To the Editor In the United States, COVID-19 has largely become a pandemic of the unvaccinated, and persistent vaccine hesitancy reflects lingering uncertainties. Concerns about vaccine-related Bell palsy are particularly relevant to otolaryngologists, who diagnose and treat facial paralysis, provide clarity for patients, explain etiologies, curate conflicting data, and offer guidance. Three recent articles expand our understanding of this question and invite challenging new questions.1-3

Tamaki and colleagues3 report the relative risk of new-onset or recurrent Bell palsy as 6.8 among unvaccinated patients with COVID-19 vs matched, vaccinated patients without COVID-19. Recurrence rate for Bell palsy after COVID-19 was 8.6% within 8 weeks, approximating lifetime recurrence. Were some cases simply persistent Bell palsy, rather than reactivation? Was facial palsy of other etiologies coded as Bell palsy? Administrative data carry risk of misclassification, but risk of acquiring Bell palsy with COVID-19 seems greater than risk of Bell palsy from vaccination.

Shemer and colleagues2 use a case-control design to analyze Israel’s experience with Bell palsy during a campaign where 92% of citizens aged 50 years or older were vaccinated in 73 days. Stable Bell palsy rates in the emergency department compared with prior years and no significant association between vaccination status and Bell palsy suggest that—at least for the Pfizer vaccine—vaccination does not significantly increase Bell palsy risk. How did Israel achieve near-universal vaccination? How can other nations catalyze similar public buy-in?

Chang1 reveals the challenges of pinning down the base rate of Bell palsy and places the previous studies into context, comparing data from the Centers for Disease Control and Prevention databases and other sources. After this detailed accounting, the key conclusion is less about Bell palsy and more about our fallible human nature. The author1 notes that risk of Bell palsy pales in comparison to the risk of illness and death posed by COVID-19. If our reaction to risk, and particularly vaccine hesitancy, is dictated more by instinct and emotion than logic and statistics, what is the way forward?

Although vaccine hesitancy has deep roots, progress can made through understanding cognitive biases,4 innumeracy, and the history of mistrust in medicine.5 Cognitive biases entice us to overweight emotionally resonant chance outcomes; innumeracy—sometimes worn as a badge of honor—can obscure understanding; and mistrust is a legacy borne of medical misdeeds still heavy on the nation’s collective conscience. By exemplifying honesty, transparency, and a sincere desire to share knowledge, we may improve public health during the current and future pandemics.

Corresponding Author: Michael J. Brenner, MD, Otolaryngology–Head & Neck Surgery, University of Michigan Medical School, 1500 E Medical Center Dr, 1903 Taubman Center, SPC 5312, Ann Arbor, MI 48104 (mbren@med.umich.edu).

Published Online: December 9, 2021. doi:10.1001/jamaoto.2021.3564

Conflict of Interest Disclosures: None reported.

2.Shemer  A, Pras  E, Einan-Lifshitz  A, Dubinsky-Pertzov  B, Hecht  I.  Association of COVID-19 vaccination and facial nerve palsy: a case-control study.   JAMA Otolaryngol Head Neck Surg. 2021;147(8):739-743. doi:10.1001/jamaoto.2021.1259PubMedGoogle ScholarCrossref 4.

Kahneman  D.  Thinking, Fast and Slow. New York, New York: Farrar Straus Giroux; 2011.