Tetanus results from the neurotoxin secreted by the bacterium Clostridium tetani. On average, the Centers for Disease Control (CDC) has reported 90 cases per year in the United States since vaccinations were implemented to prevent the infection (68). The most consistent early symptom is trismus. Without treatment, the infection is lethal in 30% of patients. A rare localized form of tetanus, termed cephalic tetanus, causes facial paralysis and usually results from an ipsilateral facial wound.

Cephalic tetanus refers to tetanus with paresis or paralysis of any muscle supplied by the cranial nerves. This flaccid paralytic involvement is differentiated from the more common spastic muscle involvement usually seen in tetanus infections. Cephalic tetanus remains a rare variant of tetanus infections, with one review finding cephalic tetanus in 23 cases out of a total of 1025 cases with diagnosed tetanus infections (2.2%) (69).

Various mechanisms have been proposed. One difficulty has been explaining how the toxin or bacteria causes a flaccid paralysis instead of the more typical spastic paralysis. Rose theorized a compressive theory of facial injury (70). Russel favored neuritis due to the tetanus toxin (71). Binet thought that the neurotoxin may behave in a dose-dependent fashion, causing flaccid paralysis at lower concentrations and spastic paralysis at higher concentrations (72). Brunner theorized that selected subtypes of tetanus toxin having different effects might provide the answer (73). Vakil proposed a central etiology of dysfunction, citing an EMG study that did not demonstrate any denervation potentials as evidence (69).

The treatment for cephalic tetanus is the same as for generalized tetanus. Elimination of the toxin by wound debridement and killing active bacteria with penicillin as well as administration of the antitoxin and initiation of immunization are crucial. Patients may also require varying degrees of supportive therapy. The facial paralysis often persists despite resolution of muscle spasm in other parts of the body (69).

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