensive physical therapy
• Psychotherapy support (prolonged ICU stays are psychologically traumatic)
• Administer second dose of Td/Tdap before discharge; complete full vaccination series (natural infection does not confer immunity)[2]

17. Disposition

• All suspected cephalic tetanus → ICU admission — even mild cases warrant ICU-level monitoring given the risk of rapid generalization and airway compromise[1-2]
• Admission criteria: Any patient with trismus + cranial nerve palsy + compatible wound history
• Observation is insufficient: Cephalic tetanus can progress to generalized tetanus with respiratory failure within hours[1-2]
• Specialist consultation: Infectious disease, critical care/intensivist, neurology (to help exclude mimics), surgery/ENT (wound debridement), and anesthesia (airway management)
• Discharge criteria: Resolution of spasms, stable autonomic function, ability to swallow safely, completion of initial vaccination, and arrangement for outpatient vaccination series completion[1]

18. Follow Up / Return Precautions

• Recovery timeline: Inhibitory neurotransmission takes 4–6 weeks to restore; median mechanical ventilation duration in severe cases is ~16 days; median hospital stay 22–30 days[2][11]
• Vaccination completion: Full primary series required post-discharge (natural infection does not confer immunity); administer additional Td/Tdap dose before discharge, then complete series per ACIP schedule[2][6]
• Follow-up timing: Infectious disease and primary care follow-up within 1–2 weeks of discharge
• Return precautions: Immediate return for new jaw stiffness, muscle spasms, difficulty breathing, difficulty swallowing, fever, or any neurological symptoms
• Long-term outcomes: Most survivors achieve good functional recovery — in one French cohort, 61% of ICU survivors had no lasting disability at ~4 years follow-up, even among elderly patients[2]
• Patient counseling: Emphasize that recovery is slow but most patients improve considerably with sustained supportive care; stress the critical importance of completing the vaccination series[2]

References

1. Tetanus. — Ergönül Ö, Kolsuz S, Figueroa JP. Lancet. 2026.

2. Tetanus: Recognition and Management. — Sudarshan R, Sayo AR, Renner DR, et al. The Lancet. Infectious Diseases. 2025.

3. Teaching Video NeuroImages: Cephalic Tetanus: Not Every Facial Weakness Is Bell Palsy. — Nascimento FA, Hammoud N, Augusto FD. Neurology. 2019.

4. Facial Neuromuscular Junctions and Brainstem Nuclei Are the Target of Tetanus Neurotoxin in Cephalic Tetanus. — Fabris F, Varani S, Tonellato M, et al. JCI Insight. 2023.

5. Tetanus. — Yen LM, Thwaites CL. Lancet. 2019.

6. Prevention of Pertussis, Tetanus, and Diphtheria With Vaccines in the United States: Recommendations of the Advisory Committee on Immunization Practices (ACIP). — Liang JL, Tiwari T, Moro P, et al. MMWR. Recommendations and Reports : Morbidity and Mortality Weekly Report. Recommendations and Reports. 2018.

7. What Is Tetanus?. — Zhou S, Malani P. The Journal of the American Medical Association. 2026.

8. Magnitude, Patterns, and Associated Predictors of Cardiovascular Events in Tetanus: A 2-Year, Single-Center, Ambidirectional Cohort Study Involving 572 Patients. — Pham OKN, Tran BN, Duong MC, et al. Open Forum Infectious Diseases. 2023.

9. FDA Drug Label. — Updated date: 2010-10-28. Food and Drug Administration.

10. Tetanus Surveillance - United States, 2009-2023. — Hughes MM, Amin AB, Rubis AB. Morbidity and Mortality Weekly Report. Surveillance Summaries. 2026.

11. Management and Outcome of Adult Generalized Tetanus Patients in a Tertiary Hospital in Anhui, China: A Retrospective Study. — Huang J, Cai E, Ding W, et al. Frontiers in Public Health. 2025.

12. Heart Rate Variability as an Indicator of Autonomic Nervous System Disturbance in Tetanus. — Duong HTH, Tadesse GA, Nhat PTH, et al. The American Journal of Tropical Medicine and Hygiene. 2020.

13. Maternal and Neonatal Tetanus. — Thwaites CL, Beeching NJ, Newton CR. Lancet. 2015.

14. Magnesium Sulphate for Treatment of Severe Tetanus: A Randomised Controlled Trial. — Thwaites CL, Yen LM, Loan HT, et al. Lancet. 2006.