J Korean Med Sci.  2024 Apr;39(16):e140. 10.3346/jkms.2024.39.e140.

The Impact of the COVID-19 Pandemic on Bell’s Palsy and Ramsay-Hunt Syndrome: A Multicenter Retrospective Study

• Kwak MY
• Lee HY
• Lee SA
• Jeong J
• Chung JH
• Kim J
• Jun BC
• Yeo SG
• Kim SH
• Lee JD

• KMID: 2555476
• DOI: http://doi.org/10.3346/jkms.2024.39.e140

Abstract

Background
This article presents a comprehensive review of data on the impact of facial palsy during the coronavirus disease 2019 (COVID-19) pandemic. The possible causes and pathophysiological mechanisms of changes in the epidemiology of facial palsy during the COVID-19 pandemic are also discussed.
Methods
This multicenter retrospective cohort study included 943 patients diagnosed with Bell’s palsy or Ramsay Hunt syndrome. This study compared patient demographics, comorbidities, symptoms, and treatments before the COVID-19 pandemic (from 2017 to 2019) and during the COVID-19 pandemic, from 2020 to 2022).
Results
Following the COVID-19 outbreak, there has been a significant increase in the number of cases of Bell’s palsy, particularly among elderly individuals with diabetes. Bell’s palsy increased after the COVID-19 outbreak, rising from 75.3% in the pre-COVID-19 era to 83.6% after the COVID-19 outbreak. The complete recovery rate decreased from 88.2% to 73.9%, and the rate of recurrence increased from 2.9% to 7.5% in patients with Bell’s palsy. Ramsay Hunt syndrome showed fewer changes in clinical outcomes.
Conclusion
This study highlights the impact of the COVID-19 pandemic on the presentation and management of facial palsy, and suggests potential associations with COVID-19. Notably, the observed increase in Bell’s palsy cases among elderly individuals with diabetes emphasizes the impact of the pandemic. Identifying the epidemiological changes in facial palsy during the COVID-19 pandemic has important implications for assessing its etiology and pathological mechanisms of facial palsy disease.

Keyword

Bell’s Palsy; Ramsay Hunt Syndrome; COVID-19; Facial Palsy

Reference

1. World Health Organization. COVID-19 Weekly Epidemiological Update. Edition 150. Geneva, Switzerland: World Health Organization;2023.

2. Egilmez OK, Gündoğan ME, Yılmaz MS, Güven M. Can COVID-19 cause peripheral facial nerve palsy? SN Compr Clin Med. 2021; 3(8):1707–1713. PMID: 34056546.

3. Okuno T, Takada D, Shin JH, Morishita T, Itoshima H, Kunisawa S, et al. Surgical volume reduction and the announcement of triage during the 1st wave of the COVID-19 pandemic in Japan: a cohort study using an interrupted time series analysis. Surg Today. 2021; 51(11):1843–1850. PMID: 33881619.

4. Li X, Raventós B, Roel E, Pistillo A, Martinez-Hernandez E, Delmestri A, et al. Association between covid-19 vaccination, SARS-CoV-2 infection, and risk of immune mediated neurological events: population based cohort and self-controlled case series analysis. BMJ. 2022; 376:e068373. PMID: 35296468.

5. Codeluppi L, Venturelli F, Rossi J, Fasano A, Toschi G, Pacillo F, et al. Facial palsy during the COVID-19 pandemic. Brain Behav. 2021; 11(1):e01939. PMID: 33159420.

6. Tamaki A, Cabrera CI, Li S, Rabbani C, Thuener JE, Rezaee RP, et al. Incidence of Bell Palsy in patients with COVID-19. JAMA Otolaryngol Head Neck Surg. 2021; 147(8):767–768. PMID: 34165518.

7. Zammit M, Markey A, Webb C. A rise in facial nerve palsies during the coronavirus disease 2019 pandemic. J Laryngol Otol. 2020; 134(10):1–4.

8. Sevil E, Değer Kulaksiz B, Islamoglu A. Association between the inflammatory parameters and prognosis of Bell’s Palsy. NORTHWESTERN MEDICAL JOURNAL. 2021; 1(2):35–41.

9. Gupta KK, Balai E, Tang HT, Ahmed AA, Doshi JR. Comparing the use of high-dose to standard-dose corticosteroids for the treatment of Bell’s Palsy in adults-a systematic review and meta-analysis. Otol Neurotol. 2023; 44(4):310–316. PMID: 36706448.

10. Mutlu A, Kalcioglu MT, Gunduz AY, Bakici B, Yilmaz U, Cag Y. Does the SARS-CoV-2 pandemic really increase the frequency of peripheral facial palsy? Am J Otolaryngol. 2021; 42(5):103032. PMID: 33857779.

11. Aslan M, Çiçek MT. Can isolated sudden sensorineural hearing loss (SSNHL) and idiopathic acute facial paralysis (Bell’s Palsy) be symptoms of COVID-19? Am J Otolaryngol. 2021; 42(5):103129. PMID: 34214773.

12. Martin-Villares C, Alba JR, Gonzalez-Gimeno MJ. Data from 235 cases of Bell’s Palsy during COVID-19 pandemic: were there clusters of facial palsy? Neuroepidemiology. 2021; 55(6):495–496. PMID: 34515163.

13. Choi GW, Yon DK, Choi YS, Lee J, Park KH, Lee YJ, et al. Comparing the clinical manifestations of Bell’s Palsy between pre-COVID-19 pandemic and COVID-19 pandemic periods. J Clin Med. 2023; 12(4):1700. PMID: 36836235.

14. Nikolich-Žugich J. The twilight of immunity: emerging concepts in aging of the immune system. Nat Immunol. 2018; 19(1):10–19. PMID: 29242543.

15. Aviv-Sharon E, Aharoni A. Generalized logistic growth modeling of the COVID-19 pandemic in Asia. Infect Dis Model. 2020; 5:502–509. PMID: 32766462.

16. Shanshal M, Ahmed HS. COVID-19 and herpes simplex virus infection: a cross-sectional study. Cureus. 2021; 13(9):e18022. PMID: 34667693.

17. Bayani F, Hashkavaei NS, Arjmand S, Rezaei S, Uskoković V, Alijanianzadeh M, et al. An overview of the vaccine platforms to combat COVID-19 with a focus on the subunit vaccines. Prog Biophys Mol Biol. 2023; 178:32–49. PMID: 36801471.

18. Soeiro T, Salvo F, Pariente A, Grandvuillemin A, Jonville-Béra AP, Micallef J. Type I interferons as the potential mechanism linking mRNA COVID-19 vaccines to Bell’s Palsy. Therapie. 2021; 76(4):365–367. PMID: 33858693.

19. Nham E, Song JY, Noh JY, Cheong HJ, Kim WJ. COVID-19 vaccination in Korea: past, present, and the way forward. J Korean Med Sci. 2022; 37(47):e351. PMID: 36472087.

20. Zhang H, Sanchez Gomez D, Repajic M, Liu AK. Another case of Bell’s Palsy recurrence after Pfizer-BioNTech COVID-19 vaccination. Cureus. 2022; 14(7):e27422. PMID: 35910698.

21. Yu BY, Cen LS, Chen T, Yang TH. Bell’s Palsy after inactivated COVID-19 vaccination in a patient with history of recurrent Bell’s Palsy: a case report. World J Clin Cases. 2021; 9(27):8274–8279. PMID: 34621891.

22. Repajic M, Lai XL, Xu P, Liu A. Bell’s Palsy after second dose of Pfizer COVID-19 vaccination in a patient with history of recurrent Bell’s Palsy. Brain Behav Immun Health. 2021; 13:100217. PMID: 33594349.

23. Uysal HA, Güllüoğlu H. Comparison of facial palsy cases before and during the pandemic coronavirus disease-2019. Med J Bakirkoy. 2023; 19(2):156–162.

24. Nourazari S, Davis SR, Granovsky R, Austin R, Straff DJ, Joseph JW, et al. Decreased hospital admissions through emergency departments during the COVID-19 pandemic. Am J Emerg Med. 2021; 42:203–210. PMID: 33279331.

25. Lima MA, Silva MT, Soares CN, Coutinho R, Oliveira HS, Afonso L, et al. Peripheral facial nerve palsy associated with COVID-19. J Neurovirol. 2020; 26(6):941–944. PMID: 33006717.

26. Islamoglu Y, Bercin S, Aydogan S, Sener A, Tanriverdi F, Gunaydin GP, et al. Assessment of SARS-CoV-2 in the cerumen of COVID-19-positive patients. Ear Nose Throat J. 2021; 100(2 Suppl):155S–157S. PMID: 33054373.

27. Zhang J, Lu H, Zeng H, Zhang S, Du Q, Jiang T, et al. The differential psychological distress of populations affected by the COVID-19 pandemic. Brain Behav Immun. 2020; 87:49–50. PMID: 32304883.

28. Katz J, Yue S, Xue W. Herpes simplex and herpes zoster viruses in COVID-19 patients. Ir J Med Sci. 2022; 191(3):1093–1097. PMID: 34247308.

29. Xu R, Zhou Y, Cai L, Wang L, Han J, Yang X, et al. Co-reactivation of the human herpesvirus alpha subfamily (herpes simplex virus-1 and varicella zoster virus) in a critically ill patient with COVID-19. Br J Dermatol. 2020; 183(6):1145–1147. PMID: 32790074.

30. Peitersen E. Bell’s Palsy: the spontaneous course of 2,500 peripheral facial nerve palsies of different etiologies. Acta Otolaryngol Suppl. 2002; 122(549):4–30.

31. Katusic SK, Beard CM, Wiederholt WC, Bergstralh EJ, Kurland LT. Incidence, clinical features, and prognosis in Bell’s Palsy, Rochester, Minnesota, 1968–1982. Ann Neurol. 1986; 20(5):622–627. PMID: 3789675.

32. Kopitović A, Katanić F, Kalember S, Simić S, Vico N, Sekulić S. Bell’s Palsy-retroauricular pain threshold. Medicina (Kaunas). 2021; 57(3):263. PMID: 33805591.

33. Lee HY, Kim MG, Park DC, Park MS, Byun JY, Yeo SG. Zoster sine herpete causing facial palsy. Am J Otolaryngol. 2012; 33(5):565–571. PMID: 22445107.

34. Furuta Y, Ohtani F, Aizawa H, Fukuda S, Kawabata H, Bergström T. Varicella-zoster virus reactivation is an important cause of acute peripheral facial paralysis in children. Pediatr Infect Dis J. 2005; 24(2):97–101. PMID: 15702035.

35. Hato N, Sawai N, Teraoka M, Wakisaka H, Takahashi H, Hinohira Y, et al. Valacyclovir for the treatment of Bell’s Palsy. Expert Opin Pharmacother. 2008; 9(14):2531–2536. PMID: 18778190.

36. Chu WK, Lin KY, Sun HY, Chen YC, Cheng A. Herpes zoster aseptic meningitis and Ramsay Hunt syndrome in an immunocompetent young adult post mild COVID-19 - a coincidence? J Microbiol Immunol Infect. 2023; 56(5):1114–1115. PMID: 37147243.

37. Woo CJ, Chou OH, Cheung BM. Ramsay Hunt syndrome following COVID-19 vaccination. Postgrad Med J. 2022; 98(1164):738–739. PMID: 34987077.

38. Lakhoua G, Charfi O, Dabbeche S, Zaiem A, Kastalli S, Daghfous R, et al. An atypical Ramsey Hunt syndrome after covid 19 immunization. Therapie. 2023; 78(4):442–443. PMID: 36031436.

39. Hwang YS, Kim YS, Shin BS, Kang HG. Two cases of Ramsay-Hunt syndrome following varicella zoster viral meningitis in young immunocompetent men: case reports. BMC Neurol. 2023; 23(1):43. PMID: 36707826.