Tetanus physical examination

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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1] Michael Maddaleni, B.S.; Associate Editor(s)-in-Chief: Usama Talib, BSc, MD [2]

Overview

Tetanus initially presents with muscle stiffness. The distribution may vary with the type of tetanus. The masseter muscles are commonly involved with an accompanying headache. Neck stiffness, difficulty swallowing, generalized muscle spasms including the abdominal and back muscles and sweating may be seen later in the disease. In severe cases, respiratory paralysis may develop, which presents with apnea, hypoxia and hypercapnia.

Physical Examination

Tetanus initially presents with muscle stiffness. The distribution may vary with the type of tetanus. The masseter muscles are commonly involved with an accompanying headache. Neck stiffness, difficulty swallowing, generalized muscle spasms including the abdominal and back muscles and sweating may be seen later in the disease. In severe cases, respiratory paralysis may develop, which presents with apnea, hypoxia and hypercapnia.

Tetanus must be suspected in patients with:

• An injury involving contact of broken skin with contaminated environment, soil or dust.
• An absent or inconsistent history of immunizations.

Physical examination of a patient with tetanus may reveal the following:

General Appearance

• Severe muscular spasm (location varies with the type)
  • Opisthotonos
  • Leg extension with arm flexion
  • Risus sardonicus
• May be in respiratory distress

Vitals

• Fever
• Tachycardia
• Elevated blood pressure

Musculoskeletal

• Spasms of the diaphragm and intercostals
• Stiff abdominal wall

Respiratory

• Tachypnea
• Dyspnea

Cardiovascular

• Normal S1 and S2
• Hypertension
• Arrhythmia

Autonomic

• Intervals of
  • Bradycardia and hypotension accompanied by of
  • Tachycardia and hypertension

Abdominal

• Stiffening of the abdominal muscles

The physical examination may vary according to the type of tetanus. Specific findings associated with the various types of tetanus may include:

Local Tetanus

• Limited area of spasm
• The affected area is in close proximity to a contaminated wound
• Contraction is usually painful and associated with swelling
• Generalized tetanus may follow localized tetanus

Cephalic Tetanus

• Ear infection or head injury may be seen
• Trismus
• Signs of CN III, IV, VI, VII and XII involvement including:
  • Tilting of the mouth
  • Inability to close the eye
  • Inability to move the tongue
  • Diplopia
• Abnormal eye movements
  • Dysphagia
• Confusion
• Symptoms of stroke

Generalized Tetanus

• Descending spasm
• Trismus may present initially
  • Followed by stiffness of the neck
  • Difficulty in swallowing
  • Stiffness of abdominal muscles
• Other symptoms include
  • Elevated temperature
  • Sweating
  • Elevated blood pressure
  • Episodic rapid heart rate
• Spasms may occur frequently and last for several minutes
• Spasms may continue for 3-4 weeks
• Complete recovery may take months

Neonatal Tetanus

• Unhealed, unhygienic umbilical stump
• Trismus (spasm of masseter muscle)
• Risus sardonicus (spasm of facial muscles)
• Clenched hands
• Dorsiflexion of the feet
• Opisthotonus (spasm of spinal muscles)

The Spatula Test

The "spatula test" is a clinical test for tetanus that involves touching the posterior pharyngeal wall with a sterile, soft-tipped instrument, and observing the effect. A positive test result is the contraction of the jaw (biting down on the "spatula"), and a negative test result would normally be a gag reflex attempting to expel the foreign object.

Lock-jaw in a patient suffering from tetanus.- Source:Wikimedia Commons

An infant suffering from neonatal tetanus.- Source:Wikimedia Commons