key: cord-0744624-oh681a4v authors: Barron, David; Richards, Owen; Archer, Fleur; Abdelrazek, Mohamed; Ranjan, Rajesh; Omolokun, Omotakin title: A Cluster of Children with Facial Nerve Palsy in High Prevalence Area for COVID-19 date: 2021-08-08 journal: Public Health Pract (Oxf) DOI: 10.1016/j.puhip.2021.100173 sha: a1e7222ed41e96a161f0b8d6e98d7f9748125f74 doc_id: 744624 cord_uid: oh681a4v OBJECTIVES: COVID-19 is a disease of varying presentation and neurological sequelae of the disease are being studied. Following a cluster of paediatric facial nerve palsy (FNP) cases in an area of South Wales with a high prevalence of COVID-19, we conducted an opportunistic study to determine whether there has been an increase in incidence of FNP and if there is an association between the FNP and COVID-19 in children. STUDY DESIGN: A retrospective cohort study. Using the case series from 2020 and comparing it with previous years. METHODS: We reviewed the incidence of FNP between 2015-2020 across two hospitals within the health board. The incidence was compared with that in 2020 including a cluster of six children in 14 weeks, presenting to the Royal Glamorgan Hospital between June and October. RESULTS: There were 48 cases of children with FNP across both hospital within the study years. Seven (7) cases in 2020. The incidence was not statistically different in comparison to other years. Five out of six of these children in 2020 had antibody testing for COVID-19. All serology testing (100%) returned negative for SARS-CoV- 2 antibodies. In high prevalence area for COVID-19, cases of children with FNP have not shown a commensurate increase. we have found no causal link between COVID-19 and FNP in children. While this is a small study, larger cohort studies are needed to support this finding. CONCLUSION: As new strains of COVID-19 are being reported in UK, South Africa and Brazil, physicians need to continue to be vigilant for consistent pattern of signs and symptoms, especially in children. Infections with Covid-19 have passed 84 million cases with over 1.8 million deaths reported worldwide to date. 1 Whilst most patients experience mild symptoms or are asymptomatic 2 , there is emerging research of differing sequelae of the viral illness. Neurological syndromes have been associated with COVID-19 3 including anosmia, ageusia, Guillain Barré syndrome and encephalopathy 4 , facial nerve palsies (FNPs) 5, 6 and "long Covid". 7 As a group of medical students placed on a Paediatric Assessment Unit in Royal Glamorgan Hospital (RGH) Wales with the highest prevalence of in South Wales at the time (including remarkably high rates of intra-hospital transmission), we were surprised at the number of children presenting with FNP. According to the Paediatric team, this was not a common occurrence. We reviewed these cases to see if there had been a significant increase in the incidence of FNP in 2020 in comparison to previous years, and to see if cases were related to the Covid-19 pandemic as a neurological sequela of the infection. J o u r n a l P r e -p r o o f This was an opportunistic study conducted on the Paediatric ward of the RGH in Wales. A retrospective review of cases presenting with FNP between June and October 2020. The study was conducted in the Paediatric ward of the Royal Glamorgan hospital. All children between ages 0 to 16 years presenting with facial weakness was enrolled in the study. Each patient was diagnosed, treated, and followed up using the same systematic structure at different points in time. The diagnosis of FNP was made by two physicians grade Registrar and Consultant respectively who completed their assessments independently on two separate occasions. All attendee, regardless of presenting symptoms, were required to complete a Covid-19 health check questionnaire prior to assessment on the same day of referral. Children with high scores were offered Covid-19 testing. A clinical diagnosis of FNP was made in six children during a 14-week period. The severity of FNP was documented using the House-Brackmann score. Blood pressure checks and a full J o u r n a l P r e -p r o o f blood count were done as part of routine care before commencement of a weeklong course of steroid treatment following evidence-based guidelines. 8 All patients were followed up at one and four weeks to check for resolution of facial weakness and after gaining consent, antibody testing for Covid-19 was performed on five out of six of these children upon recall on the 15th or 16th of October 2020. Competing Aetiologies for FNP were explored during the history but ruled out using clinical judgement. Each patient was discharged the same day and advised to return for reassessment in 1 and 4 weeks. The incidence of FNP in 2020 was compared with previous years using statistical package Children with traumatic birth injuries causing palsy, and children with a secondary diagnosis like cerebral palsy, Chiari Malformation and other syndromes were excluded from the entries. There were 48 cases of FNP across both hospitals from the year 2015 to 2020. 30 in RGH and 18 in PCH, the distribution of cases across the two hospitals can be seen in figure 1.0 and patient demographics are detailed in Table 1 .0. Of the six cases in between June and October 2020 in RGH, a chi-squared test demonstrates that the change in incidence of FNP across the years is non-significant (p value = 0.263). In RGH, six patients were seen between June and October 2020. There was no history of pyrexial, headaches, sore throat, otalgia, or trauma. There were also no signs of an auricular rash. Consequently, both clinicians were satisfied with idiopathic facial nerve palsy as the diagnosis and further invasive investigations were deemed unnecessary and likely to cause unwarranted distress to the patients. All patients scored grade III or IV on the House Brackmann scale. On reassessment at 1 and 4 weeks, each patient's symptoms were resolving in keeping with the diagnosis of FNP. Two of the six children had Covid-19 testing during the episode of FNP, (not for symptoms but because policies changed to universal testing during the pandemic) both testing returned negative. One of the six children tested positive for Covid-19 three months after initial presentation with FNP and unlikely to be related. Five out of six children had antibody testing For Covid-19 performed on the 15th and 16th of October 2020, at least ten days after initial presentation with FNP. All serology testing There is extremely limited data in children to compare our finding with. To our knowledge this is the first cluster in children looking intently for a causal link to COVID-19. While asking for COVID-19 symptoms, it was difficult for the young to volunteer symptoms of loss of taste or sense of smell and similarly on questioning. Our sample size was small, but we were able to get antibody testing on five of these children. Some antibody tests were performed within the recommended 6-week waiting period, potentially allowing insufficient time for detectable immunoglobulin G SARS-CoV-2 antibodies to be produced. A prospective study could have allowed us to be more explorative in our quest to exclude other causes of FNP. Written consent was obtained from study participant. Written consent was obtained from parents for participation and publication. J o u r n a l P r e -p r o o f The datasets generated and/or analysed during the current study are not publicly available due [to protection of personal data and fairness.] but are available from the corresponding author on reasonable request. There is no conflict of interest. No funding was obtained for the study. FA contributed to the introduction and background information. DB contributed to the study design and methodology. MA contributed to the data analysis and interpretations. OR contributed to the literature search and discussions. RR contributed to the medical management, recruitment and obtaining of consent. OO contributed to the recruitment, formatting, editing and supervision of the study. All authors have read and approved the manuscript. We like to acknowledge the kindness and support of the entire paediatric staff of the Royal Glamorgan hospital during the study. J o u r n a l P r e -p r o o f Highlights. • At the peak of the pandemic, our counties had one of the highest rates of COVID-19 transmission in the UK. • We had a cluster of children with facial nerve palsy presenting during this peak. • We studied to see if there was a causal link between these cases and the COVID-19 pandemic. Albeit a reduction in hospital attendances and hospitalisations, our study found no increase in the incidence of Facial Nerve palsy in children in comparison to previous years. Our study found no causal link between COVID-19 and isolated Facial Nerve palsy in children. In a high endemic setting, neurological syndromes attributable to COVID-19 in children is extremely rare. With Novel strains of COVID-19 emerging, our finding could serve as a welcomed reassurance to the medical society that infection in children when present are mostly mild or without symptoms. COVID-19) Dashboard Clinical characteristics of COVID-19 in 104 people with SARS-CoV-2 infection on the Diamond Princess cruise ship: a retrospective analysis The emerging spectrum of COVID-19 neurology: clinical, radiological and laboratory findings Peripheral facial nerve palsy associated with COVID-19 Facial palsy during the COVID-19 pandemic Facing up to long COVID Clinical practice guideline: Bell's palsy Epidemiological and clinical characteristics of 99 cases of 2019 novel coronavirus pneumonia in Wuhan, China: a descriptive study Nervous system involvement after infection with COVID-19 and other coronaviruses Neurologic Manifestations of Hospitalized Patients With Coronavirus Disease Barré Syndrome Associated with SARS-CoV-2 Miller Fisher syndrome and polyneuritis cranialis in COVID-19 A Case Report of Acute Motor and Sensory Polyneuropathy as the Presenting Symptom of SARS-CoV-2. Clinical Practice and Cases in Emergency Medicine An overview of smell and taste problems in paediatric COVID-19 patients Anosmia and Ageusia: Not an Uncommon Presentation of COVID-19 Infection in Children and Adolescents Neurologic and Radiographic Findings Associated With COVID-19 Infection in Children Bell's palsy in a pediatric patient with hyper IgM syndrome and severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) Facial Nerve Paralysis Pearls & Oy-sters: Facial nerve palsy in COVID-19 infection Pneumonia with Facial Nerve Palsy and Olfactory Disturbance Neuromuscular Complications With SARS-COV-2 Infection: A Review Peripheral facial nerve palsy associated with COVID-19 A rise in facial nerve palsies during the coronavirus disease 2019 pandemic CLUSTER OF CHILDREN WITH FACIAL NERVE PALSY IN HIGH PREVALENCE AREA FOR COVID-19 Cwm Taf Morgannwg University Health Board, Paediatrics department, Royal Glamorgan Hospital, Ynysmaerdy Cwm Taf Morgannwg University Health Board, Paediatrics department, Royal Glamorgan Hospital, Ynysmaerdy CF 47 9DT. Email: omotakin@netscape.net Telephone M 2 2 3 2 3 3 1 3 1 4 2 1 F 2 2 3 3 1 4 2 0 1 1 1 1