Bilateral trochlear nerve palsy and downbeat nystagmus in a patient with cephalic tetanus
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Cephalic tetanus is a rare form of localized tetanus. Facial paresis, trismus, and dysphagia may be presenting symptoms. Blepharospasm caused by tonic spasms of the eyelids is the most common ocular manifestation.1 We describe a patient with cephalic tetanus who had multiple cranial nerve palsies, including the presence of bilateral trochlear nerve paresis and downbeat nystagmus.
Case report. A 79-year-old man developed left facial pain and hypersensitivity to light touch around his left eye in August 1996. Within weeks he noticed painful tightening of his right jaw, difficulty swallowing, and nocturnal tongue biting. Spasms of the jaw were triggered when he attempted to eat, and at times he was unable to remove a toothbrush from his mouth. Neurologic examination initially revealed completely normal ocular function. Right jaw opening was impaired, and his tongue deviated leftward. Brain MRI and CSF examinations were normal. CBC, chemistry profile, sedimentation rate, and Lyme titers were also negative. Several days later he developed marked bilateral ptosis, vertical diplopia, and dysphonia.
Neuroophthalmologic examination revealed a right hypertropia in the primary position, which worsened in left gaze and right head tilt. In addition, the patient had a left hypertropia in right gaze and on left head tilt. Prism measurements revealed a 4 …
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