Introduction
Tetanus is an infection characterized by muscle spasms, and begins in the jaw muscles, of which findings also known as lockjaw or trismus. The spasms also affect the facial muscles and progress to the rest of the body. Prolonged muscular action causes powerful and painful contractions of muscle groups. Many patients complain of dysphagia due to mastication disorder. Manifestations of tetanus are usually managed with muscle relaxants only. The normal time course of tetanus is variable, but severe symptoms can persist for more than 2 months. Some patients are treated with botulinum toxin for dysphagia, however several complications such as decreased mastication force, bruising, headache, and the limitation of smile were reported.
We report a patient with oropharyngeal dysphagia due to tetanus, who was successfully treated with facial muscle massage and muscle relaxants.
Case Report
An 84-year-old female patient admitted to the Department of Otorhinolaryngology because of tongue mass and pain. After admission, she exhibited whole body rigidity, desaturation and the loss of consciousness. Tetanus was diagnosed and she was transferred to the intensive care unit. She was treated with intravenous metronidazole 500mg and tetanus immunoglobulin plus Td vaccination. After she regained consciousness, she was educated to relax facial muscles. In spite of medical treatment, she could not open the mouth.
After she moved to the general ward, she was transferred to the Department of Rehabilitation Medicine. Initially videofluoroscopic swallowing study (VFSS) was not possible because she could not open the mouth and chew. Treatment with facial massage and muscle relaxants (diazepam 2mg per day) was started. To re-establish the proper length and flexibility of muscles, we used effleurage, kneading, friction, and stretching. Approximately 30-minute facial massage of mastication muscles such as temporalis, pterygoid, and masseter muscles was performed twice a day.
After 4 weeks of treatment, she could open the mouth. Trismus was remarkably reduced. She could undergo VFSS. Oral transit time was 4.08sec, and she could chew food 13 times in 10 seconds. Vallecular and pyriform residue were grade 3, and penetration-aspiration score (PAS) was grade 6. She continued to get treatment of facial massage and muscle relaxants. Follow up study showed that oral transit time was 3.14sec, and she could chew food 15 times in 10 seconds. Vallecular and pyriform residue were grade 2, and PAS was grade 3. Currently, she can eat some solid food such as banana and grape.
Conclusion
In the present case, facial massage was effective to improve jaw opening and mastication for the patient with tetanus. After the massage the patient was able to open the mouth, the masticatory movement was improved, oral transit time was shortened, and vallecular and pyriform residue has decreased. Tetanus-induced dysphagia could be treated with muscle-oriented approach. |
