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.