CASE REPORT Mandibular Nerve Blocks for the Removal of Dentures During Trismus Caused by Tetanus Eric Meaudre, MD*, Georges Pernod, MD*, Pierre-Emmanuel Gaillard, MD*, Eric Kaiser, MD*, Emmanuel Cantais, MD*, Jacques Ripart, MD†, and Bruno Palmier, MD* *Department of Anaesthesiology and Intensive Care, Military Teaching Hospital, Ho ˆ pital d’Instruction des Arme ´es Sainte Anne, Toulon-Naval, France; †Department of Anaesthesiology, 30029 CHU Nı ˆmes, France We report a case of trismus caused by tetanus in an 80-yr- old woman who developed severe and painful masseter spasms during which she violently bit the tip of her tongue with her dentures. Bilateral mandibular blocks were performed to remove the dentures. The patient fully recovered. We suggest that mandibular blocks are a use- ful tool in the management of oral events during trismus in conscious patients. (Anesth Analg 2005;101:282–3) T he incidence of tetanus is estimated to be be- tween 500,000 to one million cases per year worldwide. Lack of immunization is the greatest risk factor for contracting tetanus, resulting in a more frequent incidence of tetanus in the elderly in developed countries, and is associated with a mortality rate of 10%– 40%. Modern intensive care management focuses on preventing death from acute respiratory failure (1). Trismus, i.e., increased masseter tone, is the initial symptom in 50%–75% of cases of tetanus (2). There may also be frequent muscular spasms of varying severity (3). We report a case in which mandibular nerve blocks were used to obtain masseter relaxation, to facilitate removal of dentures in a patient in whom the spasms caused painful biting of the tongue. Case Report An 80-yr-old woman sustained a pretibial laceration while in her garden. Her wound was cleaned and closed with 50 sutures. Her last antitetanus vaccine had been given more than 30 yr previously. She received an antitetanus vaccine at the emergency department. Although recommended by French guidelines, no immunoglobulin was administered. Five days later, she was admitted for de ´bridement, excision, and antibiotic treatment of a necrotic and malodorous wound. On the eighth day, she developed trismus and nu- chal rigidity and was transferred to the intensive care unit. Orofacial causes and dystonic drug reactions were excluded. Human tetanus immunoglobulin 3500 IU (Gammatetanos ® , LFB) was given IM. Despite the avoidance of unnecessary stimulation, she developed severe and painful masseter spasms, during which she violently bit the tip of her tongue with her dentures. The dentures could not be removed because the mouth could not be opened more than 3 mm (Fig. 1A). Bilateral mandibular nerve blocks were performed via a lateral extraoral approach. With the patient conscious and cooperative in the sitting position, a 50-mm needle (Poly- medic™) was inserted below the midpoint of the zygomatic arch. The needle was then advanced perpendicularly to the face and withdrawn and redirected slightly posteriorly to reach behind the posterior border of the pterygoid plate. The patient did not report any paresthesias. After a negative aspiration, 5 mL mepivacaine 2% was injected on each side. After 20 min, the masseter muscles were sufficiently relaxed to allow the mouth to be opened 25 mm, and the dentures were removed. Mouth care was given with tooth cleaning and swabbing the oropharynx with an applicator with pov- idone iodine (Fig. 1B). The motor block persisted for 2 h; no side effects (including intradural and/or vascular injection, facial palsy, strabismus, diplopia, ptosis ophthalmoplegia, or temporary blindness) were noted. No additional episodes of tongue biting occurred and the spasms became less painful. There was no generalized tetanus at any time. The patient was managed in the intensive care unit for 14 days. She did not have any difficulty with swallowing at any time. Enteral nutrition was given via a nasogastric tube. The trismus decreased on day 24; normal mouth opening returned after 6 wk. She fully recovered at 10 wk. Antibody levels on day 4 confirmed the lack of immunization against tetanus (0.1 kIU/L, ELISA, Laboratoires Me ´rieux, France). Discussion The diagnosis of tetanus is made on clinical grounds and requires constant vigilance, especially in high-risk Accepted for publication December 1, 2004. Address correspondence and reprint requests to Eric Meaudre, HIA Sainte Anne, Bvd Ste Anne, Service de Re ´animation, 83800 Toulon-Naval, France. Address e-mail to meaudre@club-internet.fr. DOI: 10.1213/01.ANE.0000153501.96734.3F ©2005 by the International Anesthesia Research Society 282 Anesth Analg 2005;101:282–3 0003-2999/05