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 Table of Contents  
Year : 2022  |  Volume : 7  |  Issue : 1  |  Page : 14-18

Tinnitus: A morbid clinical entity in COVID-19 patient

Department of Otorhinolaryngology and Head and Neck Surgery, IMS and SUM Hospital, Siksha “O” Anusandhan University, Bhubaneswar, Odisha, India

Date of Submission02-Aug-2021
Date of Decision15-Oct-2021
Date of Acceptance19-Nov-2021
Date of Web Publication27-Jun-2022

Correspondence Address:
Dr. Santosh Kumar Swain
Department of Otorhinolaryngology and Head and Neck Surgery, IMS and SUM Hospital, Siksha “O” Anusandhan University, K8, Kalinga Nagar, Bhubaneswar - 751 003, Odisha
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/bjhs.bjhs_87_21

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Coronavirus disease-2019 (COVID-19) is a highly infectious respiratory disease caused by the severe acute respiratory syndrome-coronavirus-2 (SARS-CoV-2), which result in plethora of health implications. The COVID-19 epidemic has impacted the lives of millions of people worldwide, wreaking havoc on health-care delivery, economic activity, and social connection. Although the majority of COVID-19 patients have respiratory symptoms, some experience neurological manifestations. The impact of the SARS-CoV-2 infection on the cochlea is a novel presentation which is not explored to date. Because of the risk of COVID-19 infection spreading from person to person, the majority of countries implemented social distancing and suggested people for home isolation. Social distancing and stay home protocol inducing stress and depression because of social isolation. Tinnitus has been documented in COVID-19 infection. However, tinnitus is not properly investigated in COVID-19 patients. Viral infections usually cause intracochlear damage and result in auditory dysfunction. Presently, there is little evidence for the direct relation of novel coronavirus and tinnitus. Tinnitus and hearing loss are important inner ear manifestations are reported in different literature which is considered morbid clinical entity in the present COVID-19 pandemic. This review article discusses details of this epidemiology, etiopathology, assessment, and management of tinnitus among patients with SARS-CoV-2 infection.

Keywords: Cochlea, COVID-19, hearing loss, SARS-CoV-2 infection, tinnitus

How to cite this article:
Swain SK. Tinnitus: A morbid clinical entity in COVID-19 patient. BLDE Univ J Health Sci 2022;7:14-8

How to cite this URL:
Swain SK. Tinnitus: A morbid clinical entity in COVID-19 patient. BLDE Univ J Health Sci [serial online] 2022 [cited 2022 Aug 14];7:14-8. Available from: https://www.bldeujournalhs.in/text.asp?2022/7/1/14/348281

Coronavirus disease-2019 (COVID-19) infection is caused by the severe acute respiratory syndrome-coronavirus-2 (SARS-CoV-2).[1] Clinical presentations of COVID-19 patients vary from mild upper airway symptoms to acute respiratory distress syndrome (ARDS) along with fever, body ache, cough, hyposmia, and taste disturbances.[1] The length of clinical symptoms ranges from acute (up to 4 weeks), continuing (4 to 12 weeks), and long COVID (lasting more than 12 weeks).[2] The COVID-19 patients may present with neurological symptoms along with respiratory problems. Up to 30% of COVID-19 individuals may experience neurological symptoms.[3] The neuroinvasive nature of SARS-CoV-2 is still being studied. The neurologic manifestations such as headache, impaired consciousness, and dizziness have been reported among COVID-19 patients.[4] Olfactory and taste disturbances are two neurological manifestations found in COVID-19 patients.[5] In addition to variety of clinical symptoms, some COVID-19 patients present inner ear manifestations such as dizziness, tinnitus, and otalgia.[2] Although there is increasing evidence of neurological manifestations in COVID-19 infection, neurotological symptoms such as tinnitus have been only marginally investigated in the current pandemic. Tinnitus is the impression of sound in the absence of an external or internal source, and it has a substantial impact on the patient's quality of life.[6] The involvement of cochleovestibular system by SARS-CoV-2 and stress in COVID-19 pandemic result in cochlear symptoms such as tinnitus.[7] The important diagnostic element of the patient with tinnitus is often by medical history data. There are no comprehensive epidemiological studies of tinnitus among COVID-19 patients, implying that these medical conditions are underresearched. The purpose of this review article is to go over the etiopathology, epidemiology, clinical symptoms, assessment, and management of tinnitus in COVID-19 infection in greater detail.

  Methods of Literature Search Top

We performed a literature search of tinnitus among COVID-19 patients from the database of PubMed, Scopus, Medline, and Google Scholar search with terms tinnitus, hearing loss, cochlear symptoms, and COVID-19 infections with cochleovestibular symptoms. We looked at a variety of recent works from national and international journals. All articles were read and analyzed, with relevant data being extracted. A flowchart of the selected articles is in [Figure 1]. This manuscript reviews the details of tinnitus among COVID-19 patients with its epidemiology, pathophysiology, clinical presentations, assessment, and its management. This review study will undoubtedly serve as a foundation for future prospective investigations on tinnitus in COVID-19 patients, which will aid in the prevention of this morbid clinical entity.
Figure 1: Flowchart showing method of literature search

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  Epidemiology Top

The World Health Organization declared the COVID-19 outbreak a global pandemic on March 11, 2020, following the fast spread of the SARS-CoV-2 virus.[8] Fever, headache, myalgia, dyspnea, loss of smell, taste, and auditory symptoms such as tinnitus, a morbid clinical entity reported in some patients with COVID-19 infection. The prevalence of cochleovestibular symptoms such as tinnitus in COVID-19 patients is still a topic of discussion.[9] The prevalence of tinnitus among COVID-19 patients is still very low. Tinnitus is claimed to affect anywhere from 6.6% to 18.6% of people.[10] The prevalence of tinnitus increases to around 30% in the age of 55 years and older.[11] Despite the significant incidence of tinnitus in the community, about a quarter of persons with the condition require treatment.[12] According to one study, the prevalence of tinnitus rises with age and peaks around 60 to 69 years old or 70 to 79 years old.[13] Tinnitus in COVID-19 individuals has been recorded in a few publications in the medical literature; however, there are no common characteristics. One study showed 7.6% of people infected with COVID-19 infection experiences hearing impairment, 14.8% suffered by tinnitus, and 7.2% presented vertigo.[14] However, the small hospital-based studies of tinnitus in COVID-19 hospital cannot provide accurate information for the prevalence of such clinical entity.

  Etiopathology Top

Viral infections often cause sensorineural hearing loss, the majority of them typically involve/damage the labyrinthine cells; however, few viruses can involve auditory brainstem.[15] COVID-19 infections are reported to be associated with otoneurological symptoms such as tinnitus and balance disorders.[9] The neurotrophic and neuroinvasive nature are the typical features of the SARS-CoV-2.[16] One study showed brain involvement by coronavirus infection and cause possible neuroauditory impairment.[17] The COVID-19 infection may directly affect the central nervous system or result vascular damage causing vasculitis to mimic mechanism for varicella-zoster and human immunodeficiency virus (HIV).[17] The vasculopathy of the COVID-19 infection can be direct features of hypercoagulability.[18] Moreover, the relationship with COVID-19 treatment by chloroquine or hydroxychloroquine which are known etiology for labyrinthine damage and result tinnitus.[19] COVID-19 infection has been shown to have negative effects on the outer hair cells of the cochlea in one research.[20] However, the lack of major cochlear symptoms does not imply that cochlear function is safe and healthy. The most common type of auditory system injury caused by viral infection is intracochlear; however, a few viruses can also cause auditory brainstem injury. Direct viral damage to the organ of Corti, stria vascularis, or spiral ganglion, injury mediated by the patient's immune system against virus expressed proteins (cytomegalovirus), and immunocompromised resulting in the secondary bacterial infection of the ear are some of the mechanisms behind peripheral auditory system injury (measles and HIV).[21]

  Tinnitus Following COVID-19 Vaccination Top

Tinnitus is rare following vaccination; however, it has been documented after rabies, hepatitis, measles, and H1N1 vaccines along with sensorineural hearing loss.[22] The tinnitus may occur following Pfizer vaccine against COVID-19 infection as well as another mRNA vaccine Moderna and the viral vector vaccine Vaxzevria by AstraZeneca are rare.[23] During Phase 3 trial of Pfizer, 0.03% of vaccine recipients reported tinnitus, but all of them were associated with risk factors such as hypothyroidism, hypertension, depression, prior history of tinnitus, allergic rhinitis, and medicine use.[23] A clinical presentation of tinnitus following COVID-19 vaccine and possible mechanism for its development is still not known. A hypersensitivity reaction may be responsible for pathogenesis, resulting in abnormal autoimmune response (mediated through circulating immune complexes or cytotoxic vestibulocochlear autoantibodies) or vasculitis event with subsequent localized injury to the cochlea).[24] Past history of atopy and autoimmune diseases may increase the chance of dysregulated autoimmune response. An immunization anxiety-related reaction may be postulated because anxiety has also been related to severity and persistency of tinnitus.[25]

  Stress in COVID-19 Pandemic and Tinnitus Top

The rapid spread of COVID-19 infection resulted in a global pandemic. To break the chain of transmission of this virus such as SARS-CoV-2, numerous regional lockdowns were enforced. These lockdowns reduced the social interactions in the community.[26] Although lockdowns reduced the spread of the virus, the restrictive measures resulted negative impact on well-being and affected the mental health of the general population.[27] People were instructed to stay at home, maintain social distance guidelines, and many places such as schools, offices, and recreational centers. Certain populations are highly affected in COVID-19 pandemic with negative impact on their life. The tinnitus has bidirectional relationship with stress. Stress aggravate tinnitus which is being initiated or exacerbated during stressful time like COVID-19 pandemic.[28] As tinnitus affect a person differently, the impact of pandemic on preexisting tinnitus in a person is not exactly known. One study showed the tinnitus was becoming worse in lockdown period of the COVID-19 pandemic.[29] The severity of tinnitus in COVID-19 pandemic is associated with stress of the patient, social isolation resulting grief, frustration, stress, and nervousness.

  Clinical Implication Top

As the COVID-19 pandemic is expected to stay for longer period, health or physiological, social, and emotional consequences are likely to last a long time. Those COVID-19 patients are socially isolated, lonely, and with poor quality sleep is at high chance of developing severe tinnitus. Patients with tinnitus often mention that they are neglected by health-care professionals by not recognizing the problems faced by hearing loss and tinnitus.[30] Tinnitus is much more unpleasant for females and those under the age of 50 years during the COVID-19 pandemic.[15] The factors which exacerbate tinnitus include self-isolation, experiencing loneliness, poor sleep, and decreased levels of physical exercises.[31] Anxiety, depression, and financial burden during the pandemic further contribute toward more bothersome of tinnitus. Several patients presented with tinnitus and hearing loss, with unilateral sensorineural hearing loss being the most frequently recorded.[15] Auditory symptoms in COVID-19 individuals have been recorded to resolve in some people and to linger in others for 6 to 7 months.[32]

  Assessment of Tinnitus Top

COVID-19 patients those were taken ototoxic medications such as hydroxychloroquine or chloroquine, should be evaluated with proper history taking because these medications have been linked to higher chance of hearing loss, tinnitus, and balance difficulties.[33] Hearing issues, such as the onset or exacerbation of tinnitus, should be observed in COVID-19 patients. Tinnitus is more likely to affect COVID-19 patients who are socially isolated, lonely, or have poor sleep. Before beginning an audiological inquiry, a thorough history must be taken, as well as otological and neurotological investigations, including tuning fork tests. Detail audiological assessments are required, which include tuning fork test, pure-tone audiometry, and tympanometry.[34] Pure tone audiometry testing and tympanometry by an audiologist in a soundproof room are helpful to rule out any hearing loss and tinnitus. In the current pandemic, pure tone audiometry and tympanometry should be performed with all safety measures for the COVID-19. Middle ear pathology and  Eustachian tube More Details are better assessed by tympanometry. Type-A tympanogram indicates normal middle ear. Type-C indicates eustachian tube dysfunction, and Type-B indicates fluids in the middle ear. The detailed evaluation of vertigo is evaluated by the proper history taking and different clinical tests for balance. Audiometric assessment should be done for intensity and frequency and of the tinnitus in patients with COVID-19 infections or post-COVID-19 patients. Otoacoustic emissions (OAEs) are a type of energy produced by the cochlea's outer hair cells. OAE may be spontaneous (SOAEs), evoked by transient stimuli such as clicks or tone bursts (TEOAEs). TEOAEs are not invasive tests and can be easily performed. This test needs lesser time, lesser cost, and higher sensitivity.[35] TEOAE may show reduced amplitude, which indicates subtle deterioration of the functions of the outer hair cell in the cochlea. As COVID-19 infection has deleterious impact on the outer hair cells of the cochlea affect low-frequency threshold in pure tone audiogram and also affect TEOAE and Distortion product otoacoustic emission (DPOAE) low-frequency amplitudes. The damaged outer hair cells of the cochlea are seen by decreased amplitude of the TEOAEs and DPOAEs. Magnetic resonance imaging is done to rule out any lesions in the brain and inner ear.

  Management of Tinnitus Top

The most effective treatment for COVID-19 infections is still being researched urgently. There are currently no randomized clinical trials demonstrating that a specific medication improves patient outcomes in COVID-19 infection.[36] It is always challenging for clinician to identify the etiology of COVID-19 infections for cochleovestibular symptoms such as tinnitus and start appropriate treatment to get maximum clinical recovery. During managing tinnitus, evaluation for thyroid function tests, lipid profile, hypertension, allergies, and factors inducing tinnitus such as mental stress, caffeine consumption, aspirin, and nicotine intake must be taken into consideration and managed.[37] The accurate treatment of tinnitus is yet to be developed because of its complex pathophysiology. Drugs such as lidocaine, antidepressants, benzodiazepines, and caroverine are tried and given some benefit for managing tinnitus. Gingko biloba is a common alternative medicine prescribed by several clinicians for the treatment of tinnitus.[20] Masking, tinnitus retraining therapy (TRT), amplification, and minimizing the triggering chemicals, as well as ambient factors, are all nonpharmacological therapeutic methods. Masking is a technique that uses an external sound to cover or partially mask tinnitus. TRT is more successful than masking since it incorporates counseling and sound generator therapy. Undoubtedly, the COVID-19 pandemic is interrupted the routine health-care service; however, cochlear symptoms such as tinnitus required intervention for curing such morbid clinical entity. Tinnitus in COVID-19 patients need urgent treatment otherwise, it causes depression or worse if untreated. Management of tinnitus in patients with COVID-19 infection is not properly described in the literature. Unknown etiology may be the cause for tinnitus in COVID-19 infections. The educational counseling is helpful for improvement of the tinnitus; however, such treatment is less effective in the current COVID-19 pandemic. The patient counseling is not sufficient for managing the stress and anxiety in COVID-19 pandemic, and anxiety is a known contributing factor for exacerbation or origin of tinnitus.[38] In COVID-19 pandemic, lifestyle modifications appear to be one of the risk factors for making tinnitus worse and conversely the greatest factor for betterment of tinnitus in some cases during the current pandemic. Self-made coping methods such as doing exercise in outdoors, relaxation, and spending time in outdoors are important techniques for the reduction of tinnitus and its distress during the pandemic. Meeting with family members and friends are common resources for reducing tinnitus during the current pandemic. Other resources which increase the coping include outdoors activities and spending time in nature. Exercises and relaxing mind are considered useful coping techniques during the pandemic. The intervention of tinnitus by incorporating relaxation and mindfulness by repeated relaxation and mindfulness reduce the tinnitus.[39] The attention is diverted by focusing on different activities for minimizing the severity of tinnitus.[39] Aggravation of tinnitus in social isolation can be managed by online-based cognitive behavioral therapy.

  Conclusion Top

Otoneurological symptoms such as tinnitus may be found in COVID-19 patients. The precise pathophysiological mechanisms resulting tinnitus remain unclear. Tinnitus in COVID-19 infection has been described as neurotrophic and neuroinvasive potentials of SARS-CoV-2 virus. More research is required to access the exact pathophysiology of tinnitus in patients with SARS-CoV-2 infection and persistence of symptoms even after this infection and also a need a high-quality study on large sample research to investigate the impact of COVID-19 infections toward audiovestibular system. On this emerging health issue, decision makers require timely evidence. Infection with COVID-19 will most likely teach us a lot about the long-term repercussions of this human-destructive disease. Further study is required to fully comprehend the etiopathogenesis of tinnitus in patients of COVID-19 infections.

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