Otogenous Tetanus and Chronic Otorrhoea

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Otogenous tetanus and chronic otorrhoeaBy S. D E and S. K. D E (Calcutta, India)

IntroductionCL. TETANI gains access to human body through skin or mucous membrane,broken either by trauma or disease process. Well known routes are traumaticwounds, uterine sepsis, burns, umbilical cord sepsis and operative wounds.A patient jmay also be infected through an infected middle ear, when it isknown as otogenous tetanus.The incidence of otogenous tetanus is rare in western countries, and thereis not much discussion or publication on this subject which is even omittedfrom the majority of textbooks of surgery and medicine dealing with the subjectof tetanus. It is surprising how often this route of infection in tetanus is foundin this country.to survey the distribution of tetanus, but a WHO review of available data forthe period 1950-60, suggests thattetanus mortality has been increasing inmost developing countries [WHO Chronicle, 1965). Incidence of this diseaseisjyery high in Ind ia and a large nu m ber of cases hav e been repo rted from var iouscentres of this subcontinentBhatt and Anwikar (1962), Laha and Vaishya(i965)._Incidence in Calcutta, which is a large industrial city, is very high andaverage admission of tetanus cases in 'Infectious Disease Hospital' of Calcuttacomes to nearly 2,000 per year (De, 1966). This hospital caters for the whole ofgreater Calcutta and even outside, comprising a population of about 10 million.Among these cases, a considerable proportion, particularly children, belong tothe otogenous group.

Different authors have published reports on otogenous tetanus in Indiaand abroad. Vakil, Shah, Tulpule, Nadkarni, and Joshi, (1966) have publishedreports on 2,031 cases of tetanus out of which 321 cases are found to be_otogenous (15-8 per cen t). W agle (1963) repo rted 25 cases of otoge nou stetanus out of 53 cases of tetanus with various portals of entry (47-1 per cent).Hazra and Agnihotri (i960) have reported two cases of otogenous tetanussupervening on chronic suppurative otitis media from which cl. tetani wasisolated. Patel and Joag (1959) have mentioned chronic otorrh oea as a prom inentcause of tetanus. Stonham (1938) and Corcoran (1938) have each reported onecase of otogenous tetanus.Criteria for diagnosis of otogenous tetanusDiagnosis of tetanus is essentially clinical, bacteriological confirmation isnot always possible. In otogenous tetanus, though the portal of infection issupposed to be the infected middle ear, attempts to demonstrate the causative

_organism in ear swabs hav e been unsuccessful in most inst anc es. Wo rk bydifferent autho rs on this subject, hav e shown this to be true . In th eir stu dy of331


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S. De and S. K. Deotogenous tetanus from Bombay, Vakil, Shah, Tulpule, Nadkarni, and Joshi(1966), have shown 16-2 per cent cases of clinical otogenous tetanus to bebacteriologically positive. They studied ear swabs from cases of (a) clinicalotogenous tetanus, (b) patients with chronic otorrhoea, otherwise healthy and(c) norm al hea lthy pati ents with no chronic ear disease. Their findings tha tcl. tetani could be isolated in a number of cases of clinical otogenous group andnone from the other two groups, strongly supports the view that tetanus inthe former group did originate from growth of cl. tetani in the middle ear.Wagle (1963) reported 25 cases of otogenous tetanus out of which q caseswere bacteriologically positive. This gives a positive result of 36 per cent whichis pretty high and confirms the same view.In our study of 1,000 cases of tetanus, 448 cases belong to the otogenousgroup (44-8 per cent). Our study is mainly clinical, ear swabs are taken onlyin 80 cases. These are cases, where ear swabs could be tak en before adm inistra-tion of serum. Out of these 80 ear swabs, toxigenic cl. tetani could be demon-strated in 15 cases and this gives a positive result of 18-7 per cent.We have selected the following criteria in our studies of otogenous tetanus:1. Sym ptom s and signs of Jtetanus.2. History of chronic ear discharge.3. Evidence of chronic suppurative otitis media on clinical examination.4. Absence of history of any trauma, or penetrating injury.5. Absence of any wound or lesion likely to serve as portal of entry ofinfection.6. Presence of toxigenic cl. tetani in ear swabs is confirmatory, but is notan essential criterion.Survey of otitis media and otogenous tetanusIt is difficult to survey the incidence of a non-notifiable disease, like otitismedia, in any community who can freely attend one of the many hospitalsof their choice situated within the metropolis. The present authors collectedmaterials from one hospital only; the patients represent only a section of thetotal population. From this survey it can be concluded, that chronic suppurativeotitis media itself forms a major portion of patients attending the E.N.T.clinics of different hosp itals of Ca lcu tta. It h as been observed from a one yearsurvey of hospital records (1965-66) that chronic suppurative otitis mediaforms about 25-5 per cent of all new cases attending the E.N.T. Outpatients'Clinic (Table I).

TABLE I.INCIDENCE OF CHRONIC SUPPURATIVE OTITIS MEDIA.

Tota l num ber of all new pat ients in 1965-6C in E.N .T.clinicNum ber of new cases of chronic suppurative otitismedia of all agesin the same period

31.000 (approx).

The age distribution of these cases of chronic suppurative otitis media isshown in Table II. 332


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Clinical recordsTABLE II.

AGE INCIDENCE OF CHRONIC SUPPURATIVE OTITIS MEDIA.Age in years

Below 10 years11-20 years2i-30 yearsAbove 31 years

No. of cases4,1042,1841,008624

Pecentage5 2 %2 7 - 5 %! 2 - 7 %7 - 8 %

From our clinical survey of tetanus during the period 1965-66 we havecollected 1,000 cases of tetanus of which 448 (44-8 per cent) were otogenoustetanus. This figure alone shows how common is this route of infection in thiscountry. Considering the high incidence of chronic otorrhoea and the numberof otogenous tetanus cases the importance of prophylaxis of tetanus cannotbe overemphasized. The incidence of otogenous tet an us as published by differentauthors in this country is shown in Table III.

TABLE III .INCIDENCE OF OTOGENOUS TETANUS

Name of authorWagle (1963)Barua (1961)Laha and Vaishya (1965)Vakil et al. (1966)De (1966)Present series

Percentageincidence4 7 - i %3o-9%7-2%15-8%46-5%44-8%

AetiologyExciting factor is the same as in other types of tetanus, i.e. infection bytoxigenic cl. tetani. The disease is more common in children as shown in Table

IV. The higher incidence in children is attributed to the following factors:(1) Higher incidence of chronic suppurative middle-ear disease in this agegroup.(2) Less careful aural hygiene: children with chronic otorrhoea are neglectedparticularly in slums and villages due to lack of social education and loweconomic conditions.(3) Self contamination is common in children.Predisposing factorsContamination of infected ears occurs due to unclean and unhygienic habits.People in slums and villages often clean their children's ears with unclean,dirty cotton wool or dirty linen. Often dir ty broom sticks utilized for the purposeof cleansing floors, house compounds and cowsheds, are used as swab sticksfor cleaning the ears. This m ay serve as a vehicle for imp lan tat ion of the organismin the ear.

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S. De and S. K. DeTABLE IV.

INCIDENCE OF TETANUS IN DIFFERENT AGES.

Xo injuryCh. otorrhoeaTraumaUterine sepsisVacc ination . .Surgical operationOral sepsisBurnsSkin infectionTotal

Below10 yrs.

824 3 29 418

1258

6 4 2

Age in years"-3O ' 31-50yrs. yrs.

18 11144 6131

423

2 1 8

2277615112

1 2 6

Above5 ys.6

814

Tota'

" 744S1752 0 7

1 91 0591 0

1,000

_Infected and unclean water may also play some part in the causation of thedisease. In villages and slum areas, tanks are often dirty and stagnant. People^and animals both use the same tank for bathing and water may naturally becontaminated. Patients with chronic otorrhoea while using the same tank maybe infected through the water.Social and economic conditionIt has been observed that chronic otorrhoea and otogenous tetanus occurmore commonly in people of poor economic condition, living in unhvgienicsurroundings of slums and villages. It is rarely seen among the richer sectionof the population. It is also rare in educated people who get their chronicotorrhoea treated at an early stage and maintain better aural hygiene.Tetanus may also occur through the ear by way of trauma or foreign body.Meseck (1926), Chalier and R ousse t (1928) (quoted b y Bishop et al.) each reportedof tetanus arising from a foreign body in the external auditory canal, but thesetypes of cases have not been considered in the present discussion.Incubation periodThe determination of incubation period in otogenous tetanus is not possibleas the condition of chronic suppurative otitis media is long standing and theprobable date of entry of infection cannot be determined.Clinical feature of otogenous tetanusThe clinical features resemble tetanus from other sources such as trauma,uterinesepsis, surgical operations, burns, vaccination, etc. But for someunknown reason, the majority of cases of otogenous tetanus tend to be lesssevere. The sym ptom s and signs are less acute and th e mo rtality rate is also less.Mortality from otogenous tetanus has been found to be less in comparisonto tetanus from other sources (Table V). In the present series, it was 28-8 percent. Several other workers on the subject of tetanus, have found this to betru e (Table VI), thoug h the portaljjf infe ction is situated w ithin head and neckarea which it is commonly believed carries a higher risk. This observed fartremains unexplained at present.

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Clinical recordsTABLE V.

.MORTALITY OF TETANUS IN RELATION TO DIFFERENT SOURCE OFINFECTION OR LESION IN OUR SERIES

Source of infection No. ofcasesNo injury or any other ;source . .Chronic otorrhoeaTraumaUterine sepsisVaccination

1 1 74487 52 0 71 9Surgical operation . . ! 10Oral sepsis

Skin infectionBurn5

1 09

TABLE VI.

No. ofdeaths Percentage

4 1 32-4%129 28-8%851 2 91 4

4 8 - 5 %6 2 - 3 %7 3 - 6 %5 5O%3 6 0 %4 4O%2 Z Z Z /Q

MORTALITY RATE IN OTOGENOUS TETANUS.

AuthorFatel and Joag (1959)Barua (1961)Laha and Vaishva (1965)Vakil, B. J. Shall, S. C.Tulpule, T. H., Nadkarni,M. S., and Joshi, B. X. (1966)Wagle (1963)Our series

Percentage2 5 %1 5 - 7 %

44-4%1 4 - 3 %36-5%2 8 - 8 %

TreatmentTreatment of otogenous te tanu s is the same as in other forms of te tanus anddetails are unnecessary in a communication like this. But the ear infection

should be treated and, if necessary, surgical intervention should be undertaken,to eradicate the chronic infection at a later date when the te tanus is controlled.Prophylactic measures are important considering the high incidence oftetanus following chronic otorrhoea. Active immunization with toxoid in_patients__with chronic otorrhoea as a routine should be given due consideration.Social education, regular E.N.T. check up and aural toilet are importantprophylactic measures.Summary

Chronically infected ear as a portal of entry of tetanus infection is discussedin detail. This route of infection is common in the vast majority of tetanus casesin India, particularly in the age group below 10 years. A survey of chronicsuppurative otitis media is also made with particular reference to differentage groups and its role as source of tetanus infection is discussed. Variousaetiological factors relating to otogenous tetanus are illustrated. Though the

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S. De and S. K. Deexciting factor is the same in all cases of tetanus, low economic conditions,unclean habits, lack of social education and bathing in infected water areprobably some of the more important predisposing factors.

AcknowledgementsThe authors express their feeling of gratitude to the Superintendents of theInfectious Disease Hospital and S.S.K.M. Hospital, Calcutta, for allowing us touse hospital records for preparation of this communication.

REFERENCESBARUA, A. R. (1961) J. Indian med. Ass., 37, 270.BHATT, A. N., and ANWIKAR, A. K. (1962) / . Indian med. Ass., 38, 71.B ISHOP, J. M., DUB OSE, R. H., and HAMLIX, F. E. (1932) / . Amer. med. Ass., 98,1546.Chron. Wld Hlth Org. (1965) 19, 28.CORCORAN, J. (1938) Brit. med. J., 1, 1004.D E , S. (1966) Calcutta med. J., 63, 302.HAZRA, A. K., and AGNIHOTRI , S. R. (i960) Indian J. med. Sci., 14, 197.L A H A , P. N., and V A I S H Y A P. D. (1965) / . Ind. med. Ass., 44, 422.P A T E L , J. C, and JOAG, G. G. (1959) Indian J. med. Sci., 13, 834.STONHAM, F. V. (1938) Brit. med. J., 1, 386.V A K I L , B. J., S H A H , S. C, T U L P U L E , T. H., X A D K A R X I , M. S., and J O S H I , B. N.(1966) / . Indian med. Ass., 46, 6.WAGLE, C. S. (1963) Indian/, med. Sci., 17, 157.283 Ra bind ra Sarani ,Calcut ta-5,Ind ia .

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Otogenous Tetanus and Chronic Otorrhoea

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