Characteristic Changes in First-Visit Patients with Peripheral Facial Palsy before and during COVID-19 Pandemic: A Single Center Retrospective Study (preprint)

(1) Background: The COVID-19 pandemic has affected healthcare utilization rates on a global scale. This study aimed to analyze whether the COVID-19 pandemic affected the characteristics of first-visit patients with peripheral facial palsy visiting a Korean Medicine hospital and to observe characteristics changes in them. (2) Methods: This study analyzed the electronic medical records of 2,310 first-visit patients with peripheral facial palsy who visited the Facial Palsy Center, Korean Medicine Hospital, Kyung Hee University Medical Center from January 1, 2019 to December 31, 2021 in terms of demographic characteristics, disease phase, residence locations, hospital visit route, and patient care type. (3) Results: There were significant relationships between the presence of the COVID-19 pandemic (i.e., before and during) and the number of patients by disease phase (p=0.043), residence locations (p=0.003), residence locations in Seoul (p=0.003), and patient care types (p=0.003). (4) Conclusions: There were several differences in characteristics of first-visit patients with peripheral facial palsy visiting a Korean Medicine hospital during COVID-19 pandemic in terms of demographic characteristics, disease phase, residence locations, residence locations in Seoul, and patient care types.

A case with prolonged headache after COVID-19 vaccination and later developed Bell's palsy.

PURPOSE: During COVID-19 pandemic, the authorization of emergent usage of new vaccine has raised suspicions and doubts about potential adverse events related to vaccination. Among the reported adverse events related to ChAdOx1/nCoV-19 vaccine, facial paralysis did not have an incident rate higher than natural occurrence like mRNA vaccines. However, temporal association between vaccination and facial palsy have been documented in several studies. Here, we report a case of an otherwise healthy 23-year-old Taiwanese female who experienced prolonged headache since the second day postvaccination and developed facial palsy on the tenth day. CASE REPORT: A 23-year-old Taiwanese female who was previously healthy experienced intermittent right side throbbing headache, general malaise, myalgia and fever. Headache, transient ear pain and right scalp numbness developed in the next few days but quickly resolved. On day ten after vaccination, signs of facial palsy on the right side of her face was noticed. The results of brain Magnetic Resonance Imaging (MRI) with contrast displayed no abnormality. Facial stimulation and blink reflex tests were compatible with right facial neuropathy. CONCLUSION: Reactivation of latent herpes virus has been suggested as one of the possible mechanisms underlying the phenomenon, but the causal pathophysiology related to the symptom needs further validation. Moreover, in the event of facial palsy post-vaccination, alternative diagnoses such as Guillain-Barre syndrome (GBS), Ramsey-Hunt syndrome, Lyme disease, trauma, central nervous system infection (CNS) infection, or stroke should also be considered.

Facial Palsy Induced by Covaxin in Adolescent Female - A Rare Case Report.

BACKGROUND: The world has seen nearly 2 years of a pandemic caused by the SARS-CoV-2 virus, notoriously known as COVID-19. Several vaccines have been approved under Emergency Use Authorization (EUA) to combat the disease, one of which is Covaxin, an inactivated adjuvant SARSCoV- 2 vaccine that is generally well tolerated and has fewer side effects. However, we recently have seen a rare case of facial palsy (paralysis) following Covaxin vaccination in an adolescent girl. CASE PRESENTATION: A 16 years old adolescent girl presented with chief complaints of left side deviation of mouth with difficulty in closing right eye after 29 days of receiving the first dose of Covaxin, which was finally diagnosed as a "Covaxin induced facial palsy". Her symptoms were alleviated with some supportive measures, steroid and antiviral treatment, with full recovery. CONCLUSION: The case depicts facial nerve paralysis following Covaxin use, possibly the first of its kind. This case illustrates plausible explanation to Covaxin use and occurrence of facial palsy, however, further studies required to establish causal relationship.

Transient Bell's palsy following Covid-19 vaccination.

Bell's palsy is described as an acute, unilateral mononeuropathy of the facial nerve resulting in partial or complete paralysis of the face with no identifiable cause. Although facial palsy is often idiopathic, its development soon after the BB-152 Covid vaccine is exceedingly rare. We report a patient with transient acute-onset unilateral infranuclear facial palsy following vaccination, after an exhaustive work-up for other common causes was negative. With no detectable aetiology the likelihood of an association of the Covid-19 vaccine and Bell's palsy remains.

Intratemporal mucormycosis: a rare COVID-19 sequelae.

A man in his 50s presented with a 2-month history of left ear discharge associated with hearing loss and weakness of left half of face since 15 days. The patient had no comorbidities, but he gave history of being treated for COVID-19 pneumonia 2 months ago post which he started experiencing left-sided aural symptoms. Clinical examination of ear revealed a subtotal perforation with multiple granulations in middle ear. Facial nerve examination revealed grade 3 lower motor neuron palsy. The biopsy of the granulations was sent to aid in diagnosis which later confirmed left ear mucormycosis. Otological involvement with facial palsy and sudden sensorineural loss in a patient with prior history of COVID-19 has not been reported until in literature. We try to communicate our experience to bridge the gap in understanding and managing this extremely rare occurrence of mucormycosis in the ear of a patient diagnosed with COVID-19 infection.

Facial Palsy in COVID-19 Patient: A Case Report.

Facial paralysis is one of the common problems leading to facial deformation. COVID-19 virus rarely has been shown to be associated with facial palsy. Here we present a case of a 60-year-old woman who presented with features of left lower motor facial palsy signs along with common features suggestive of COVID-19 infection. Brain imaging did not reveal any pertinent pathology but her polymerase chain reaction for COVID-19 was positive. This case highlights the fact that acute COVID-19 infection can be considered a cause of motor neuron facial palsy in the ongoing pandemic of COVID-19. Cases with neurological features suggestive of facial palsy therefore should be suspected of acute COVID-19 infection based on other pertinent findings of COVID-19 infection and thus polymerase chain reaction testing should be done. Keywords: case reports; COVID-19; facial palsy.

Concurrent facial and trigeminal nerve palsies in a child following COVID-19 vaccination with the Pfizer vaccine.

We present the case of a teenaged boy who attended our Ear, Nose and Throat Emergency clinic with a left-sided lower motor neuron (LMN) facial nerve paralysis associated with sensory loss in the distribution of the ophthalmic (V1) and maxillary (V2) divisions of the trigeminal nerve. This happened 3 days following a first dose of the Pfizer-BioNTech BNT162b2 vaccine. He had a House-Brackmann grade V facial palsy, with marked inability to close the left eye. He was treated with a 10-day course of oral steroids and referred to ophthalmology for eye care. He had an MRI scan of the head, which revealed no space occupying lesions or other abnormalities. Over the 6-week period of follow-up, the patient's V1 and V2 sensation gradually resolved, along with improvement of his LMN facial nerve palsy to House-Brackmann grade 3. Despite the potential temporal relationship, it is not possible to establish a causal relationship between the patient's symptoms and the Pfizer-BioNTech BNT162b2 vaccine, thus further research is required.

Ischemic Stroke in a COVID-19-Infected Patient: A Case Report and Literature Review (preprint)

Ischemic stroke is a recognized neurological consequence of acute COVID-19 infection. A 61-year-old black African farmer with right-sided weakness was sent to the emergency hospital on September 19, 2022, within three hours of the onset of the impairment. He suffered a serious accident while working in the rural region fifteen years prior. Generalized body weakness, including weakness in the right upper and lower extremities while he was moving around, left facial paralysis, an inability to walk without assistance, difficulty swallowing, difficulty speaking, a two-day fever, a headache, and shortness of breath were all reasons why the patient was brought into the emergency room. An X-ray of the chest was taken, and it revealed scattered reticulations, coarse, somewhat bilateral crepitation, and diffuse bilateral infiltrates. The patient's cardiovascular checkup revealed nothing unusual. According to the Glasgow Coma Scale, the eye opening reaction was 1/4, the motor response was 3/6 (abnormal flexion), and the verbal response was 3/5 (inappropriate words). He started having trouble breathing and needed five intranasal doses of oxygen per minute to stay saturated. He began taking 81 mg of low-dose aspirin every day for a month. For ten days, he took 75 mg of clopidogrel orally once every day.

Hypoglossal nerve palsy after SARS-CoV-2 vaccination - report of two cases.

BACKGROUND: SARS-CoV-2 vaccination is associated with an increased risk for Bell's palsy and some other neurological disorders assumed to be of autoimmune origin. While facial nerve palsy is frequent and usually idiopathic, hypoglossal nerve palsy is rare, and a specific cause is almost always found. We firstly report two patients who developed isolated hypoglossal nerve palsy shortly after SARS-CoV-2 vaccination. CASE PRESENTATION: Two otherwise healthy patients, a 49-year-old man and a 39-year-old woman, developed unilateral hypoglossal nerve palsy 10 and 7 days after the second SARS-CoV-2-vaccination (AstraZeneca and BioNTech/Pfizer), respectively. In both subjects, needle electromyography showed denervation and rarefication of motor units. CT, MRI, examination of blood and CSF as well as ENT exam were unremarkable. In both subjects symptoms gradually improved. CONCLUSION: Due to close temporal relationship, the absence of other etiologies, and spontaneous improvement we suspect the vaccination as the cause for hypoglossal nerve palsy in both patients. This is further supported by the rarity of isolated hypoglossal nerve palsies, especially in idiopathic cases. We suggest the addition of hypoglossal nerve palsy to the list of neurological injuries potentially caused by SARS-CoV-2 vaccination.

Multiple Sclerosis Presenting as Intracranial Hypertension in the Setting of COVID-19 Infection (preprint)

Background Multiple sclerosis (MS) and Idiopathic Intracranial Hypertension (IIH) occur more commonly in women of childbearing age. There is cerebral spinal fluid (CSF) altered dynamics in both diseases causing them to have similar presentation at times. Coronavirus disease 19 (COVID-19) have also been reported to affect the Central Nervous System (CNS) of any age.Case Presentation: We report A-19-year-old male who initially presented with headaches, and fever and was diagnosed with COVID-19 infection. A few days later, he developed acute severe left eye pain, blurred vision, diplopia, and left ear tinnitus. The patient was found to have reduced visual acuity, left sixth nerve palsy, esotropia and asymmetric bilateral papilledema. Later, he developed left facial nerve palsy. MRI of the brain showed extensive demyelinating lesions. Lumbar puncture revealed significantly increased intracranial pressure (ICP) and positive oligoclonal bands.Conclusion This is a unique case of MS presenting with intracranial hypertension (IH) in the setting of COVID-19 infection that could have been the trigger for the MS clinical attack.

Bell's Palsy Following SARS-CoV-2 Vaccines: A Systematic Review and Meta-Analysis (preprint)

Background and Objective Bell's palsy (BP) has been considered as a serious adverse event following the SARS-CoV-2 vaccination. Many studies have reported BP following vaccination, although neither a causative relationship nor a prevalence of the condition higher than the general population has been established. The outcomes of interest were to compare BP incidence among (a) SARS-CoV-2 vaccine recipients, (b) nonrecipients in the placebo or unvaccinated cohorts, (c) different types of SARS-CoV-2 vaccines, and (d) SARS-CoV-2 infected vs. SARS-CoV-2 vaccinated individuals. Methods We performed a systematic search through MEDLINE (via PubMed), Web of Science, Scopus, Cochrane library, and Google Scholar from the inception to August 15, 2022. We included articles reporting individuals receiving any SARS-CoV-2 vaccine in whom BP had occurred. Studies reporting facial paralysis due to etiologies other than BP were excluded. Random- and fixed-effects meta-analyses using the Mantel-Haenszel method were conducted for the quantitative synthesis. Newcastle-Ottawa scale (NOS) was used to assess the quality. The study was conducted in line with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guideline, and the protocol was registered with PROSPERO (CRD42022313299). Analyses were carried out using the R, version 4.2.1 (R package 'meta' version 5.2-0). Results Fifty studies were included, of which 17 entered the quantitative synthesis. First, pooling four phase-3 randomized controlled trials (RCT) indicated BP occurrence was significantly higher in SARS-CoV-2 vaccines (77, 525 doses) compared to placebo (66, 682 doses) (OR = 3.00, 95% CI = 1.10 - 8.18, I2 = 0%). Second, pooling nine observational studies of mRNA SARS-CoV-2 vaccine doses (13, 518,026) and matched unvaccinated individuals (13, 510,701) revealed no significant increase in the odds of BP in the vaccinated group compared to the unvaccinated group (OR: 0.70 (95% CI 0.42-1.16), I2=94%). The third meta-analysis suggested that post-vaccination BP among first dose Pfizer/BioNTech recipients (22,760,698) did not significantly differ from that in first dose Oxford/AstraZeneca recipients (22,978,880) (OR = 0.97, 95% CI = 0.82 - 1.15, I2 = 0%). According to the fourth meta-analysis, BP was significantly more commonly reported after SARS-CoV-2 infection (2,641,398) than after SARS-CoV-2 vaccinations (36,988,718) (RR = 4.03, 95% CI = 1.78 - 9.12, I2 = 96%). Conclusion Our meta-analysis suggests a higher incidence of BP among vaccinated vs. placebo groups. BP occurrence did not significantly differ between Pfizer/BioNTech and Oxford/AstraZeneca vaccines. SARS-CoV-2 infection posed a significantly greater risk for BP than SARS-CoV-2 vaccines.

A case report of unilateral cervical lymphadenopathy and multiple cranial neuropathies following mRNA-COVID-19 vaccination.

BACKGROUND: We report a rare case of ipsilateral multiple cranial neuropathy and ipsilateral lymphadenopathy following mRNA-COVID-19 vaccination. CASE PRESENTATION: A 41-year-old male visited our emergency room complaining of dysphagia and hoarseness that started a week after receiving COVID19 mRNA vaccination (in his right arm). During his hospitalization, he also complained of right side hearing loss and diplopia. Neurological examination depicted a right IV nerve palsy, ipsilateral facial paresthesia and peripheral facial paresis. Otorinolaryngological examination revealed right vocal cord paralysis. A brain magnetic resonance imaging showed enhancement of the right VII and VIII cranial nerves in the auditory canal. The lumbar puncture revealed increased protein concentration and lymphocytic pleocytosis in the cerebrospinal fluid (CSF). Additionally, a neck computed tomography (CT) scan showed a swollen right supraclavicular lymph node. We hypothesize that the ipsilateral cranial neuropathies of IV, VI, VII, VIII and X, associated with cervical lymphadenopathy, was possible caused by a post-vaccination immune-mediated reaction. The patient was treated with a 5-day course of intravenous methylprednisolone (1000 mg/day), and a gradual improvement was observed. CONCLUSIONS: Similarly, to other vaccines, it is possibly that also mRNA vaccines may act as triggers of non-specific autoimmune neurological syndromes.

A case of Miller Fisher syndrome with delayed onset peripheral facial nerve palsy after COVID-19 vaccination: a case report.

BACKGROUND: To prevent the spread of the novel coronavirus disease 2019 (COVID-19) infection, various vaccines have been developed and used in a large number of people worldwide. One of the most commonly used vaccines is the mRNA vaccine developed by Moderna. Although several studies have shown this vaccine to be safe, the full extent of its side effects has not yet been known. Miller-Fisher syndrome (MFS) is a rare condition that manifests ophthalmoplegia, ataxia, and loss of tendon reflexes. It is a subtype of Guillain-Barré syndrome and an immune-mediated disease related to serum IgG anti-GQ1b antibodies. Several vaccines including those for COVID-19 have been reported to induce MFS. However, there have been no reports of MFS following Moderna COVID-19 vaccine administration. CASE PRESENTATION: A 70-year-old man was referred to our hospital due to diplopia that manifested 1 week after receiving the second Moderna vaccine dose. The patient presented with restricted abduction of both eyes, mild ataxia, and loss of tendon reflexes. He was diagnosed with MFS based on his neurological findings and detection of serum anti-GQ1b antibodies. The patient was administered intravenous immunoglobulin, and his symptoms gradually improved. Five days after admission, the patient showed peripheral facial paralysis on the right side. This symptom was suggested to be a delayed onset of peripheral facial nerve palsy following MFS that gradually improved by administration of steroids and antiviral drugs. CONCLUSION: There have been no previous reports of MFS after Moderna COVID-19 vaccination. This case may provide new information about the possible neurological side effects of COVID-19 vaccines.

Bilateral facial palsy with paresthesias, variant of Guillain-Barré syndrome following COVID-19 vaccine: A case series of 9 patients.

Several cases of Guillain-Barré Syndrome (GBS) associated with COVID-19 vaccination have been reported, including the rare subtype known as Bilateral Facial Palsy with paresthesias (BFP). To date, it is not known whether a causal relationship may exist between the two. We report 9 cases of BFP in patients vaccinated against COVID-19 in the previous month. Nerve conduction studies revealed demyelinating polyneuropathy in 4 patients, and 5 presented bilateral, focal facial nerve involvement, exclusively. Ganglioside antibody panel was positive in 4 patients (anti-GM1=2, anti-GD1a=1 and anti-sulfatide=1). Seven patients received intravenous immunoglobulin treatment, one plasma exchange, and one patient died from sudden cardiac arrest following arrhythmia before treatment could be administered. Rates of BFP following COVID-19 vaccination, did not differ from those reported in previous series. Epidemiological studies are essential to determine whether a causal relationship may exist between this rare form of GBS and COVID-19 vaccination.

Epidemiology, clinical features, and treatment modalities of facial nerve palsy in COVID-19 patients: a systematic review.

BACKGROUND: Coronavirus disease 2019 (COVID-19) is responsible for a wide variety of multi-system clinical features. Facial nerve palsy (FNP) is identified as one of the neurological complications of the virus. This work aims to systematically review the clinical picture, laboratory/imaging findings, treatment options, and prognostic factors of FNP in COVID-19 patients. METHODS: Using six online databases, a search was conducted to include all articles with patients infected with COVID-19 and presenting with unilateral or bilateral FNP. Screening for eligibility and data extraction were done by three and four independent reviewers, respectively. Descriptive analyses and data visualizations were done using Google Sheets. Survival analysis and Kaplan-Meier plotting were done by R software. RESULTS: The data from 22 studies included 32 patients who were infected with COVID-19 and presented with clinical features of FNP. Fourteen patients were male while 18 were female. FNP affected 29 patients unilaterally and 3 patients bilaterally. The imaging findings confirmed that complications of FNP were COVID-19 related. Additionally, antivirals combined with steroids had the lowest median time (21, IQR = 8) to clinical improvement compared to steroid-only (30, IQR = 15) and antiviral-only (33, IQR = 3.5) treatments. CONCLUSION: This study has shown a potential correlation between the increased incidence of FNP and COVID-19. We have also found that combining antivirals with steroids may have better outcomes in patients with FNP and COVID-19 although the evidence to support this claim is not strong enough. Further studies are required to assess the extent of linkage between the two conditions and how to properly manage FNP when encountered in COVID-19 patients.

Delayed Acute Perimyocarditis and Bilateral Facial Nerve Palsy in a Patient with COVID-19.

A 41-year-old Japanese man was admitted to our hospital with acute perimyocarditis 4 weeks after coronavirus disease 2019 (COVID-19) infection. Ten days after admission, the patient showed bilateral facial nerve palsy in the course of improvement of perimyocarditis under treatment with aspirin and colchicine. After prednisolone therapy, perimyocarditis completely improved, and the facial nerve palsy gradually improved. Acute perimyocarditis and facial nerve palsy can occur even 4 weeks after contracting COVID-19.