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 Table of Contents  
CASE REPORT
Year : 2019  |  Volume : 25  |  Issue : 1  |  Page : 37-39

Otogenic tetanus though immunisable but still existing


Department of ENT, Dr. Vaishampayan Memorial Government Medical College, Solapur, Maharashtra, India

Date of Web Publication19-Jun-2019

Correspondence Address:
Dr. Seema Ramlakhan Gupta
1108, BLDG.4, MMRDA Colony, Jai Bhavani Nagar, Manpada, Thane (West), Maharashtra
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/indianjotol.INDIANJOTOL_111_18

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  Abstract 


Otogenic tetanus is an uncommon entity which may follow ear suppuration or ear injury. Straightforward diagnosis may not be possible if the otolaryngologist is not familiar with the entity. Delay in diagnosis may lead to serious consequences. The global incidence of tetanus is still estimated at about one million cases annually with a high case fatality ratio. These patients initially present with discharging ears; therefore, this case report is intended to increase awareness among otolaryngologists who would be the first to diagnose and initiate appropriate management. In spite of simple preventive measures available through immunization, tetanus remains a major cause of mortality in some developing countries such as India.

Keywords: Clostridium tetani, otitis media, tetanus


How to cite this article:
Gupta SR, Vakharia SD. Otogenic tetanus though immunisable but still existing. Indian J Otol 2019;25:37-9

How to cite this URL:
Gupta SR, Vakharia SD. Otogenic tetanus though immunisable but still existing. Indian J Otol [serial online] 2019 [cited 2019 Dec 5];25:37-9. Available from: http://www.indianjotol.org/text.asp?2019/25/1/37/260716




  Introduction Top


Tetanus is a vaccine-preventable disease caused by Clostridium tetani which is a Gram-positive, spore-forming bacterium. The global incidence of tetanus is still estimated at one million cases annually, with a case fatality ratio ranging from 20% to over 50%.[1] Tetanus spores are introduced into the body by practices that expose open wounds to contamination from soil or animal feces.[2] Otitis media is inflammation of the middle ear cleft. It is a common childhood infection, predominantly in lower socioeconomic group.[3] Insertion of a contaminated object picked from the bare floor to clean the discharging ear is a possible source of infection. The exotoxin (tetanospasmin) produced by tetanus organisms initiates a cascade in the nervous system that leads to the clinical manifestations which include locked jaw, dysphagia, muscular rigidity, and spasm. Tetanus immunization is an important public health intervention and constitutes a cost-effective strategy to reduce both the morbidity and mortality associated with it.


  Case Report Top


An 8-year-old girl from low socioeconomic background visited our hospital with a complaint of inability to open mouth and dysphagia for 2–4 days. She had a history of upper respiratory tract infection and discharging left ear for 1–2 months. Furthermore, a history of repeated use of stick or pin or pen for ear cleaning was found. The patient was initially treated by a medical officer at primary health center for otitis media and upper respiratory tract infection with both systemic and topical antibiotics, but there was no improvement.

Later, the patient had admitted to pediatric ward at our hospital and then referred to otorhinolaryngology department for ear discharge and to assess the need for tracheostomy. There was no associated fever, nausea and vomiting, or weight loss. The history for tetanus vaccination was doubtful, informant being parents and so was booster administration. Examination of the patient's left ear revealed yellowish, mucopurulent, moderate quantity, nonfoul-smelling, and nonblood-stained discharge with small central perforation in the tympanic membrane [Figure 1]. She had trismus (one finger opening), so it was difficult to examine the oral cavity. She had grinning face (risus sardonicus) with nasal-twang with mild stiffness of neck and hand muscles [Figure 2]. The rest of the ENT examination and systemic examination including Chvostek sign and Trousseau's signs were unremarkable.
Figure 1: Discharge from the left ear

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Figure 2: Risus sardonicus (a facial expression characterized by raised eyebrows and grinning) caused due to spasm of facial muscles

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Investigations

Ear swab was sent for Gram stain which was reported as C. tetani. Serum calcium was in normal range and blood culture did not show any growth.

Differential diagnoses were (1) chronic suppurative otitis media with intracranial complication, (2) hypocalcemic tetany, and (3) otogenic tetanus.

Treatment

Besides constant monitoring of her vitals, she was started on both local and systemic broad-spectrum antibiotics. Intravenous penicillin was given. With no improvement in 24–36 h, she was then given tetanus immunoglobulins (TIGs). Supportive treatment include isolation of patient, sedation, muscle relaxant, regular ear suctioning, and nonsteroidal anti-inflammatory drugs were given. The patient was also given tetanus toxoid after partial improvement of symptoms. Later on, cultures from ear discharge were also reported as positive for C. tetani. The patient was discharged on the 8th day of admission and was advised regular follow-up, but she did not follow up.


  Discussion Top


Hyman and Bower reported the first case of otogenic tetanus in 1934.[4] Tetanus is caused by C. tetani which is a Gram-positive, anaerobic, motile, and nonencapsulated rod. It forms spores that can survive in dry soil for years, and the only effective way to kill the spores is to process them through autoclave for 15 min.[5]

Tetanus has also been linked to socioeconomic factors, level of personal and environmental hygiene, and lack of awareness on prompt treatment of ear infections.[6] Despite committed efforts and targeted campaign by the World Health Organization with a goal to eradicate it, tetanus is still reported, mainly from the developing countries. Issues with health-care delivery in remote localities, inadequate funds for transportation, and lack of parental awareness were cited as the prime reasons responsible in the developing world. Because childhood vaccination does not confer lifelong protection with disease even in immunized, it has been suggested that adolescents and adults should receive booster shots.[6]

Otogenic tetanus is a subtype of cephalic tetanus, usually limited to the muscles and nerves of the head and neck, but can also progress to a more generalized form. It usually is the result of tetanus spores gaining entry into the middle ear of otitis media through a tympanic membrane perforation. Otogenic tetanus may also result from contaminated ear injuries or attempted ear surgeries with unsterile instruments, especially in nonimmunized.[7] Ear discharge and devitalized tissue located in the middle ear or mastoid in chronic suppurative otitis media provide an ideal growth medium for anaerobic tetanus organisms.[8] C. tetani produces a neurotoxin called as tetanospasmin. Tetanospasmin enters the nervous system at the myoneural junctions of alpha motor neurons and binds to presynaptic inhibitory synapses, thus preventing release of inhibitory neurotransmitters. This leads to insidious surge in muscle tone and rigidity. Incubation period of tetanus may vary from 2 days to a few months.[9] Incubation period and the period of onset are directly related to disease severity and treatment response in otogenic tetanus, because they are indicative of the quantity of toxin released and distance travelled within the nervous system. They, hence, have prognostic significance; while patients with a longer onset period developed milder form of tetanus responsive to treatment, those with shorter onset period ran a more severe course and poor treatment response.[8],[9]

Otogenic tetanus is treated conservatively in acute phase and needs collaboration of both otolaryngologist and physician. Management of otogenic tetanus has been on similar lines to that of general tetanus. The patients are assessed thoroughly for their vitals, respiratory status, and grade of severity of rigidity along with systemic examination. All the patients are kept in isolation to avoid light, noise, and other disturbances. TIG is usually given in a dose ranging from 1500 to 3000 IU. Local ear toilet to clear off the stagnant secretions and debris from the external canal and middle ear is essential; appropriate culture-directed antibiotics should be initiated. Smaller percentage of patients require sedation, muscle relaxants, and artificial respiration through endotracheal intubation or tracheostomy.[6],[9] Patients and their relatives should be counseled about the importance of immunization. In developed countries, the widespread use of tetanus toxoid for active immunization, improved wound care management, and the use of TIG for postexposure prophylaxis and for treatment have contributed greatly to decrease the incidence of tetanus. Relapse of otogenic tetanus has also been reported which can have dreadful consequences.[10]


  Conclusion Top


Tetanus which is a manageable and preventable disease can lead to high morbidity and mortality if not diagnosed timely and treated. Treatment is very costly as compared to vaccination which is free of cost. This case report emphasis on few important aspects:

  1. Education regarding immunization specially in low socioeconomic population
  2. Importance of ear swab for culture and sensitivity
  3. To increase the awareness among otorhinolaryngologist in cases of ear discharge not responding to antibiotics
  4. Booster dosage of tetanus toxoid and proper wound care
  5. Atraumatic techniques and meticulous care to use well-sterilized instruments should be followed in all surgical manipulations of the ear to prevent injury-related otogenic tetanus
  6. Meticulous history of tetanus immunization should be elicited in all children presenting with otitis media, especially in developing countries.


Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Lau LG, Kong KO, Chew PH. A ten-year retrospective study of tetanus at a general hospital in Malaysia. Singapore Med J 2001;42:346-50.  Back to cited text no. 1
    
2.
Cook TM, Protheroe RT, Handel JM. Tetanus: A review of the literature. Br J Anaesth 2001;87:477-87.  Back to cited text no. 2
    
3.
Akinpelu OV, Amusa YB, Komolafe EO, Adeolu AA, Oladele AO, Ameye SA, et al. Challenges in management of chronic suppurative otitis media in a developing country. J Laryngol Otol 2008;122:16-20.  Back to cited text no. 3
    
4.
Hyman I, Bower AG. Otogenic tetanus: Report of a case. JAMA 1934;103:480.  Back to cited text no. 4
    
5.
Lorber B. Gas Gangrene and other Clostridium-Associated Diseases in Principle and Practice of Infectious Diseases. 5th ed. London: Churchill Livingstone; 2000.  Back to cited text no. 5
    
6.
Ogunkeyede SA, Fasunla AJ, Adeosun AA, Lasisi OA. Otogenic tetanus: Continuing clinical challenge in the developing country. J Rhinolaryngo Oto 2013;1:87-90.  Back to cited text no. 6
    
7.
Patel JC, Mehta BC. Tetanus: Study of 8,697 cases. Indian J Med Sci 1999;53:393-401.  Back to cited text no. 7
[PUBMED]  [Full text]  
8.
Sykes MK, Davis JA. Otogenic tetanus. Br Med J 1965;2:482.  Back to cited text no. 8
    
9.
Akinbohun A, Ijaduola G. Otogenic tetanus among children in Ibadan, Nigeria. Internet J Otorhinolaryngol 2008;10:1-4.  Back to cited text no. 9
    
10.
Sharma A, Kapoor S. Relapse in a child with otogenic tetanus. Trop Doct 2006;36:56-7.  Back to cited text no. 10
    


    Figures

  [Figure 1], [Figure 2]



 

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