The Journal of Laryngology and Otology October 1992, Vol. 106, pp. 923-924

Dysphagia as a major symptom of tetanus J. Ross, N. J. MURRANT (Aberdeen)

Abstract Dysphagia is a common symptom presenting to ENT departments. Two cases of tetanus with dysphagia as a major symptom are discussed, together with a review of previously reported cases. Although tetanus is a rare disease in the United Kingdom, the possibility of this diagnosis should be borne in mind in patients presenting with progressive dysphagia, especially if there are other head and neck symptoms present.

Case report Case 1 A 52-year-old lady was initially referred by her general practitioner with bilateral jaw pain, present for several days. There were no other symptoms referable to the upper aero-digestive tract and examination at that time revealed no ear, nose and throat, nor any dental cause for her pain. Over the next ten days she began to experience increasing difficulty swallowing, together with spasm in the stemomastoid muscles. Examination now showed her to have risus sardonicus and marked sternomastoid spasm. Her voice was weak, she was unable to swallow her own saliva and she had a very poor cough. She was however alert and orientated and her respirations were adequate. Further questioning revealed that she had pricked her finger whilst pruning roses a few days before the onset of symptoms. Laboratory investigations revealed a slight leucocytosis of 13.7 x 10' cells per litre. Arterial bloodgases were within normal limits and a chest X-ray was clear. A clinical diagnosis of tetanus was made and she was admitted to the ENT unit where treatment was commenced with benzyl penicillin, tetanus immunoglobulin, anti-tetanus toxoid, diazepam infusion and analgesia. Despite this, she developed increasing respiratory difficulties. A tracheostomy was therefore performed and she was transferred to the Intensive Care Unit; her respiratory function improved enough to avoid ventilatory assistance. She made steady progress thereafter with the head and neck muscle spasms settling over a period of ten days. The tracheostomy was successfully decannulated after 14 days. She was discharged from hospital, off all medication, 18 days after admission. At follow-up one month later she had no swallowing difficulties nor any muscle spasms. The tracheostomy wound was well healed and she was discharged from further follow-up. Case 2 A 52-year-old lady was admitted to the ENT department with a two-week history of slowly progressive dysphagia. She also complained of mild stiffness and aching of the neck and shoulders. Further questioning after the diagnosis had been established, revealed that she had cut her finger on a rusty nail four weeks previously. Examination on admission was normal; full blood count, urea and electrolytes, lateral soft tissue neck X-ray and chest X-ray were all unremarkable. A barium swallow was performed and was reported as showing a mass impinging on the hypopharynx (Fig. 1).

FIG. 1 Barium swallow showing apparent mass in hypopharynx preventing passage of barium. (Arrowed).

Accepted for publication: 8 July 1992. 923

924 The patient therefore underwent direct laryngoscopy, pharyngoscopy and oesophagoscopy under general anaesthesia. This demonstrated an entirely normal upper aero-digestive tract. The following day, two days after admission, she developed trismus and dysphonia. There was generalized increase in muscle tone, with spasm and jerking on testing triceps reflexes. A clinical diagnosis of tetanus was made. In view of the increasing respiratory difficulties an elective tracheostomy was performed. She was treated in the Intensive Care Unit with midazolam and papaveratum infusion, benzyl penicillin, anti-tetanus toxoid and human anti-tetanus globulin. Nasogastric feeding was commenced, but ventilation was not required. After five days her condition improved sufficiently for transfer back to the ENT ward. Six days later the tracheostomy was successfully decannulated. Her subsequent progress was marred by the development of acute left ventricular failure secondary to an anterior myocardial infaction. She was transferred to the Coronary Care Unit where she responded well to treatment. She made a slow, but uncomplicated recovery from this and was well at the time of discharge. There were no sequelae from either her tetanus or the tracheostomy. Discussion Tetanus is a rare disease in the United Kingdom: a total of five cases were notified in Scotland in 1989 and 1990 (Weekly Reports of Communicable Diseases, Scotland, 1989 and 1990). In England and Wales, where the population is ten times that of Scotland, 71 cases were notified between 1979-1983 (Report from the Public Health Laboratory Service Communicable Disease Centre, 1986). Many of the head and neck symptoms of early tetanus, such as dysphagia, dysarthria and pain and stiffness of the muscles of mastication may come on insidiously. There may also be an initial absence of symptoms outside the upper aero-digestive tract, as in the two cases outlined above, and the patient may therefore present to the ENT department. There are five previously reported cases of tetanus presenting with dysphagia. All gave a history of gradually worsening swallowing difficulties over a period of up to 14 days before developing major signs and symptoms of tetanus, such as respiratory deterioration and generalized muscular spasm (Weider and Tingwald, 1970; Watanabe et al., 1984; Wang and Karmody, 1985; Kasanzew et al., 1989; Scholz et al., 1989). In most of these cases minor symptoms such as jaw and neck ache, mild voice change and mild trismus were present synchronously with the dysphagia. There was only one case reported as presenting with dysphagia as the only symptom (Watanabe et al., 1984). All of the patients reported, including the two cases detailed here, were over 45 years of age and five of the seven were women. This age and sex incidence would appear to be a reflection of the incidence of all tetanus cases, one series finding 50 per cent of all cases occurring over the age of 50 (Atrakchi and Wilson, 1977) and the notification rate for women over the age of 45

Key words: Deglutition disorders; Tetanus.

J. ROSS, N. J. MURRANT

years old being higher than that for men of the same age group (Report from the Public Health Laboratory Service Communicable Disease Surveillance Centre, 1986). Contrast swallow examinations were performed in each case reported. In one, there was no evidence of obstruction (Scholz et al., 1989), but cricopharyngeal spasm was identified in two (Wang and Karmody, 1985; Kasanzew et al., 1989). In the remaining two cases, the contrast examinations were reported as showing no entry of contrast from hypopharynx into oesophagus, but the exact point of obstruction was not specified (Weider and Tingwald, 1970; Watanabe et al., 1984). The chances of any individual department managing a patient with tetanus are small. However we would submit that the diagnosis be borne in mind in any patient with subacute progressive dysphagia. It is important to take a full history and to elicit any other head and neck symptoms and signs, cognizant of the fact that muscle pain and spasm may be very mild in the early stages of the disease. It is also noteworthy that the barium swallow examination may be misleading, in that no spasm may be demonstrated, or the obstruction may appear to be a mass.

Acknowledgements We would like to thank Mr L. C. Wills and Mr H. A. Young for their kind permission to report patients under their care. We should also like to thank the Medical Illustration Department for reproducing prints of the contrast swallow.

References Atrakchi, S. A., Wilson, D. H. (1977) Who is likely to get tetanus? British Medical Journal, 1: 179. Communicable Disease Surveillance Centre (1986) Report from the PHLS Communicable Disease Surveillance Centre. British Medical Journal, 293: 680-682. Kasanzew, M., Browne, B., Dawes, P. (1989) Tetanus presenting as dysphagia. Journal of Laryngology and Otology, 103: 229-230. Scholz, D. G., Olson, J. M., Thurber, D. L., Larson, D. E. (1989) Tetanus: an uncommon cause of dysphagia. Mayo Clinic Proceedings, 64: 335-338. Wang, L., Karmody, C. S. (1985) Dysphagia as the presenting symptom of tetanus. Archives ofOtolaryngology, 111: 342-343. Watanabe, H., Makishima, K., Arima, T, Mitsuyama, S. (1984) Dynamics of swallowing in tetanus. Journal of Laryngology and Otology, 98: 953-956. Weekly Reports Communicable Diseases Scotland (1989 and 1990) Notification of infectious diseases and food poisoning. Weider, D. J., Tingwald, E R. (1970) Dysphagia as initial and prime symptom of tetanus. Archives of Otolaryngology, 91: 479^481. Address for correspondence: Dr J. Ross, Registrar, Department of Otolaryngology, Aberdeen Royal Infirmary, Foresterhill, Aberdeen AB9 2ZB.

Dysphagia as a major symptom of tetanus.

Dysphagia is a common symptom presenting to ENT departments. Two cases of tetanus with dysphagia as a major symptom are discussed, together with a rev...
272KB Sizes 0 Downloads 0 Views