Cephalic tetanus is a subtype of tetanus, which is associated with cranial nerve palsies and occurs in 1 % to 3 % of tetanus cases. We present a case of cephalic tetanus in an elderly patient with facial nerve palsy as an initial symptom. The patient was a 75-year-old man who had injured his face during gardening. Nine days after the injury, trismus with right facial nerve palsy occurred. Twelve days after the facial injury, he visited our hospital and was admitted immediately. He had severe fatigue, facial nerve palsy, severe trismus, and scabbing and induration at the lesion. CT examination revealed no characteristic findings, such as a fracture or dental infection, except for wood-chip-like materials in the injured area. After that, frequent tonic spasms of the legs occurred, and cephalic tetanus was diagnosed. The spasms developed to general convulsions, and the patient received respiratory care with sedation and tracheal intubation in the ICU. The latency period of tetanus was 9 days, and the onset period was about 84 hours. Chronic obstructive pulmonary disease resulted in severe ventilator-associated pneumonia. In the fourth stage of tetanus, the patient was asked to do mouth-opening exercises and deglutition exercises, and occlusion reconstruction was also performed. He recovered from cephalic tetanus and was discharged from the hospital on day 119 after the onset of disease.