Idiopathic Facial Paralysis- A Covid-19 Induced Psycho-Social Impact

Clinical update: Bell palsy is a diagnosis of exclusion

A temporal association with pandemic stress, COVID-19 infection or vaccination does not prove that any one factor caused an individual episode. Sudden unilateral facial weakness needs prompt medical assessment to exclude stroke, infection, trauma, tumour and other neurological causes. Evidence-based guidance supports eye protection when closure is impaired and, for appropriate adults, oral corticosteroids started within 72 hours; antiviral treatment alone is not recommended, while adding an antiviral may be considered selectively. Dental professionals should recognise red flags and refer rather than diagnose causation from stress.

Covid-19 and the existing nervousness

Covid-19 related lockdowns were observed in many countries. These lockdowns created mental instability, with most of the population experiencing a loss of career or livelihood. Due to the unexpected anxiety and stress, a case of idiopathic facial paralysis was discovered in France. Rare cases of the same, as a temporary after effect of the Covid vaccine, has also been reported in a few countries.

Facial Paralysis & Covid-19

A 49 year old French chef, on April 6th 2020, suffered painless acute right facial paralysis condition mainly due to the unrest in his professional career, which before the pandemic was very much in an excellent condition. On physical examination, the patient showed a complete right sided peripheral facial paralysis with House- Brackmann classification showing grade V impairment. The patient’s consciousness and motor coordination were excellent. There were no signs of ataxia and other neurological disturbances. The patient was given a diagnosis of idiopathic facial paralysis, as he had mentioned a similar type of temporary episode few years back, and advised Prednisone 1mg/kg daily single dose with Valaciclovir, 1000mg thrice daily for ten days. The patient was continuously followed up and he presented with severe symptoms of right sided pressing occipital and hemicranial pain from past 5 days with pericranial tenderness and trigger points over right trapezius muscles, indicating an episodic tensional type of an headache. It was managed by Codeine. Patient also had sudden episodes of psoriatic episodes over the arms. The facial paralysis did not seem to show any improvements. Further on discussion, patient revealed severe anxiety associated with his diminishing career because of Covid-19 pandemic. He was surely going to lose his employment due to the lockdown implementation post pandemic, and was extremely uncertain about his future aspects.

About Bell’s Palsy

The inflammation of the fallopian canal, a small bony tube enveloping the facial nerve, leads to a clinical condition known as Bell’s palsy. Seventh Cranial nerve is situated inside an extremely narrow canal, thereby the condition basically develops due to compression of the nerve. The face consists of fascia, facial muscles and subcutaneous tissues. The facial muscles have their origin from different site and most of the facial muscles get their nerve supply from the facial nerve. the muscles of facial expressions directly insert into the facial skin therefore contraction of these muscles will move the skin. Bell’s palsy is a temporary condition that restricts the nerve impulses transmission from the muscle to the brain, causing muscle weakness or paralysis. The facial muscles, unlike other skeletal muscles, do not go for permanent atrophy even after years of lack of function. The VII cranial nerve is a part of cranial nerve which are dispersed over the face. Hence it is very clear that only it being non functional will not affect the action or moving of the facial muscles as these muscles, will be controlled by other cranial nerves.

Causes of Bell’s Palsy

• Herpes simplex viral infection : It was in 1970, Dr Kedar Adour suggested HSV to be associated with Bell’s Palsy. In 1995, Dr Shingo Murakami pointed HSV to be the main leading factor for the development of Bell’s Palsy.
• Other viral links : Research has also shown the association of Cytomegalovirus, Epstein Barr, rubella and mumps virus with Bell’s palsy.
• HIV/AIDS : HIV can lead to the development of facial paralysis, thereby increases the chances of Ramsay Hunt syndrome and Bells Palsy.
• Bacterial infections : Lyme Disease and Otitis media can cause facial paralysis and presents with similar symptoms of Bells Palsy.
• Melkersson Rosenthal syndrome: This condition may result in unilateral or bilateral facial paralysis.
• Other causes: Facial wounds, trauma due to blunt objects, acoustic neuroma, skull bone fractures especially temporal bone, brain stem injuries, lupus, Sjogrens syndrome, Diabetes etc.

Clinical symptoms of Bell’s palsy

The onset of Bell’s palsy is sudden but symptoms can worsen during the early period. Its symptoms may be in peak within few days, but it may take as long as two weeks in few individuals. If the paralysis becomes slowly visible, then tests for other conditions needs to be done. Psychologically, the condition will show a devastating situation, particularly with patients showing longer clinical period of the disease. Family, friends and doctor may have no clue that the affected patients may be deeply saddened because of lost self esteem. Symtoms include -

• Muscles show weakness and paralysis, forehead wrinkles disappear.
• Overall droopy appearance of the eye lid shows difficulty to blink.
• Stuffy nose
• Difficulty to speak, eat and drink
• Pain in the ear or drooling
• Sensitivity to noise (hyperacusis)
• Excessive or reduced salivation with altered taste sensation
• Difficulty to close the eyelids with lack of tears
• Sensitivity to light

Following these clinical symptoms, a patient with Bells palsy will recover spontaneously from the disease within three months with no physical treatment delivered.