New research reveals that tinnitus, a common condition that causes the perception of noise in the ear and head, is being exacerbated by COVID-19 – as well as the measures helping to keep us safe.
The study of 3,103 people with tinnitus was led by Anglia Ruskin University (ARU), with support from the British Tinnitus Association and the American Tinnitus Association.
The study involved participants from 48 countries, with the vast majority coming from the UK and the US.
Published in the journal Frontiers in Public Health, the research found that 40% of those displaying symptoms of COVID-19 simultaneously experience a worsening of their tinnitus.
Although the study focused on people with pre-existing tinnitus, a small number of participants also reported that their condition was initially triggered by developing COVID-19 symptoms, suggesting that tinnitus could be a ‘long COVID’ symptom in some cases.
Tinnitus affects an estimated one in eight adults in the UK and is associated with reduced emotional wellbeing, depression, and anxiety.
The new study also found that a large proportion of people believe their tinnitus is being made worse by social distancing measures introduced to help control the spread of the virus. These measures have led to significant changes to work and lifestyle routines.
UK respondents reported this to be a greater issue compared to people from other countries, with 46% of UK respondents saying that lifestyle changes had negatively impacted their tinnitus compared to 29% in North America.
Internal worries such as fear of catching COVID-19, financial concerns, loneliness and trouble sleeping have contributed to making tinnitus more bothersome for 32% of people overall, with external factors such as increased videocalls, noisier home environments, home schooling and increased coffee and alcohol consumption also cited by respondents.
Females and the under-50s found tinnitus significantly more bothersome during the pandemic.
The study noted that as well as increasing the severity of tinnitus symptoms, the COVID-19 pandemic has also made it more difficult for people to access healthcare support for the condition.
This could further increase emotional distress and worsen tinnitus symptoms, creating a vicious cycle. Before COVID-19, more than eight out of 10 UK patients were already unhappy with the treatment options available from their health professional.
Lead author Dr. Eldre Beukes, a Research Fellow at Anglia Ruskin University (ARU) in Cambridge, England, and Lamar University in Texas, said:
“The findings of this study highlight the complexities associated with experiencing tinnitus and how both internal factors, such as increased anxiety and feelings of loneliness, and external factors, such as changes to daily routines, can have a significant effect on the condition.
“Some of the changes brought about by COVID-19 appear to have had a negative impact on the lives of people with tinnitus and participants in this study reported that COVID-19 symptoms are worsening or, in some cases, even initiating tinnitus and hearing loss.
This is something that needs to be closely examined by both clinical and support services.”
David Stockdale, Chief Executive of the British Tinnitus Association and a co-author of the study, said: “With the second wave of COVID-19 and the resulting national lockdown likely to increase feelings of stress and isolation, it’s vital that we don’t see the same mistakes as before when it comes to community health provision for people with tinnitus.
“Poor treatment of tinnitus in the early stages often leads to much worse cases and severe tinnitus can have a huge impact on mental health.
With this in mind, as the COVID-19 second wave takes hold, the healthcare system needs to ensure that anyone who develops tinnitus or experiences a worsening of their condition can access the professional healthcare support they need as quickly as possible.”
Hearing loss following viral infection has been reiterated for years. Viral-induced hearing loss is known to cause from mild to profound hearing loss, either unilateral or bilateral, conductive or sensorineural type of hearing loss. Interestingly, the effects of hearing loss accruing viral infection differ greatly according to the type of virus.
Accordingly, hearing loss may occur ensuing a few postulations including direct or indirect damage to inner ear structures as well as host immune-mediated damage. Outcome of the hearing loss also varies greatly, as some viral infections are reversible with appropriate antiviral drugs.
The recent pandemic, severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), has opened a Pandora’s box of novel intriguing clinical manifestations that are being unfolded perpetually. Although respiratory, cardiologic, and gastrointestinal symptoms are the main focus, recently olfactory and gustatory symptoms have successfully made it to the list. Recent studies have unveiled neurotrophic and neuroinvasive characteristics possessed by the novel coronavirus.1
The notion of SARS-CoV-2 infection as a precursor of hearing loss has recently been lauded.2 This has ignited the search on the evidence available on the prevalence of hearing loss among patients infected with SARS-CoV-2.
Interestingly, a previous report on coronavirus discovered the involvement of brainstem, which could explain the auditory involvement.3 Myriad theories have been postulated on the mechanism of hearing loss following SARS-CoV-2 infection.
Among them, hematogenic transmission posits the basis of hearing loss in these groups of patients. Severe acute respiratory syndrome coronavirus 2 attaches to the hemoglobin via β chain, gaining entry into erythrocytes, which acts as a transporter ergo, infecting all tissues by binding to the surface receptor, angiotensin-converting enzyme 2 (ACE2).
As ACE2 has been reported to be abundant in the brain, medulla oblongata,4 and temporal lobe, the hearing center becomes affected, paving the way to hearing loss. Severe acute respiratory syndrome coronavirus 2 causes cytokine release once it binds to the surface receptor, ACE2.
Therefore, the hearing center becomes affected by the inflammatory mediators released upon binding to the surface receptors in the temporal lobe. Additionally, as SARS-CoV-2 deoxygenates the erythrocytes, possibility of hypoxia of the hearing center may lead to permanent damage, causing permanent hearing loss.
Another plausible hypothesis of hearing loss is ensuing reduced perfusion to the hearing organs due to ischemia.5 When ACE2 found in vascular smooth muscle becomes infected, and clot formation diminishes blood supply, thus causing ischemic damage, which may contribute to the hearing loss.
The elderly group, which has been the main target population of severe SARS-CoV-2 infection, is prone to hearing loss, especially following the ischemia theory. We postulate that the reason behind scantily reported cases on hearing loss among patients infected with SARS-CoV-2 is that the infected patients with hearing loss present in grave conditions require urgent resuscitation.
In the past, viral infection has been associated with sudden sensorineural hearing loss (SSNHL). Inflammation of the auditory pathway, including cochlear nerve, cochlea, and perilymphatic tissue, as well as cross-reaction between the antigens in the inner ear and virus have all been linked as the culprit in causing SSNHL.6
Additionally, indirect virus transmission from cerebrospinal fluid to the inner ear structures can also explain the cause behind SSNHL.7
Many reports have linked SARS-CoV-2 infection to a number of peripheral neuropathies; therefore, the possibility of impairment of transmission of auditory pathway is high among patients infected with SARS-CoV-2. Interestingly, recent articles on the association between Guillain-Barre syndrome (GBS) and SARS-CoV-2 infection have emerged.
While auditory spectrum neural disorder has been linked with GBS, immune-mediated complex accruing SARS-CoV-2 infection may lead to permanent hearing loss in these group of patients.8
The conductive element of the hearing pathway can become affected ensuing ascending infection from the nasopharynx, which could lead to fluid built behind the middle ear causing middle ear effusion. Initial presentation of SARS-CoV-2 infection with otalgia and tinnitus has been reported.9
A literature search of articles published in PubMed was conducted on July 7, 2020, using the following search terms: hearing loss, sensorineural hearing loss, SSNHL, conductive hearing loss, SARS CoV 2, and COVID 19 to investigate the association between hearing loss in SARS-CoV-2 infection.
A total of 7 articles were obtained, of which 3 cross-sectional study and 4 case reports (Table 1).2,9-14 A total of 35 patients with age ranging from 20 to 60 years were included. All patients included had hearing loss as a primary symptom and the accompanying symptoms were tinnitus, vertigo, and otalgia. The most common audiological test includes pure-tone audiometry, tympanometry, and otoacoustic emission. Interestingly, SSNHL was noted in 1 case,13 and 1 patient presented with acute otitis media revealed conductive hearing.9 None of the authors mentioned on the outcome of hearing loss. However, it is noteworthy, in 1 study cochlear implant was performed under local anesthesia in a patient who developed SSNHL.
Summary of Characteristics and Main Findings Included in This Study.
|Authors||Study design||Total patients||Age (range)||Gender||Laterality||Associated symptoms||Audiological test||Audiological finding||Treatment|
|- Type B tympanometry|
- Right mild-moderate CHL
Transient evoked OAE
|- High hearing threshold at 4 kHz|
- Lower transient evoked OAE amplitude
|Sriwijitalai and Wjwanitkit,2 Thailand||CR||1||N/A||F||N/A||N/A||N/A||N/A||N/A|
|Sun et al,11 China||CR||1||38||M||Both sides||Tinnitus||Tympanometry||N/A||N/A|
|Galougahi et al,12 Iran||CS||6||(20-40)||4 F|
|Pure-tone audiometry||High frequency SNHL||N/A|
|Kilic et al,13 Turkey||CS||5||(29-54)||M||3 Left|
|Degen et al,14 Germany||CR||1||60||M||Bilateral||Tinnitus||OAE||Left profound SNHL|
Right complete deafness
Left intratympanic triamcinolone
It is now important that hearing loss needs to be investigated among patients positive for SARS-CoV-2 infection and especially the patients who have recovered from SARS-CoV-2 infection as the possibility of permanent hearing loss cannot be ignored.
We would like to highlight on hearing loss as one of the clinical manifestations of SARS-CoV-2 infection, notably sensorineural hearing loss. Early detection of hearing loss is imperative as early intervention of viral-induced hearing loss has positive outcome. In the same vein, permanent hearing loss has been known to have detrimental effect on the quality of life of the affected individuals.
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More information: Eldré W. Beukes et al, Changes in Tinnitus Experiences During the COVID-19 Pandemic, Frontiers in Public Health (2020). DOI: 10.3389/fpubh.2020.592878