Letter to Editor on "Acute Lagophthalmos Due to Bell's Palsy Could Be a Sign of COVID-19" by Ibrahim Ozdemir et al.

We read with enormous attention the paper by Ozdemir et al. highlighting the possibility of an association between severe acute respiratory syndrome coronavirus-2 (SARS-CoV-2) and lagophthalmos due to Bell’s palsy (BP). We are grateful for the views of the authors to encourage discussion on significant aspects of clinical manifestations of coronavirus infection (COVID-19). As a result, we wish to present some of our comments related to this valuable article. First of all, clinical symptoms and signs of central nervous system (CNS) and peripheral nervous system (PNS) involvement can be detected in up to 25% of coronavirus infected patients. Some researchers suggest the term ”Neuro-COVID syndrome” for presentations with pure CNS and PNS involvement at onset. Based on the iterature, there are more than 21 clinical manifestations of neurological disorders in these patients. Some authors believe that there is an association between COVID-19 and BP due to a neuro-immunological process involving microbial and nerve antigens. Moreover, you can find an association between COVID-19 immunisation and BP in the literature. Another important problem in the management of patients with BP is the role of immunosuppressants like glucocorticoids. Can these medications lead to a flare up of hidden COVID-19 activity in infected patients? On the other hand, the data show that broad suppression of immune reactions during acute severe COVID-19 can be beneficial in higher risk patients using glucocorticoids. The authors concluded that lagopthalmos due to BP could be a sign of COVID-19. As a result, how we can treat the patients with both COVID-19 and BP? These questions may be answered in the future. In the end, the nature of the study, the narrow inclusion and exclusion criteria and the small sample size can be limiting. We once again appreciate the authors for this research and hope that our explanation will help this valuable journal’s readership.