PhiliPPine Journal of otolaryngology-head and neck Surgery 3332 PhiliPPine Journal of otolaryngology-head and neck Surgery PhiliPPine Journal of otolaryngology-head and neck Surgery Vol. 35 no. 2 July – december 2020 PhiliPPine Journal of otolaryngology-head and neck Surgery Vol. 35 no. 2 July – december 2020 ORIGINAL ARTICLES ABSTRACT Objective: This study aims to investigate which, if any head and neck symptoms (trismus, dysphagia, alterations in speech or facial movements, and dyspnea) might be good predictors of outcomes (mortality, tracheostomy, discharged, decannulated) and prognosis of tetanus patients. Methods: Design: Retrospective Cohort Study Setting: Tertiary National University Hospital Patients: Seventy-three (73) pediatric and adult patients diagnosed with tetanus and admitted at the emergency room of the Philippine General Hospital between January 1, 2013 and December 31, 2017. Demographic characteristics, incubation periods, periods of onset, routes of entry, head and neck symptoms, stage, and outcomes were retrieved from medical records and analyzed. Results: Of the 73 patients included, 53 (73%) were adults, while the remaining 20 (27%) were pediatric. The three most common head and neck symptoms were trismus (48; 66%), neck pain/ rigidity (35; 48%), and dysphagia to solids (31; 42%). Results of multivariate logistic regression analysis showed that only trismus (OR = 3.742, p = .015) and neck pain/ rigidity (OR = 4.135, p = .015) were significant predictors of decannulation. No dependent variable/symptoms had a significant effect in predicting discharge and mortality. Conclusion: Clinically diagnosed tetanus can be easily recognized and immediately treated. Most of the early complaints are head and neck symptoms that can help in early diagnosis and treatment resulting in better prognosis. In particular, trismus and neck pain/rigidity may predict the outcome of decannulation after early tracheotomy, but not of discharge and mortality. Keywords: tetanus; head and neck symptoms; outcome; predictors of outcome; trismus; neck pain/ rigidity; tracheotomy Tetanus remains a persistent global health problem despite its inclusion in the Expanded Program on Immunization (EPI) by the World Health Organization. Its high morbidity and mortality especially in developing countries is unjustified by its preventable nature and course. One million cases are reported annually with a case fatality ratio ranging from 6% to Head and Neck Symptoms as Predictors of Outcome in Tetanus Patients Angeli C. Carlos-Hiceta, MD,1 Ryner Jose D. Carrillo, MD, MSc,2,3 Jose Florencio F. Lapeña, Jr., MA, MD3 1Department of Otorhinolaryngology Philippine General Hospital University of the Philippines Manila 2Department of Anatomy, College of Medicine, University of the Philippines Manila 3Department of Otorhinolaryngology College of Medicine – Philippine General Hospital University of the Philippines Manila Correspondence: Prof. Dr. José Florencio F. Lapeña, Jr. Department of Otorhinolaryngology Ward 10, Philippine General Hospital University of the Philippines Manila Taft Avenue, Ermita, Manila 1000 Philippines Phone: (632) 8554 8467 Telefax: (632) 8524 4455 Email: lapenajf@upm.edu.ph, jflapena@up.edu.ph The authors declared that this represents original material that is not being considered for publication or has not been published or accepted for publication elsewhere, in full or in part, in print or electronic media; that the manuscript has been read and approved by the authors, that the requirements for authorship have been met by each author, and that all the authors believe that the manuscript represents honest work. Disclosures: The authors signed disclosures that there are no financial or other (including personal) relationships, intellectual passion, political or religious beliefs, and institutional affiliations that might lead to a conflict of interest. Presented at the Philippine Society of Otolaryngology Head and Neck Surgery Analytical Research Contest. December 7, 2019. Palawan Ballroom, Edsa Shangri La Hotel, Mandaluyong City. Philipp J Otolaryngol Head Neck Surg 2020; 35 (2): 32-36 c Philippine Society of Otolaryngology – Head and Neck Surgery, Inc. Creative Commons (CC BY-NC-ND 4.0) Attribution - NonCommercial - NoDerivatives 4.0 International PhiliPPine Journal of otolaryngology-head and neck Surgery 3332 PhiliPPine Journal of otolaryngology-head and neck Surgery PhiliPPine Journal of otolaryngology-head and neck Surgery Vol. 35 no. 2 July – december 2020 PhiliPPine Journal of otolaryngology-head and neck Surgery Vol. 35 no. 2 July – december 2020 ORIGINAL ARTICLES 72% depending on the availability of a well-equipped intensive care unit.1 The diagnosis of tetanus is clinical, and the primary complaints and history are important in determining the course of the disease.2 Most of these early complaints and presenting symptoms (trismus, dysphagia, alterations in speech or facial movements, and dyspnea) concern the head and neck region, making otolaryngologic evaluation indispensable.3 However, there is lack of local protocols that focuses on the prognosis and outcome of tetanus in association with head and neck symptoms. The Cole staging system is currently used in determining prognosis.4 Existing severity scores such as Philips, Dakar and Tetanus severity score (TSS) are utilized as predictors of outcome.5 Only the Dakar score includes spasm as one of its variables; none have taken into account head and neck symptoms as prognostic parameters despite their being the most common early presentation. Although preventable through immunization, this disease remains an important threat worldwide. If not recognized early, it may progress to disability and worse, death. This study aims to investigate which, if any head and neck symptoms (trismus, dysphagia, alterations in speech or facial movements, and dyspnea) might be good predictors of outcomes (mortality, tracheostomy, discharged, decannulated) and prognosis of tetanus patients. METHODS This retrospective cohort study included all pediatric and adult patients diagnosed with tetanus and admitted at the emergency room of the Philippine General Hospital between January 1, 2013 and December 31, 2017. The patient lists were retrieved from the yearly census of the departments of neurosciences, pediatrics and otorhinolaryngology. This study was approved by the University of the Philippines Manila Research Ethics Board (UPMREB 2018-391-01). Informed consent was waived by the board. All in-patient and out-patient records of identified patients were considered for inclusion and retrieved from the hospital records section. Patients that were diagnosed with tetanus at the out-patient department but not subsequently admitted and those with incomplete records were excluded. Data was collected as specified in the Case Report Form. Only head and neck symptoms (trismus, dysphagia, alterations in speech or facial movements, and dyspnea) were considered, and all other symptoms like abdominal rigidity, fever, generalized rigidity or stiffening were not included. Outcomes of the disease listed included: mortality, tracheostomy, discharged, decannulated. Deidentified data was tabulated, encoded, and summarized into frequencies/rates (mortality, case fatality rate) and percentages using the MS Excel for Mac v.15.13.3 (Microsoft Corp. 2015, Redmond, WA, USA). Multivariate logistic regression analysis was performed using Stata 14 (Stata Corp. 2015, College Station, TX, USA) to determine the predictors of the three dependent variables. A stepwise selection approach was applied in model building. The independent variables were the presence or absence of trismus, dysphagia to solids, dysphagia to liquids, dysarthria, Chvostek sign, dyspnea, and neck pain/ rigidity, while the dependent variables were discharge, mortality, and decannulation. A p-value of less than or equal to .05 was considered statistically significant. RESULTS A total of 78 patients from all age groups and genders who were clinically diagnosed with tetanus between January 1, 2013 and December 31, 2017 were included in the initial list. Five were subsequently excluded; two males with incomplete records and three (1 female, 2 males) who were only seen in the out-patient department but not admitted to the emergency room. A total of 73 patients were finally included in this study. Their ages ranged from 3 to 79 years old, with 53 (73%) adults and 20 (27%) pediatric. There were 50 (68%) males and 23 (32%) females. The three most common head and neck symptoms were trismus (48; 66%), neck pain/rigidity (35; 48%) and dysphagia to solids (31; 42%). The incubation period ranged from 1 to 30 days, while the period of onset was one to nine days. The specific route or source of disease in the majority were wounds or burns (47; 64%), followed by dental caries (15; 21%) and animal bites (11; 15%). Of the 73 patients, only 19 (26%) had a history of immunization for tetanus, although there was no mention if a complete dose or booster was administered. Sixty seven patients (92%) already presented with moderate to severe disease: 23 (32%) were Stage II and 44 (60%) were already Stage III. Only six patients (8%) were diagnosed as Stage I. All patients, despite the severity of the disease, underwent tracheostomy. Of these, 35 (48%) were decannulated, 59 (81%) were discharged from the hospital, while 14 (19%) expired in hospital. Thirty four out of fifty males (68%) presented with wound/burns possibly sustained during work (occupational accidents). Majority of patients had incubation periods of less than 7 days (45/73; 62%) and 58% of those patients had severe disease (Stage III). Sixty two percent (31/50) of those with period of onset of less than 3 days had Stage III disease. Sixty one percent (33/54) of those who did not receive any vaccination for tetanus were staged III tetanus patients. More severe cases of tetanus or those stage III patients (22/37 patients; 59%) stayed longer than 26 days in the hospital. Twenty-seven percent (12/45) of those patients with incubation periods of less than 7 days expired PhiliPPine Journal of otolaryngology-head and neck Surgery 3534 PhiliPPine Journal of otolaryngology-head and neck Surgery PhiliPPine Journal of otolaryngology-head and neck Surgery Vol. 35 no. 2 July – december 2020 PhiliPPine Journal of otolaryngology-head and neck Surgery Vol. 35 no. 2 July – december 2020 ORIGINAL ARTICLES and 18% (9/50) of those patients with periods of onset of less than 3 days expired. Causes of death were sepsis and cardiopulmonary complications. The case fatality rate increased with age from 18% for those < 40 years old, to 20% for those 40 to 59 years old, and 22% for those > 60 years old. Predictors versus outcomes for multivariate logistic regression analysis are presented in Table 1. Chvostek sign was omitted in all analysis due to collinearity. The remaining independent variables were not found to be significant predictors of discharge and mortality (Table 2 and 3, respectively). On the other hand, results of the analysis showed that only trismus (OR = 3.742, p = .015) and neck pain/ rigidity (OR = 4.135, p = .015) were significant predictors of decannulation (Table 4). The final model used was: Decannulation = 0.151 + 2.93 (Trismus) + 3.43 (Neck pain/rigidity) DISCUSSION Our present study found that trismus, neck pain/rigidity, and dysphagia to solids were the most common head and neck symptoms. Trismus is a common initial symptom in tetanus that may be unilateral early in the course of disease, but usually progresses to bilateral Table 1. Predictors vs Outcome for Multivariate Logistic Regression Analysis Y YY YN NN N TRACHEOSTOMY N (%) DECANNULATED N (%) MORTALITY N (%) DISCHARGED N (%) Trismus With opening Slight opening No opening Dysphagia to solid Yes No Dysphagia to liquid Yes No Dysarthria Yes No Chvostek Yes No Dyspnea Yes No Neck pain/ rigidity Yes No 9 (100) 48 (100) 16 (100) 31 (100) 42 (100) 29 (100) 44 (100) 18 (100) 55 (100) 0 0 20 (100) 53 (100) 35 (100) 38 (100) 5 (56) 40 (83) 14 (88) 27 (87) 32 (76) 25 (86) 34 (77) 17 (94) 42 (76) 0 0 15 (75) 44 (83) 27 (77) 32 (84) 4 (44) 8 (14) 2 (12) 4 (13) 10 (24) 4 (14) 10 (23) 1 (6) 13 (24) 0 0 5 (25) 9 (17) 8 (23) 6 (16) 4 (44) 8 (14) 2 (12) 4 (13) 10 (24) 4 (14) 10 (23) 1 (6) 13 (24) 0 0 5 (25) 9 (17) 8 (23) 6 (16) 5 (56) 40 (83) 14 (88) 27 (87) 32 (76) 25 (86) 34 (77) 17 (94) 42 (76) 0 0 15 (75) 44 (83) 27 (77) 32 (84) 0 27 (56) 8 (50) 14 (45) 21 (50) 15 (52) 20 (45) 8 (44) 27 (49) 0 0 8 (40) 27 (51) 21 (60) 14 (37) 9 (100) 21 (44) 8 (50) 17 (55) 21 (50) 14 (48) 24 (55) 10 (56) 28 (51) 0 0 12 (60) 26 (49) Í14 (40) 24 (63) 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 Table 2. Multivariate logistic regression analysis for outcome DISCHARGE ODDS RATIO p Value Coefficient Estimate STD Error 95% CONFIDENCE INTERVAL Trismus Dysphagia to solid Dysphagia to liquid Dysarthria Dyspnea Neck pain/rigidity 1.957483 1.057708 1.322432 4.041451 0.71226 0.6248123 .5830814 1.377268 1.350769 1.169684 .6801732 .6356587 .249 .968 .836 .232 .618 .459 .6716595 .0561042 .2794724 1.396604 -.3393123 -.470304 .6242783 - 6.137872 .0711268 - 15.72889 .0936691 - 18.67025 .4082257 - 40.01053 .1877907 - 2.701488 .1797529 - 2.171817 Table 3. Multivariate logistic regression analysis for outcome MORTALITY ODDS RATIO p Value Coefficient Estimate STD Error 95% CONFIDENCE INTERVAL Trismus Dysphagia to solid Dysphagia to liquid Dysarthria Dyspnea Neck pain/rigidity .5108601 .9454406 .7561826 .2474359 1.403982 1.600481 .5830814 1.377268 1.350769 1.169684 .6801732 .6356587 .249 .968 .836 .232 .618 .459 -.6716595 -.0561042 -.2794724 -1.396604 .3393123 .470304 .1629229 - 1.60185 .0635773 - 14.05939 .0535611 - 10.67588 .0249934 - 2.449625 .3701664 - 5.325077 .4604439 - 5.563193 Table 4. Multivariate logistic regression analysis for outcome DECANNULATION ODDS RATIO p Value Coefficient Estimate STD Error 95% CONFIDENCE INTERVAL Trismus Dysphagia to solid Dysphagia to liquid Dysarthria Dyspnea Neck pain/rigidity 3.74158 .2944081 3.833531 .5039372 .569629 4.135222 .015 .314 .259 .313 .380 .015 1.319508 -1.222789 1.343786 -.6853035 -.56277 1.419541 .5428817 1.214637 1.190193 .6793768 .6413111 .5822732 1.291081 - 10.84318 .0272301 - 3.183099 .3719673 - 39.50874 .133073 - 1.908372 .1620717 - 2.00206 1.320891 - 12.94585 involvement.5 Similar to our findings, other head and neck symptoms that present as the chief complaint aside from trismus are stiffness of the neck and dysphagia.3,6 Our findings suggest that tetanus patients with trismus or neck pain/rigidity are more likely to be decannulated. Thus, patients presenting with either of these head and neck symptoms that undergo immediate tracheostomy and management may have a higher chance of resolution of symptoms and decannulation. Although PhiliPPine Journal of otolaryngology-head and neck Surgery 3534 PhiliPPine Journal of otolaryngology-head and neck Surgery PhiliPPine Journal of otolaryngology-head and neck Surgery Vol. 35 no. 2 July – december 2020 PhiliPPine Journal of otolaryngology-head and neck Surgery Vol. 35 no. 2 July – december 2020 ORIGINAL ARTICLES the decannulation time was not recorded in the study, future research may include this variable for further comparison and analysis. As Mukherjee highlighted, the efficacy of tracheostomy in the treatment of tetanus cannot be overemphasized.7 He also stated that the sooner tracheostomy is done, the better for the patient.7 Fasunla recommended that patients diagnosed as Stage II must undergo tracheostomy sooner for better chances of survival, and that tetanus patients in general must not be allowed to reach Stage III before the procedure is commenced, since prognosis becomes poor.8 The reason for this is if tracheostomy was not initiated earlier, these patients would have died of asphyxia or cardiorespiratory failure.8 This correlates well with our findings that most of our patients (92%) already had Stage II and III or moderate to severe disease, which is mostly determined by the severity of the trismus. The decision for tracheostomy is made right away when trismus is observed. If trismus becomes more severe, the feasibility of orotracheal intubation for temporary airway protection becomes more difficult, hence tracheostomy is administered as a definitive airway protection measure. The key component is early detection of symptoms, specifically trismus and neck pain/rigidity, for immediate initiation of intervention to attain a favorable prognosis and outcome. Referring to Cole Staging, it is noted that even during Stage I, there is already trismus of mild severity, which raises the suspicion of tetanus. Thus, the importance of trismus as a symptom cannot be overemphasized in tetanus infection. Its presence leads to early detection and management to achieve a good outcome, survival, and in our case, decannulation. Aydin et al. found a direct correlation between the clinical stage and the requirement of tracheostomy.3 Sun et al. stated that the mainstays of treatment were early ventilatory support and tracheostomy.9 Orotracheal intubation may be an initial intervention, but to ensure long term ventilatory support, tracheostomy may be performed early.10 Although some did not advocate routine tracheostomy in tetanus cases, there were still those who considered it a lifesaving procedure, especially in moderate and severe stages.2,8 Smith and Drew emphasized that all tetanus patients should at least be considered candidates for tracheostomy.2 As part of the course of the disease, laryngeal and respiratory muscle spasm may ensue without prior notice and cause sudden death. Early tracheostomy is preferred over endotracheal intubation because the latter can provoke laryngospasm and thus exacerbate airway distress.11 Other reasons for tracheostomy include difficulty in intubation and reintubation in patients with severe hypertonic state, and prolonged intubation and mechanical ventilator support of more than 7 days in adults and greater than 30-60 days in pediatric patients.8 A study by Espinosa and Vinco looked into the relationship between the timing of tracheostomy and outcomes of tetanus, such as length of hospital stay, length of mechanical ventilation, morbidity, and mortality rate.12 They defined early tracheostomy as performed within 24 hours from time of admission while those performed beyond 24 hours were classified as late tracheostomy. Results of this study showed that early tracheostomy in moderate and severe stage tetanus led to shorter length of hospital stay and length of mechanical ventilation than late tracheostomy.12 With that in mind, early tracheostomy becomes a justifiable step in patients with moderate to severe tetanus.8 Once tracheostomy is immediately initiated and management is early administered especially in moderate to severe cases such as Stage II and III, good prognosis, which can be manifested by decannulation, becomes more likely. In our study, the case fatality rate increased with age, consistent with findings of the Research Institute for Tropical Medicine (RITM) report.4 Sixty two percent (62%) of our patients had incubation periods of less than 7 days, and 58% of those patients were already assessed as Stage III or severe disease. Moreover, 62% of those with periods of onset of less than 3 days already had Stage III disease. Fasunla identified a short incubation period as one of the factors associated with more severe disease.8 Miranda-Filho et al. identified a cut-off incubation period of <10 days and period of onset of <48 hours that indicate worse prognosis; those with incubation period of >10 days and period of onset of >48 hours are associated with better prognosis.13 Sixty one percent (61%) of those who did not receive any vaccination for tetanus were staged III during admission. Although a complete dose has not been proven to give lifelong protection against tetanus, it is still recommended that a complete dose be accomplished before 6 years of age followed by booster shots between ages 11 and 18 years and every 10 years in adults.8 According to the Centers for Disease Control and Prevention, the antitoxin levels of most persons approach the minimal protective level by 10 years after the last dose. Therefore, routine boosters are recommended every 10 years.14 Unfortunately, there was no mention of booster shots in the chart entries of our patients. Dyspnea can be considered a deadly predictor of negative outcome. Another important parameter derived from logistic regression analysis is the coefficient estimate. The sign of the coefficient estimate tells the direction of the relationship between the dependent variable and outcome. A positive coefficient indicates an increased likelihood of an outcome from happening, while a negative one decreases its likelihood. With a negative coefficient estimate for outcomes “discharge” and “decannulation,” tetanus patients are less likely to be discharged and decannulated due to such possible reasons as: “need for/connected to a mechanical ventilator,” “infection,” “complications (ventilator-associated pneumonia, comorbidities),” or more severe disease since they “already progressed to spasms of muscles of respiration.”7 PhiliPPine Journal of otolaryngology-head and neck Surgery 3736 PhiliPPine Journal of otolaryngology-head and neck Surgery PhiliPPine Journal of otolaryngology-head and neck Surgery Vol. 35 no. 2 July – december 2020 PhiliPPine Journal of otolaryngology-head and neck Surgery Vol. 35 no. 2 July – december 2020 ORIGINAL ARTICLES ACKNOWLEDGEMENTS We would like to acknowledge Ruby Anne King, MD, PhD and John Robert C. Medina, RMT, MD, MHS for helping with the statistics. REFERENCES 1. Chalya PL, Mabula JB, Dass RM, Mbelenge N, Mshana SE, Gilyoma JM. Ten-year experiences with tetanus at a tertiary hospital in Northwestern Tanzania: A retrospective review of 102 cases. World J Emerg Surg. 2011 Jul 8;6(20):1-8. DOI: 10.1186/1749-7922-6-20. PubMed PMID: 21740539; PubMed Central PMCID: PMC3159100. 2. Smith AT, Drew SJ. Tetanus: A case report and review. J Oral Maxillofac Surg. 1995 Jan;53(1):77- 80. DOI: 10.1016/0278-2391(95)90509-x. PubMed PMID: 7799128. 3. Aydin K, Caylan R, Caylan R, Bektas D, Koksal I. Otolaryngologic aspects of tetanus. Eur Arch Otorhinolaryngol. 2003 Jan;260(1):52–6. DOI: 10.1007/s00405-002-0508-4. PubMed PMID: 12520358. 4. Research Institute for Tropical Medicine. Management of Tetanus. In: Management Protocols of Infectious and Tropical Diseases, Volume 2. Manila: Research Institute for Tropical Medicine; 2013. p. 1-28. 5. Thwaites CL, Yen LM, Glover C, Tuan PQ, Nga NTN, Parry J et al. Predicting the clinical outcome of tetanus: the tetanus severity score. Trop Med Int Health. 2006 Mar;11(3):279-287. DOI: 10.1111/j.1365-3156.2006.01562.x. PubMed PMID: 16553907. 6. Hetzer DC, Hilsinger RL. The otolaryngologist and tetanus. Otolaryngol Head Neck Surg. 1986 Nov;95(4):511-5. DOI: 10.1177/019459988609500416. PubMed PMID: 3106917. 7. Mukherjee DK. Tetanus and tracheostomy. Ann Otol Rhinol Laryngol. 1977 Jan-Feb;86(1 Pt 1):67- 72. DOI: 10.1177/000348947708600110. PubMed PMID: 835974. 8. Fasunla AJ. Challenges of tracheostomy in patients managed for severe tetanus in a developing country. Int J Prev Med. 2010;1(3):176–181. PubMed PMID: 21566788; PubMed Central PMCID: PMC3075528. 9. Sun KO, Chan YW, Cheung RT, So PC, Yu YL, Li PC. Management of tetanus: A review of 18 cases. J R Soc Med. 1994 Mar;87(3):135-7. PubMed PMID: 8158589; PubMed Central PMCID: PMC1294391. 10. Hsu SS, Groleau G. Tetanus in the emergency department: a current review. J Emerg Med. 2001 May;20(4):357–365. DOI: 10.1016/s0736-4679(01)00312-2. PubMed PMID: 11348815. 11. World Health Organization. Current recommendations for treatment of tetanus during humanitarian emergencies. [Internet]. WHO Technical Note. 2010 Jan;1-6. [cited 2019 Feb 1] Available from https://www.who.int/diseasecontrol_emergencies/who_hse_gar_dce_2010_ en.pdf. 12. Espinosa WZ, Vinco VV. Timing of tracheostomy and outcomes in moderate and severe tetanus: a cross-sectional study. Philipp J Otolaryngol Head Neck Surg. 2019 Dec 2;34(2):20-23. DOI: https://doi.org/10.32412/pjohns.v34i2.915. 13. Miranda-Filho DB, Ximenes RAA, Barone AA, Vias VL, Vieira AG, Albuquerque VMG. Clinical classification of tetanus patients. Braz J Med Biol Res. 2006 Oct;39(10): 1329-1337. DOI: 10.1590/ s0100-879x2006001000009. PubMed PMID: 17053841. 14. Centers for Disease Control and Prevention. Epidemiology and Prevention of Vaccine- Preventable Diseases. Chapter 21: Tetanus. Hamborsky J, Kroger A, Wolfe S, eds. 13th ed. Washington D.C. Public Health Foundation, 2015. p. 341-351. [Cited 2019 Feb 15] Available from https://www.cdc.gov/vaccines/pubs/pinkbook/tetanus.html. “Dyspnea” and “neck pain rigidity” showed a positive coefficient estimate in mortality outcome. This is consistent with the literature.4,14 Tetanus follows a descending pattern from trismus or lockjaw to neck stiffness, dysphagia, rigid abdomen, progressing to laryngospasm and spasm of muscle of respiration.11,14 As the course of the disease progresses, mortality becomes more likely.4 One limitation of this study is our small sample size. A larger sample size may provide more data and possibly include more patients in Stage I that did not undergo tracheostomy. Tracheostomy as a surgical procedure comes with various complications that is why some authors only recommend tracheostomy for moderate to severe stages of tetanus.2,8 Another limitation of our study is that we did not further investigate the cause of death of some patients, and whether there were complications from tracheostomy. We recommend further studies to evaluate the complications of the procedure and perform a cost- benefit analysis in tetanus patients. Future studies may employ a larger sample size to explore and describe not only trends, but significant results and associations. Moreover, the inclusion of all presenting (head and neck, and non-head and neck) symptoms in the comparison and analysis may provide a more holistic approach to tetanus. In conclusion, trismus and neck pain/rigidity are the most common initial head and neck symptoms of tetanus, with a significant relationship to decannulation. A patient with such symptoms should raise a high index of suspicion for tetanus so that early diagnosis and expeditious intervention (including tracheostomy) can be initiated. To secure the airway via tracheostomy among tetanus patients manifesting with potential difficult airway access heralded by trismus and neck rigidity may allow decannulation but not necessarily favor discharge or decrease in mortality. Nevertheless, early tracheostomy should decrease morbidity attributed to frequent or recurrent intubation. Securing the airway and initiating medical management improves prognosis, making survival and decannulation more likely.