key: cord-0905362-3kasid5c
authors: Au, Sunny Chi Lik
title: Facial nerve palsy: the importance of face mask and shield removal examination under the COVID-19 pandemic
date: 2022-04-05
journal: Vis J Emerg Med
DOI: 10.1016/j.visj.2022.101339
sha: ad39359dc70287276362fb4c8a1a454fa419a94b
doc_id: 905362
cord_uid: 3kasid5c

nan

A 94-year-old lady was referred to the ophthalmology clinic for eyelid problems. She complained of increased tearing over her right eye for few days without any pain. She was wearing a N95 face mask and a transparent face shield, which had an elastic forehead band and brow foam pad, upon her emergency attendance under the COVID-19 pandemic. Emergency physicians detected significant lagophthalmos over her right eye upon instructed lid closure, (Figure 1 ) thus referred her to ophthalmologist for further management. Patient's face shield and face mask were not removed for exam under the local Omicron outbreak, thus brow exam and face exam were omitted.

By removing the face shield and face mask, there was obvious loss of right sided forehead wrinkles, and failure to lift the right brow despite instruction. (Figure 2 ) She had bilateral dermatochalasis, but right lower lid ectropion was still obvious upon comparison with the left side. Going down the face, there was loss of right nasolabial fold, as compared to the left. And her right angle of mouth was drooping despite no drooling. Extraocular movement was full in all direction, without any evidence of other cranial nerve palsy. Patient has no recent trauma or previous surgery, and her hearing is not affected with normal otoscope findings. Palpation did not find any parotid gland swelling, and neuroimaging was normal. Idiopathic Bell's palsy was diagnosed by exclusion. Oral prednisolone was given upon discharge.

Under the COVID-19 pandemic, face mask, or even face shield, wearing is widely practiced among the public to prevent aerosols and droplet transmission of the SARS-CoV-2 viruses, especially with the Omicron variant. Hospital, particularly the emergency department, is treated as high risk area as there are potential COVID-19 patients; and full compliance with face mask upon arrival was suggested by authorities. Being an essential personal protective equipment, face mask and shield covered most of our faces to offer the protective effect. However, subtle but important clinical signs of the face may be missed without taking the face mask and shield off for physical examinations. In our case, examining the brow ptosis, loss of nasolabial fold and drooping of mouth angle are essential for diagnosis of facial nerve palsy. [1] Multiple Choice Questions Facial nerve palsy can present with lower lid ectropion and lagophthalmos due to weakness of the orbicularis muscles. If left unattended, it can progress to exposure keratopathy with secondary infection, especially on those eyes with poor Bell's reflex like in our case. Tight face mask wearing, e.g. N95 respirator, can sometimes pull out the lower lid to cause apparent lower lid ectropion, or even lagophthalmos. Weakness of facial muscles in 7 th nerve palsy leads to loss of nasolabial fold and drooling of saliva from angle of the mouth. Therefore, face mask removal examination under the COVID-19 pandemic is so important for diagnosing facial nerve palsy. 

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