Message for the clinic: what is the ‘take-home’ message for the
clinician?
covid 19 virus causes very frequent cranial nerve damage.
mostly only covid-19 treatment is sufficient for the regression of
symptoms.
some symptoms may last longer than 3 months.
Close follow-up of patients with cranial nerve involvement is important,
as there are no long-term covid 19 follow-up results.
Introduction:
The COVID-19 disease emerged in Wuhan province of China in November 2019
and spread across the world in a short time, resulting in a pandemic
(1). The first case in Turkey was detected
on March 11, 2020. Since then, the disease has continued to spread
rapidly, and the number of cases has increased in all provinces.
Coronaviruses are a large family of viruses that are seen as the
causative agent of a wide range of clinical symptoms from the common
cold to severe pneumonia, such as Middle East Respiratory Syndrome
(MERS-CoV) and Severe Acute Respiratory Syndrome (SARS-CoV). SARS-CoV2,
responsible for the COVID-19 disease, is considered to be the most
effective of this family of viruses, which has led to the ongoing
pandemic (2). Disease symptoms may vary
depending on the patient’s additional diseases and state of the immune
system (3). In previous studies, it was
shown that most of the symptomatic cases affected by this disease had
underlying comorbidities, such as diabetes, hypertension, and heart
diseases (4). However, studies conducted
to date have reported different rates for these comorbidities.
The incubation period of COVID-19 is around five days in the initial
stage of the disease, and although the most common complaints are fever,
cough, myalgia, headache, and joint pain, patients can also present with
many different symptoms, including taste and smell disorders, diarrhea,
and weakness. Complaints due to the involvement of different cranial
nerves are also observed in a significant number of patients.
Determining the distribution of these carnal nerve impairments according
to age, gender and complaints, and revealing the prevalence in infected
people can provide guidance in the combat against the disease.
In this context, we aimed to reveal the frequency and severity of
cranial nerve symptoms in COVID-19-positive patients that presented to a
pandemic hospital located in the Southeast Anatolia region in Turkey.
Material and Method:
After receiving the ethics committee approval of Harran University
(dated 15.06.2020 and numbered HRU/20.11.16), the data of 356 patients
with a positive polymerase chain reaction (PCR) test for COVID-19, who
received treatment in our hospital between June 2020 and August 2020
were prospectively evaluated. The only inclusion criterion was accepted
as PCR test positivity. Patients without a PCR test result or those with
a negative test result despite the presence of clinical and radiological
signs of COVID-19 were excluded from the study. The patients were
divided into two groups according to their clinical conditions: those
that presented to the hospital with complaints and had a positive PCR
result, and those that did not have any related complaint but were
detected to have a positive PCR result during routine screenings. In our
hospital, all nasopharyngeal swab samples have been being taken by
otorhinolaryngologists since the onset of the pandemic. In addition, all
physicians are assigned to work in hospital services and intensive care
follow-up. This allowed our study team to carry out the entire treatment
and evaluation process from the patients’ examination at the time of
presentation to discharge. All demographic characteristics of the
patients, namely age, gender, height, and weight, as well as
presentation complaints, examination findings, and hematological and
radiological data were evaluated. The patients were questioned in terms
of comorbidities (hypertension, heart diseases, diabetes mellitus,
asthma, and chronic obstructive pulmonary disease). Medical treatment
and maintenance treatments received by the patients during
hospitalization and after discharge were recorded. The duration of the
patients’ stay in hospital services and the intensive care unit, as well
as the recovery time of their symptoms were also evaluated by our study
team. Asymptomatic patients that were incidentally diagnosed with
COVID-19 by screening were only followed up. Symptoms that emerged
during the follow-up were evaluated and noted.
If the patients were PCR positive, they were routinely treated in the
hospital regardless of their complaints. During the treatment, all
cranial nerve examinations were performed by otorhinolaryngologists,
neurologists and ophthalmologists on the first day of hospitalization
and on the day of discharge. In order to increase compliance with
follow-up after discharge and to evaluate changes in complaints after
discharge, a survey form
consisting of yes/no 19 questions was administered to all patients
during and after hospitalization (Fig. 1). At the end of treatment, when
a swab was taken for the pre-discharge control PCR test, the patient was
examined again, and the same survey was used to evaluate the regression
of complaints or the emergence of new pathologies.. All patients who
were planned to be discharged at the end of the treatment were
discharged after the last cranial nerve evaluations by
otorhinolaryngologists, neurologists and ophthalmologists. The survey
was repeated on the 15th and 30thdays after discharge by telephone communication. The questions in this
survey inquired whether there was a change in the already known clinical
condition of the patient or whether a new complaint appeared. In case of
a newly developed pathology, the patient was called back to the hospital
for a re-examination. For the patients without any newly developed
pathological condition, the results of the survey were compared in
relation to the symptoms of the cranial nerves at the time of first
admission.
In all PCR-positive COVID-19 cases, the otorhinolaryngologists,
neurologists and ophthalmologists performed the individual examination
of the following nerves: olfactory (sense of smell), optic (visual
field, visual acuity, and pupil reflex), oculomotor (eye movement, pupil
reflex, and upper eyelid drooping), N. trochlearis (inward gaze
restriction), N. trigeminus (corneal reflex, facial hypoesthesia, nasal
mucosal hypoesthesia, weakness in masticatory muscles, and asymmetry or
weakness in jaw opening), N. abducens (lateral gaze restriction), N.
facialis (facial asymmetry, loss of taste, Schimmer’s test, corneal
reflex, and reduced salivation), (soft palate palsy, gag reflex,
swallowing functions, and dysphagia), N. vagus (laryngeal examination,
vocal cord movements, oculocardiac reflex, swallowing functions,
pharyngeal reflex, and hoarseness), N. accessorius (weakness in
abduction above 90 degrees of the arm, weakness in the
sternocleidomastoid muscle, and problems with the rotation of the head),
and N. hypoglossus (tongue movement disorder or weakness).
Since there was no excessive accumulation in our hospital due to the
pandemic being in the early stages, all cases with a positive PCR test
were hospitalized as per our health policy. For this reason, the
complaints that developed or regressed during both treatment and
hospitalization were closely monitored by examining each patient and
communicating with them personally.