Bilateral facial nerve palsy after COVID 19 vaccination

Background: There has been lot of speculation around the possible side effects associated with COVID vaccination and incidence of facial palsy is one of them. Bilateral facial palsy is less likely to be idiopathic as compared to unilateral facial nerve palsy and warrants further investigations to find any secondary cause. COVID 19 infection and the vaccinations for the same are also included in the unique list of differentials. Case report: We report an interesting case of bilateral rapidly sequential facial nerve palsy following the administration of COVID vaccination that showed subsequent improvement. We provide literature review to report the current incidence of same, secondary to the vaccination as well the infection itself Case presentation: Following the introduction of COVID 19 vaccine, there have been reports of various cranial nerve involvement including lower motor neuron type facial paresis. Bilateral facial palsy is less likely to be idiopathic as compared to unilateral palsy(23% vs 70%) and requires further work up to determine the etiology before determining to be idiopathic. Unilateral facial palsy(FP) has been reported in the Phase I and II trials for Pfizer and Moderna vaccine, with a total of 7 cases reported in these initial trials. To date, there is no direct evidence that these vaccines have increased the incidence of facial palsy as compared to adverse events reported with other vaccines or compared to COVID 19 infection itself. We report a unique case of bilateral lower motor neuron type facial palsy noted in a young male within hours of receiving the vaccine that later improved with treatment. Reports of simultaneous bilateral facial palsy after vaccine are rare with only few cases reported to date in literature. Conclusion(s): In conclusion from current available literature, we would like to postulate that though there is a risk of facial nerve palsy following the vaccination, it is comparable to the risks associated with any other vaccinations and not been higher than the non-vaccinated population. The overall risk is higher with the actual COVID 19 infection itself as compared to the vaccine.Copyright © 2022

Teledental Consultations Using a Messaging Application during the COVID-19 Pandemic: Experience from a Singapore COVID-19 Community Care Facility

Introduction: During the 'Circuit Breaker' period of the COVID-19 pandemic in Singapore from April to June 2020, governmental policies restricted the practice of dentistry nationwide to the provision of emergency treatment only, regardless of the patient's COVID status. As such, teledentistry was used as an alternative means to continue providing some form of dental care to COVID-19-positive patients who were admitted to a COVID-19 Community Care Facility. Description: The patients were physically triaged by physicians who would send clinical photos to the author via a messaging application, who would in turn triage the patients and assess if they required referral for emergency dental treatment. For patients who did not meet the criteria for referral, the author would advise the physicians on the subsequent management plan which included, but was not limited to, the provision of symptomatic relief. Conclusion(s): This article shows the feasibility of undertaking teledental consultations using clinical photos transmitted via a messaging application. The practical implication is a reduced barrier for patients and healthcare professionals to access teledentistry, without having to resort to sophisticated equipment. Hopefully, this will translate into the continued provision of some form of dental care to patients during the ongoing pandemic as opposed to no care at all.Copyright © The Author(s) 2022.

Transjugular Approach for Recurrent Intracranial Glomus Vagale Tumors: An Ideal Approach to Preserve Hearing and Facial Nerve Function

Lateral skull base paragangliomas (glomus tumors) are rare skull base tumors arising from neuroendocrine cells. These benign tumors can be locally aggressive with potential for intracranial extension and significant morbidity as they compromise cranial nerve structures. Treatment is highly patient dependent. Herein, we present a case of recurrent glomus vagale paraganglioma requiring a multidisciplinary transjugular and transcervical approach for complete resection. A 64-year-old male was referred to the neurotology clinic in 2019 for a left skull base tumor causing progressive dysphonia and dysphagia. Exam revealed left true vocal fold weakness and no other abnormalities. Hearing was normal on the left. Magnetic resonance imaging (MRI) revealed a large hyperintense lesion of the left jugular foramen with intracranial cerebellopontine angle extension and normal flow through the sigmoid sinus and jugular vein. The patient elected for surgical removal and near-total resection was achieved via retrosigmoid craniotomy. A small portion was intentionally left in the jugular foramen to preserve the intact eleventh cranial nerve, internal jugular vein, and sigmoid sinus. Surgical pathology confirmed glomus paraganglioma. Postoperative radiation was strongly recommended, but the patient was lost to follow-up due to the COVID-19 pandemic. The patient re-presented in late 2021 with worsened dysphonia and dysphagia. Exam confirmed left true vocal fold immobility consistent with vagal nerve paralysis and a new finding of left tongue weakness consistent with hypoglossal nerve injury. MRI revealed recurrence of the lesion to dimensions larger than original presentation and complete occlusion of the sigmoid-jugular system. Hearing and facial nerve function remained fully intact, thus a transjugular approach with hearing preservation and complete surgical resection was utilized. After combined retrosigmoid and transcervical incision, the transjugular approach was utilized to resect the sigmoid sinus, the tumor of the jugular foramen, and the intracranial extension. The ear canal and facial nerve canal were preserved. The sigmoid sinus was ligated with surgical clips and the jugular vein was ligated with suture thread. Intracranially, the hypoglossal nerve was identified and preserved, and the vagus nerve was seen eroded by tumor. Pathology confirmed recurrent paraganglioma. Postoperatively, the patient recovered well but continues to endorse persistent dysphonia. His treatment plan includes radiation and thyroplasty. Multiple surgical approaches for the treatment of skull base paragangliomas have been reported including infratemporal types A to D, among others. This report identifies a rare case of recurrent paraganglioma which necessitated removal via transjugular approach. While uncommon in skull base surgery, this approach allowed identification and preservation of important neck and skull base structures (e.g., facial nerve, ear canal, spinal accessory nerve) while achieving complete gross resection. Radiation techniques have become popular alternatives for treatment of glomus tumors of the skull base due to high levels of surgery-related adverse events. Thus, skull base surgeons should be aware of the utility of the transjugular surgical technique for patients with intact hearing and facial nerve function who seek removal of intracranial jugular foramen tumors.

SOC-V-10 Hearing loss: side-effects of multiple compounds and formulations which can be monitored with functional and histological read-outs

Purpose: Hearing loss is a major global health issue affecting around 1.5 billion people worldwide, with an increasing prevalence. Acquired hearing loss is attributed to different environmental factors including ageing, noise exposure, and the intake of ototoxic medicines. Some commonly used medications can considerably affect the auditory system, resulting in cochlear and central damage that can lead to permanent hearing loss. More than 600 classes of medications are ototoxic. The most used in clinical practice are chemotherapeutics (cisplatin) and aminoglycoside antibiotics (such as gentamicin). Some investigated drugs for Covid-19 treatment (hydroxychloroquine, HCQ) and certain drug delivery agents like cyclodextrins (CD) have also been reported to induce auditory side effects. The aim of these in vivo studies was to provide functional and histological data on auditory assessments related to cisplatin, gentamicin, HCQ, and CD, when administered similarly to clinical protocol. Method(s): The studies were conducted in Wistar rats and Albino guinea pigs: * Cisplatin was administered by intraperitoneal route at 10 mg/kg in rats * Gentamicin was administered by intramuscular route at 160 mg/kg for 5 days in rats * HCQ was administered at 62 mg/kg per os daily for five days in rats * A cyclodextrin-based formulation was administered by transtym-panic route at 4 mg/mL 1 h and 30 h after noise exposure in guinea pigs Hearing was assessed using the techniques of Distortion Product Otoacoustic Emissions (DPOAE) and Auditory Brainstem Responses (ABR) at several timepoints. DPOAE are acoustic signals created and amplified by the cochlear epithelium and measured in the ear canal. DPOAE reflect the activity of outer hair cells (OHC). ABR is an electrophysiological measure of the sensorineural activity of the auditory pathway from the cochlea to the central auditory structures in response to a sound stimulus, recorded as electric potentials from scalp electrodes. A cochleogram, an FDA-recommended histological analysis for hair cell counting, was performed at the end of certain studies. Result(s): Results based on ABR thresholds, DPOAE amplitudes, and the cochleogram, showed different patterns of auditory side-effects. Cisplatin induced immediate and permanent hearing loss;gentamicin displayed delayed side-effects on auditory measures;HCQ did not affect Outer Hair Cells but might have had an effect on neurons. CD had an immediate and prolonged effect on hearing. Conclusion(s): This short presentation will help you learn the current available methods to measure hearing in preclinical in-vivo trials using two complementary functional read-outs and a histological analysis, and to determine the different sites of damage. Copyright © 2022 Elsevier B.V.

RESTING TREMOR AFTER COVID-19 INFECTION

CASE: The patient is a 66 year-old woman with history of hypertension and recovered COVID-19 presenting to the outpatient clinic for eight months of persistent resting tremor of her left arm. The tremor started shortly after she developed headache, fatigue, and epistaxis found to have COVID-19. The tremor is mild, occurs multiple times throughout the day, and usually resolves spontaneously after several seconds. The patient denies any paresthesias, muscle weakness, motor slowing, or ataxia. She has no family history of Parkinson's disease or essential tremor. On physical exam, vital signs are normal. Motor strength is 5/5 and sensation is intact throughout. Brachioradialis deep tendon reflex is 1/4 bilaterally though slightly increased on the right side. Cranial nerves II through XII are intact. Gait is normal with no evidence of shuffling. No pronator drift is evident. No cogwheel rigidity is noted. Finger-to-nose motion is normal. Throughout the appointment, the patient is noted to have an intermittent mild resting tremor in her left arm that lasts several seconds and resolves spontaneously. Laboratory results including a basic metabolic panel and thyroid stimulating hormone level are normal. Incidentally, the patient underwent a recent brain MRI for chronic sensorineural hearing loss that showed normal appearance of the internal auditory canals/ middle ear structures and no evidence of intracranial pathology. The patient was subsequently started on daily propranolol. A subsequent telemedicine visit one month later revealed that her resting tremor had nearly resolved. IMPACT/DISCUSSION: The outpatient presentation of resting tremor warrants consideration of a broad differential that includes Parkinson's disease and other causes of parkinsonism, including neurodegenerative diseases and essential tremor, among others. Furthermore, previous studies have demonstrated new onset movement disorders associated with COVID-19 including myoclonus, ataxia, action/postural tremor, catatonia, dystonia, chorea, and functional movement disorders. The exact pathophysiology of COVID-19 related movement disorders is not well understood. Of note, these prior studies did not specifically address evaluation of COVID-19 related movement disorders in the outpatient setting. CONCLUSION: The patient described above likely developed new onset left arm tremor secondary to COVID-19. Her reassuring physical exam findings, laboratory results, and head MRI suggest against other etiologies. The patient was successfully treated with propranolol. This case demonstrates the importance of neurologic assessment in the outpatient setting, particular in patients with a history of COVID-19 diagnosis. Though limited data exists on outpatient evaluation and management of movement disorders secondary to COVID-19, it is important to recognize this phenomenon as a potential diagnosis.

Can COVID-19 cause sudden sensorineural hearing loss?

Introduction Sudden sensorineural hearing loss (SSNHL) is defined as a hearing loss occurred within 3 days with decreasing of hearing level at least 30 dB in as a minimum three frequencies. The exact etiology and pathology of SSNHL is still unknown and the causes can be identified in only 10 to 15 percent of diagnosed cases. Methods Goal: To study the correlation of SSNHL and Covid-19 infections. We selected 10 patients who came to our clinic with SSNHL and who recently recovered from Covid-19 infection. They were admitted to clinic on 20-25th days of their COVID-19 infection, all selected patients were received remdesivir, intravenous steroids and plasma exchange to treat their COVID-19 infection and clinically improved. During 1-3 weeks of the treatment their noticed left-sided tinnitus and SSNHL. They all had no previous ear pathology. Results On ear examination external auditory canal canals and tympanic membranes are normal, were found negative Rinne's test on left side and Weber's test lateralising to the opposite side, tympanogram type A, no acoustic reflexes on left ear. When performed laboratory tests after 2 months of post-onset of SSNHL in all patients were found a positive COVID-19 IgG antibodies which showing initial time of SSNHL incidence. Such as, was not found any other risk factors for evolving SSNHL except Covid-19, so we came to conclusion, that the patient's SSNHL is complication of COVID-19 infection and probably this infection can cause unilateral intralabyrinthine or intracochlear hemorrhage, damages the inner ear's delicate hair cells and/or the blood supply.

COVID-19 Associated Guillain-Barre Syndrome: Comparing Six Cases of This Rare Presentation

Objective: In this case series, we present six cases of GBS in the setting of SARS-CoV-2 infection seen at our institution. Case 1/2: 88 and 80 year old females who both presented with ascending weakness and sensory deficits and had diminished reflexes on examination. Both tested positive for SARS-CoV-2 infection prior to symptom onset. CSF and electrodiagnostic work up were only performed for the second case, which demonstrated albuminocytologic dissociation and severe acute polyradiculitis, respectively. Case 3: 57 year old male who presented with left facial weakness and asymmetric hemibody weakness with diffusely reduced reflexes. He tested positive for COVID-19 infection after symptom onset. CSF studies demonstrated albuminocytologic dissociation. Case 4/5: 45 and 37 year old females who both presented with bilateral facial and lower extremity weakness and reduced reflexes. Following SARS-CoV-2 infection, CSF evaluation in both cases revealed albuminocytologic dissociation. Electrodiagnostic evaluation in the second case demonstrated acute demyelinating polyradiculopathy. Case 6: 60 year old female who presented with right eye ptosis and right lower extremity weakness/numbness following upper respiratory symptoms. Tested positive for SARS-CoV-2 infection. CSF evaluation demonstrated albuminocytologic dissociation. Background: Severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), the virus implicated in the COVID-19 pandemic is associated with a range of respiratory symptoms as well as a wide range of neurological manifestations including Guillain-Barre syndrome (GBS). Design/Methods: NA Results: NA Conclusions: In all the presented cases, some degree of weakness was present. Four of the cases demonstrated cranial nerve involvement. In two of the six cases, MRI Brain imaging revealed subtle enhancement within the internal auditory canal. CSF studies were performed on five out of the six cases, which demonstrated albuminocytologic dissociation in all the cases. Electrodiagnostic evaluation was conducted on two cases and demonstrated severe polyradiculopathy in both cases.

A rare case of external ear canal stenosis caused by COVID-19-related arterial thrombosis.

Thrombosis is a characteristic symptom of coronavirus disease 2019 (COVID-19). Here, we present a case of external ear stenosis caused by arterial thrombosis after COVID-19 infection. To the best of our knowledge, this is the first report of external ear stenosis related to COVID-19. A 62-year-old man presented with left hearing loss. The patient had a history of hospitalization for COVID-19 treatment 11 months prior to visiting our hospital. He had been experiencing ear fullness and tinnitus after COVID-19 treatment. Physical examination revealed severe left external ear canal stenosis with a subcutaneous mass. Surgical removal of the subcutaneous mass was performed. Histopathological analysis revealed that a subcutaneous thrombosis caused the external ear canal stenosis. This case describes an unusual case of external ear canal stenosis after COVID-19. Clinical and pathological findings indicate that COVID-19 affected the external ear canal. In addition, histopathological results confirmed the formation of arterial thrombosis in the temporal bone region after COVID-19 treatment. This case shows the broad range of body sites that can be involved with thrombotic events with COVID including the subcutaneous tissue around the outer ear. This observation would be helpful in investigating or explaining the various otological symptoms of COVID-19.

Training in endoscopic ear surgery using the papaya petiole.

BACKGROUND: Endoscopic ear surgery is a game changer in the field of otology. Training in endoscopic skills is essential for ENT residents, and is especially important during the coronavirus disease 2019 lockdown period. In such difficult times, ENT residents and surgeons can undergo hands-on training using a papaya petiole, even within their homes. OBJECTIVE: Endoscopic ear surgery training can be carried out using a papaya petiole, enabling the practice of grommet insertion, tympanomeatal flap elevation and foreign body removal from the external auditory canal. This model does not need any laboratory setup. RESULTS AND CONCLUSION: The hollow structure of the papaya petiole model is very similar to that of the external auditory canal, making training in endoscopic ear surgery easy. Use of the model helps a beginner to train in endoscopic handling and microsurgical instrumentation, and improves depth perception. In addition, it does not require high-end facilities to store equipment or undertake the training at any given point in time.

Assessment of SARS-CoV-2 in the Cerumen of COVID-19-Positive Patients.

OBJECTIVE: To evaluate the presence of SARS-CoV-2 virus in the cerumen of patients with COVID-19. METHODS: A prospective study was conducted in a tertiary care pandemic hospital. Sixty COVID-19 patients with cerumen in their external auditory canals were included in the study. Swabs were taken from the external auditory canal of the patients by an experienced otolaryngologist with the test swab. Sampling was done by rotating the sample swab 360° 10 times in each external auditory canal for a total of 20 times. After collection, swabs were placed into 2 mL of the sterile viral transport medium (various manufacturers), then transported and tested as soon as possible after collection. RESULTS: SARS-CoV-2 was not detected in the cerumen polymerase chain reaction (PCR) samples of any of the 60 patients with positive nasopharyngeal/oropharyngeal swabs. CONCLUSION: Cerumen cleaning is one of the most common procedures performed by otolaryngologists, and care should be taken during the procedure or due to the possibility of infection from the resulting contaminants. The cerumen contains the secretions of the glands in the external auditory canal and may contain certain pathogens that are actively found in the body. The presence of hepatitis B virus in the cerumen was examined and isolated in the cerumen. In our study, the presence of SARS-CoV-2 virus in the cerumen was evaluated in SARS-CoV-2 PCR-positive patients. SARS-CoV-2 virus was not detected in the cerumen samples of any of the patients.