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Andrade J, Sessa L, Ephrat M, Truong J, DiGregorio R. A Case Report of Sudden Sensorineural Hearing Loss (SSNHL) After Administration of the COVID-19 Vaccine. J Pharm Pract 2024; 37:753-757. [PMID: 36537083 PMCID: PMC9780564 DOI: 10.1177/08971900221147584] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022]
Abstract
Since the issuance of the emergency use authorization (EUA) of 3 coronavirus disease 2019 (COVID-19) vaccines, there have been over 180 million individuals fully vaccinated in the United States (US). With the increasing administration of COVID-19 vaccinations, there have been over 550,000 adverse events reported in the Vaccine Adverse Event Reporting System (VAERS) with approximately 230,000 experienced after receipt of the Pfizer-BioNTech COVID-19 Vaccine as of September 23rd 2021. Audio-vestibular symptoms (including Sudden Sensorineural Hearing Loss (SSNHL)) secondary to immunizations has previously been evaluated. However, this report describes the first case of bilateral sudden sensorineural hearing loss potentially due to the Pfizer-BioNTech COVID-19 vaccine. We further review the available literature regarding the treatment of Sudden Sensorineural Hearing Loss, and the association of SSNHL with previous immunizations and COVID-19 infection. Lastly, we hypothesize the underlying potential mechanisms between SSNHL and the Pfizer-BioNTech COVID-19 vaccine.
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Affiliation(s)
- Justin Andrade
- Department of Pharmacy Practice, Touro College of Pharmacy, New York, NY, USA
- Pharmacotherapy Department, The Brooklyn Hospital Center, Brooklyn, NY, USA
| | - Lauren Sessa
- ENT & Allergy Associates LLP, Lake Success, NY, USA
| | - Moshe Ephrat
- ENT & Allergy Associates LLP, Lake Success, NY, USA
| | - James Truong
- Pharmacotherapy Department, The Brooklyn Hospital Center, Brooklyn, NY, USA
| | - Robert DiGregorio
- Pharmacotherapy Department, The Brooklyn Hospital Center, Brooklyn, NY, USA
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Thai-Van H, Bagheri H, Valnet-Rabier MB. Sudden Sensorineural Hearing Loss after COVID-19 Vaccination: A Review of the Available Evidence through the Prism of Causality Assessment. Vaccines (Basel) 2024; 12:181. [PMID: 38400164 PMCID: PMC10892268 DOI: 10.3390/vaccines12020181] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/29/2023] [Revised: 02/07/2024] [Accepted: 02/10/2024] [Indexed: 02/25/2024] Open
Abstract
Sudden sensorineural hearing loss (SSNHL), a rare audiological condition that accounts for 1% of all cases of sensorineural hearing loss, can cause permanent hearing damage. Soon after the launch of global COVID-19 vaccination campaigns, the World Health Organization released a signal detection about SSNHL cases following administration of various COVID-19 vaccines. Post-marketing studies have been conducted in different countries using either pharmacovigilance or medico-administrative databases to investigate SSNHL as a potential adverse effect of COVID-19 vaccines. Here, we examine the advantages and limitations of each type of post-marketing study available. While pharmacoepidemiological studies highlight the potential association between drug exposure and the event, pharmacovigilance approaches enable causality assessment. The latter objective can only be achieved if an expert evaluation is provided using internationally validated diagnostic criteria. For a rare adverse event such as SSNHL, case information and quantification of hearing loss are mandatory for assessing seriousness, severity, delay onset, differential diagnoses, corrective treatment, recovery, as well as functional sequelae. Appropriate methodology should be adopted depending on whether the target objective is to assess a global or individual risk.
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Affiliation(s)
- Hung Thai-Van
- Department of Audiology and Otoneurological Evaluation, Hospices Civils de Lyon, 69003 Lyon, France;
- Institut Pasteur, Institut de l’Audition, 75015 Paris, France
- Faculté de Médecine, Université Claude Bernard Lyon 1, 69100 Villeurbanne, France
| | - Haleh Bagheri
- Department of Medical and Clinical Pharmacology, Centre Régional de Pharmacovigilance de Toulouse, CIC1436, Hôpital Universitaire de Toulouse, 31000 Toulouse, France;
| | - Marie-Blanche Valnet-Rabier
- Department of Clinical Pharmacology, Centre Régional de Pharmacovigilance et d’Information sur les Médicaments, Centre Hospitalier Universitaire de Besançon, 25000 Besançon, France
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Ammar H, Le Beller C, Bouccara D, Malinvaud D, Jouffroy R, Lillo-Le Louet A. Vestibular disorders following BNT162b2 mRNA COVID-19 vaccination: A retrospective case series. Fundam Clin Pharmacol 2024; 38:192-204. [PMID: 37473782 DOI: 10.1111/fcp.12942] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/27/2023] [Revised: 06/18/2023] [Accepted: 07/05/2023] [Indexed: 07/22/2023]
Abstract
BACKGROUND There are few publications regarding manifestations of vestibular disorders (VDs) following BNT162b2 mRNA COVID-19 vaccination. PURPOSE We describe cases of VD potentially related to BNT162b2 vaccination and calculate its reporting rate, in order to enlarge knowledge about this adverse effect. METHODS A retrospective analysis of cases of VD following BNT162b2 vaccination reported to the pharmacovigilance centre of Georges-Pompidou European Hospital (France), in 2021 was performed. In order to identify these cases from the pharmacovigilance database containing all our registered cases, we used the Standardised MedDRA Query (SMQ) 'vestibular disorders'. Then we analysed cases with vestibular symptoms, based on the association of typical manifestations. The reporting rate was calculated based on the number of VD cases and the number of vaccinated patients. RESULTS Among 6608 cases reported to our centre related to COVID-19 vaccines during 2021, 34 VDs associated with BNT162b2 administration were included. They were mainly reported in females (79%), 62% occurred after the first dose and 32% were serious. Symptoms had completely resolved in 13 cases (38%). Vertigo was the most common symptom followed by balance disorders. Three patients received second dose without reappearance of VD. The final diagnosis was reported in 10 patients (six cases of vestibular neuritis, two cases of central VD, two cases of benign paroxysmal positional vertigo). The regional reporting rate was 26 [95% CI: 17-34] cases of VD per 1 million persons vaccinated. CONCLUSION Although the relationship between vaccination and VD cannot be established, clinicians should be aware of this rare adverse effect.
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Affiliation(s)
- Helmi Ammar
- Pharmacovigilance Regional Centre, Hôpital Européen Georges Pompidou, AP-HP-Université Paris Cité, Paris, France
| | - Christine Le Beller
- Pharmacovigilance Regional Centre, Hôpital Européen Georges Pompidou, AP-HP-Université Paris Cité, Paris, France
| | - Didier Bouccara
- Service d'otorhinolaryngologie et de chirurgie cervico-faciale, Hôpital Européen Georges Pompidou, AP-HP, Université Paris Cité, Paris, France
- Unité CNRS UMR 8002, INCC - Integrative Neuroscience and Cognition Group, Université Paris Cité, Paris, France
| | - David Malinvaud
- Service d'otorhinolaryngologie et de chirurgie cervico-faciale, Hôpital Européen Georges Pompidou, AP-HP, Université Paris Cité, Paris, France
- Unité CNRS UMR 8002, INCC - Integrative Neuroscience and Cognition Group, Université Paris Cité, Paris, France
| | - Romain Jouffroy
- Intensive Care Unit, Ambroise Paré Hospital, Assistance Publique Hôpitaux Paris and Paris Saclay University, Paris, France
- Institut de Recherche bioMédicale et d'Epidémiologie du Sport - EA7329, INSEP - Paris University, Paris, France
- Centre de recherche en Epidémiologie et Santé des Populations - U1018 INSERM - Paris Saclay University, Paris, France
- EA 7525 Université des Antilles, Fort de France, France
| | - Agnès Lillo-Le Louet
- Pharmacovigilance Regional Centre, Hôpital Européen Georges Pompidou, AP-HP-Université Paris Cité, Paris, France
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Adhikari TR, Jamtsho S, Tenzin K, Wangchuk P, Tshering P, Jamtsho S, Mukhia S, Penjor D. Special Sensory Function Deficit among Patients with Post-COVID-19 Visiting a Tertiary Care Centre. JNMA J Nepal Med Assoc 2023; 61:874-877. [PMID: 38289741 PMCID: PMC10725220 DOI: 10.31729/jnma.8321] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/30/2023] [Indexed: 02/01/2024] Open
Abstract
Introduction Several patients who recover from COVID-19 infection continue to have persistent symptoms even after recovery from the disease. The special sensory functions such as taste, smell and hearing are affected by COVID-19 infection even after recovery from the illness. The aim of the study was to find out the prevalence of special sensory deficits among patients with post-COVID-19 visiting a tertiary care centre. Methods A descriptive cross-sectional study was conducted among adult patients who recovered from COVID-19 visiting a tertiary care centre from 1 January 2022 to 31 December 2022. After obtaining ethical approval from the Research Ethics Board of Health, data on patients who were diagnosed with COVID-19 one year ago was obtained from the surveillance register from the Ministry of Health. They were contacted by phone call and invited to the centre to participate in the study. Appropriate clinical examination and tests were carried out to assess the special sensory deficits. A convenience sampling technique was used. The point estimate was calculated at a 95% Confidence Interval. Results Among 271 patients, the prevalence of sensory function deficit was 39 (14.39%) (10.21-18.57, 95% Confidence Interval). Conclusions The prevalence of special sensory deficits after recovery from COVID-19 infections was found to be similar to the findings of other studies. Keywords anosmia; COVID-19; hearing loss.
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Affiliation(s)
- Tika Ram Adhikari
- Department of Otorhinolaryngology, Jigme Dorji Wangchuk National Referral Hospital, Thimphu, Bhutan
| | - Sonam Jamtsho
- Department of Otorhinolaryngology, Jigme Dorji Wangchuk National Referral Hospital, Thimphu, Bhutan
| | - Karma Tenzin
- Audiology Unit, Department of Otorhinolaryngology, Jigme Dorji Wangchuk National Referral Hospital, Thimphu, Bhutan
| | - Pelden Wangchuk
- Audiology Unit, Department of Otorhinolaryngology, Jigme Dorji Wangchuk National Referral Hospital, Thimphu, Bhutan
| | - Phub Tshering
- Department of Otorhinolaryngology, Jigme Dorji Wangchuk National Referral Hospital, Thimphu, Bhutan
| | - Sonam Jamtsho
- Department of Otorhinolaryngology, Jigme Dorji Wangchuk National Referral Hospital, Thimphu, Bhutan
| | - Sontosh Mukhia
- Department of Otorhinolaryngology, Jigme Dorji Wangchuk National Referral Hospital, Thimphu, Bhutan
| | - Dorji Penjor
- Department of Otorhinolaryngology, Jigme Dorji Wangchuk National Referral Hospital, Thimphu, Bhutan
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Aedo-Sánchez C, Gutiérrez G, Aguilar-Vidal E. COVID-19 and Vestibular Symptoms and Assessment: A Review. Audiol Neurootol 2023; 29:81-87. [PMID: 37703853 DOI: 10.1159/000533448] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/31/2022] [Accepted: 08/03/2023] [Indexed: 09/15/2023] Open
Abstract
BACKGROUND The current pandemic of COVID-19, caused by severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), has resulted in significant morbidity and mortality primarily associated with respiratory failure. However, it has also been reported that COVID-19 can evolve into a nervous system infection. The direct and indirect mechanisms of damage associated with SARS-CoV-2 neuropathogenesis could affect our sensory functionality, including hearing and balance. SUMMARY In order to investigate a possible association between SARS-CoV-2 viral infection and possible damage to the vestibular system, this review describes the main findings related to diagnosing and evaluating otoneurological pathologies. KEY MESSAGES The clinical evidence shows that SARS-CoV-2 causes acute damage to the vestibular system that would not leave significant sequelae. Recovery is similar to vestibular pathologies such as vestibular neuronitis and benign paroxysmal positional vertigo. Further basic science, clinical, and translational research is needed to verify and understand the short- and long-term effects of COVID-19 on vestibular function.
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Affiliation(s)
- Cristian Aedo-Sánchez
- Departamento Tecnología Médica, Facultad de Medicina, Universidad de Chile, Santiago, Chile
- Escuela de Tecnología Médica, Facultad de Medicina, Universidad de Chile, Santiago, Chile
| | - Gabriela Gutiérrez
- Escuela de Tecnología Médica, Facultad de Medicina, Universidad de Chile, Santiago, Chile
| | - Enzo Aguilar-Vidal
- Departamento Tecnología Médica, Facultad de Medicina, Universidad de Chile, Santiago, Chile
- Escuela de Tecnología Médica, Facultad de Medicina, Universidad de Chile, Santiago, Chile
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Gibson K, Ling JCC, Peters M. Experience of sudden sensorineural hearing loss following a mild COVID-19 infection. BMJ Case Rep 2023; 16:16/4/e252899. [PMID: 37055075 PMCID: PMC10105996 DOI: 10.1136/bcr-2022-252899] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/15/2023] Open
Abstract
A woman in her 30s was referred to an otolaryngologist with an acute onset of aural fullness, noise sensitivity, unilateral sudden onset hearing loss, vertigo and tinnitus. She had a confirmed COVID-19 infection 5 weeks prior. A pure tone audiogram confirmed sensorineural hearing loss. MRI identified an empty sella of the pituitary gland and without an obvious cause for hearing loss. Oral prednisolone and betahistine were prescribed, and her audiovestibular symptoms slowly improved over the subsequent months. The patient continues to experience intermittent tinnitus.
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Affiliation(s)
- Kim Gibson
- Rosemary Bryant AO Research Centre, UniSA Clinical and Health Sciences, University of South Australia, Hawthorn, South Australia, Australia
| | - John C C Ling
- Specialists on Goodwood, Adelaide, South Australia, Australia
| | - Micah Peters
- Rosemary Bryant AO Research Centre, UniSA Clinical and Health Sciences, University of South Australia, Adelaide, South Australia, Australia
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Klančnik M, Ivanišević P, Golec N, Vučemilović MZ. DOES AUDIOVESTIBULAR POST-COVID SYNDROME EXIST? Acta Clin Croat 2023; 62:88-92. [PMID: 38304374 PMCID: PMC10829947 DOI: 10.20471/acc.2023.62.01.11] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/13/2022] [Accepted: 02/14/2023] [Indexed: 02/03/2024] Open
Abstract
The purpose of this study was to present and analyze patients with audiovestibular post COVID-19 syndrome, and highlight the most characteristic and most common findings. We analyzed 87 patients aged between 20 and 86 years who presented to the Audiology Division between February 1, 2021 and July 1, 2021 after having been isolated due to the SARS-CoV-2 infection. Study patients presented with complaints of persistent hearing loss, tinnitus, and vertigo, lasting for more than 3 months. Study results showed that there was acute sensorineural hearing loss in 4 patients during the SARS-CoV-2 infection. None of the patients experienced complete hearing recovery after 3 months. High frequency hearing loss (at 4 kHz and 6 kHz) occurred bilaterally, and was found in 52 patients. This finding of gradual hearing loss was both the most characteristic and most common in COVID patients. Extensive damage can directly occur to inner ear structures, including hair cells, the Corti organ, and the cochlear nerve because of this viral infection. A total of 73 patients had tinnitus. 68 patients had unilateral tinnitus, and only 5 patients had bilateral tinnitus. Exacerbation of tinnitus was recorded in 12 patients and new-onset tinnitus in 61 patients. Vertigo occurred in 9 patients, all of which were new-onset. A conclusion of our research is that audiovestibular post-COVID syndrome does exist. Further research with more patients and over a longer period is needed to obtain a better and longer effect on the audiovestibular system and audiovestibular complications, as well as an insight into possible recovery.
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Affiliation(s)
- Marisa Klančnik
- Department of Otorhinolaryngology-Head and Neck Surgery, Split University Hospital Center, Split, Croatia
| | - Petar Ivanišević
- Department of Otorhinolaryngology-Head and Neck Surgery, Split University Hospital Center, Split, Croatia
| | - Nikolina Golec
- Department of Otorhinolaryngology-Head and Neck Surgery, Split University Hospital Center, Split, Croatia
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Almishaal AA. Comparative Study of Audiovestibular Symptoms between Early and Late Variants of COVID-19. Audiol Res 2022; 12:680-695. [PMID: 36546906 PMCID: PMC9774134 DOI: 10.3390/audiolres12060065] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/12/2022] [Revised: 11/01/2022] [Accepted: 11/03/2022] [Indexed: 12/12/2022] Open
Abstract
Audiovestibular symptoms during the acute phase of the corona virus disease 2019 (COVID-19), have been reported for earlier waves of the pandemic, while no studies investigated nor compared audiovestibular manifestations during subsequent waves of COVID-19. In the current study, we aimed to compare the occurrence of audiovestibular symptoms associated with COVID-19 between the alpha/beta, delta, and omicron variants. An online questionnaire was distributed to individuals with confirmed test results for COVID-19. We asked participants to report whether they experienced audiovestibular symptoms during the acute phase of the disease. The study included 939 participants; 120 un-infected controls and infected participants during alpha/beta (n = 301), delta (n = 102), and omicron (n = 416) predominance periods. Self-reported audiovestibular symptoms were found to be statistically significantly different between un-infected controls and COVID-19 infected individuals in all analyzed variants. Furthermore, our results showed no significant differences in audiovestibular symptoms among individuals infected during alpha/beta, delta, and omicron waves. Although individuals infected during the delta variant predominance period reported higher percentages of audiovestibular symptoms (ranging from 11.8% to 26.5% for auditory symptoms and from 12.7% to 34.3% for vestibular symptoms) than for the alpha/beta (ranging from 6.3% to 18.9% for auditory symptoms and 8.3% to 29.9% for vestibular symptoms) and omicron (ranging from 9.6% to 21.2% for auditory and 12.5 to 29.1% for vestibular symptoms) variants, this did not achieve statistical significance. With regards to auditory symptoms, the most commonly reported symptoms were aural fullness followed by hearing loss and tinnitus. With regards to vestibular symptoms, dizziness was the most commonly reported symptom followed by vertigo and unsteadiness. Logistic regression revealed that experiencing auditory symptoms were associated with other neurological symptoms, back and joint pain, and chest pain as COVID-19 symptoms. Vestibular symptoms were associated with anemia, gender, fatigue, headache, and breathing difficulties. In conclusion, our study shows that audiovestibular symptoms are common during the acute phase of early and late COVID-19 variants with no significant differences between them.
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Affiliation(s)
- Ali A Almishaal
- Department of Speech-Language Pathology and Audiology, College of Applied Medical Sciences, University of Hail, Hail 55476, Saudi Arabia
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Basoz M, Tas N, Gedik O, Ozdemir S, Aksoy F. Transient otoacoustic emissions with contralateral suppression findings in COVID-19 patients. THE EGYPTIAN JOURNAL OF OTOLARYNGOLOGY 2022. [PMCID: PMC8935605 DOI: 10.1186/s43163-022-00231-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Abstract
Objective The virus called SARS-CoV-2, which is known as the first epidemic of the twenty-first century, is known to affect the central and peripheral nervous system. In the literature, complaints of sudden hearing loss, tinnitus, and vertigo have been reported in the patients. The aim of this study is to objectively reveal the effect of the coronavirus disease 2019 on the efferent auditory system. Methods Twenty-three participants, who had the coronavirus disease 2019, were included in the study group, while 20 healthy participants were included in the control group. The test of transient otoacoustic emissions with contralateral suppression was applied to individuals who had normal audiological and immitansmetric evaluations findings. Results In audiological evaluation, a significant difference was observed between the groups in the 125–500 Hz low frequency range and 4 kHz–12.5 kHz high frequency range. In the test of TEOAE and TEOAE with contralateral suppression, a significant difference was observed between the groups at 4 kHz. Conclusion The effect of the coronavirus disease 2019 on the peripheral hearing system has been shown. Its effect on the efferent hearing system in the high frequency region has been revealed. Supplementary Information The online version contains supplementary material available at 10.1186/s43163-022-00231-z.
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The Absence of Permanent Sensorineural Hearing Loss in a Cohort of Children with SARS-CoV-2 Infection and the Importance of Performing the Audiological “Work-Up”. CHILDREN 2022; 9:children9111681. [DOI: 10.3390/children9111681] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/31/2022] [Revised: 10/19/2022] [Accepted: 10/28/2022] [Indexed: 11/06/2022]
Abstract
Background: Currently, the novel coronavirus (SARS-CoV-2) causes an acute respiratory illness named COVID-19 and is a controversial risk factor for hearing loss (HL). Herein, we aim to describe the associated symptoms and to evaluate hearing function in the COVID-19 pediatric population. Methods: A retrospective cross-sectional observational study was carried out on 37 children who contracted COVID-19 infection with no previous audio-vestibular disorders. Clinical data on the infections were collected, and an audiological assessment of all affected children was performed by using different diagnostic protocols according to their age. Results: Fever, upper respiratory and gastrointestinal manifestations were common presentations of infection. Audiological function was normal in 30 (81.08%) children, while 7 children showed an increased hearing threshold: 6 (16.21%) had transient conductive hearing loss (CHL) due to middle ear effusion and normalized at the follow-up and 1 had sensorineural hearing loss (SNHL). A single child was affected by bilateral SNHL (2.7%); however, he underwent a complete audiological work-up leading to a diagnosis of genetic HL due to a MYO6 gene mutation which is causative of progressive or late onset SNHL. Conclusions: HL needs to be considered among the manifestations of COVID-19 in children, nevertheless, we found cases of transient CHL. The onset of HL during or following COVID-19 infection does not eliminate the indication for maintaining audiological surveillance and audiological work-ups, including genetic diagnosis, to avoid the risk of mistaking other causes of HL.
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Pazdro-Zastawny K, Dorobisz K, Misiak P, Kruk-Krzemień A, Zatoński T. Vestibular disorders in patients after COVID-19 infection. Front Neurol 2022; 13:956515. [PMID: 36203969 PMCID: PMC9531925 DOI: 10.3389/fneur.2022.956515] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/30/2022] [Accepted: 08/29/2022] [Indexed: 11/13/2022] Open
Abstract
IntroductionThe COVID-19 clinical symptoms are primarily related to the respiratory system but may also be involved in many others, including the nervous system. Recently, vertigo or dizziness has been described as one of the clinical manifestations and possible complications of COVID-19.Materials and methodsThis clinical study was designed to describe the otorhinolaryngological evaluation and videonystagmographic (VNG) findings in patients with an antecedent of COVID-19 infection in the last 6 months. In this study, we sought to investigate the presence of persistent vestibular damage in healed COVID-19 patients and to determine the origin of vertigo by conducting a comprehensive vestibular examination. To evaluate the association precisely, an otoneurological assessement was conducted on all participants. The study group included 58 patients aged 23–75 years with vertigo, who were diagnosed with COVID-19 infection 6 months before the examination. Each participant was submitted to an evaluation consisting of anamnesis, otorhinolaryngological evaluation, and VNG.ResultsSpontaneous nystagmus with closed eyes was reported in 8 patients (13.8%). Positional nystagmus was observed in 15 patients (24.1%). Asymmetrical optokinetic nystagmus was observed in 18 patients (31%). A distorted record in the tracking pendulum test was present in 23 patients (39.7%). Square waves were observed in 34 COVID-19 patients (58.6%). Unilateral weakness (UW) was observed in 23 subjects (39.7%); among those with UW, 22 patients (95.7%) also demonstrated directional preponderance contralateral to the UW. Another 16 patients (27.6%) presented only directional advantage. The post-caloric recruitment was present in 38% patients.ConclusionPatients who had been diagnosed with COVID-19 seem to be more likely to suffer from vertigo/dizziness and to compensate more slowly. COVID-19 infection may cause inner ear damage and lead to vestibular dysfunction. The role of the central nervous system in the onset of equilibrium disorders should be considered. The presence of vertigo of central origin may indicate the neurotropic effect of SARS-CoV-2 following COVID-19. Imbalance may be the only symptom of COVID-19 and may also be a late complication of the disease due to post-infectious inflammation of the nervous tissue. Comprehensive studies are needed to investigate whether COVID-19 can cause long-term vestibular deficits.
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Ismaiel WF, Abdelazim MH, Wahba AA, Alsobky ME, Ibrahim AA, Ghanem SA, Rabaan AA, Ismail EI. Intratympanic injection of dexamethasone for management of labyrinthitis associated with COVID-19 disease resistant cases. Ann Med Surg (Lond) 2022; 81:104429. [PMID: 35989722 PMCID: PMC9384350 DOI: 10.1016/j.amsu.2022.104429] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/07/2022] [Revised: 08/04/2022] [Accepted: 08/12/2022] [Indexed: 11/24/2022] Open
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Wong MY, Tang WS, Zakaria Z. Unilateral sudden sensorineural hearing loss in post-COVID-19 patients: Case report. MALAYSIAN FAMILY PHYSICIAN : THE OFFICIAL JOURNAL OF THE ACADEMY OF FAMILY PHYSICIANS OF MALAYSIA 2022; 17:112-116. [PMID: 35950005 PMCID: PMC9357412 DOI: 10.51866/cr.134] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/15/2023]
Abstract
Sudden sensorineural hearing loss (SSNHL) is an otologic emergency. Sensorineural hearing loss needs to be distinguished from conductive when patients present with sudden hearing loss at the primary care level. Prompt diagnosis of sensorineural hearing loss with pure tone audiometry and immediate treatment by an otolaryngologist can improve the hearing outcome. To date, few case reports exist about SSNHL among post-COVID-19 patients, and none were reported in Malaysia. Here, we present two cases of SSNHL in patients after COVID-19 infection. We wish to highlight the association of SSNHL following COVID-19 infection for timely referral towards better audiology outcomes. Permanent hearing loss will lead to another negative impact on the long-term quality of life of COVID-19 patients.
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Affiliation(s)
- Meng Yee Wong
- MBBS (KMC Mangalore), MAFP/FRACGP, Klinik Kesihatan Jalan Perak, Jalan Perak, Jelutong, Pulau Pinang, Malaysia.
| | - Wei Shuong Tang
- MBBS (UM), MMed (Family Medicine) UM, Klinik Kesihatan Jalan Perak, Jalan Perak, Jelutong, Pulau Pinang, Malaysia
| | - Zahirrudin Zakaria
- MD (UKM), MS ORL HNS (UKM), Otolaryngology Department, Hospital Pulau Pinang, Jalan Residensi, Georgetown,Pulau Pinang, Malaysia
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Sousa FAD, Machado AS, da Costa JC, Silva AC, Pinto AN, Coutinho MB, Meireles L, Sousa CAE. Tailored Approach for Persistent Olfactory Dysfunction After SARS-CoV-2 Infection: A Pilot Study. Ann Otol Rhinol Laryngol 2022; 132:657-666. [PMID: 35822286 DOI: 10.1177/00034894221111093] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
OBJECTIVE So far, no original studies explored non-randomized, standardized protocols for COVID-19 associated olfactory dysfunction. The main objective was to determine the efficacy of a new protocol for post-COVID olfactopathy while assessing the benefit of adding adjuvant therapies to olfactory training. METHODS Patients suffering from long-lasting post-COVID-19 olfactory dysfunction were evaluated. A non-randomized protocol based on individual nasal endoscopy findings and patient's preferences was applied. Patients were assigned for olfactory training alone or olfactory training + adjuvant therapy. Participants performed olfactory objective and subjective evaluations at first consultation and 3 months after treatment, and results were compared. RESULTS A total of 47 patients were enrolled. All groups showed significant improvement in olfactory thresholds at 3-month follow-up suggesting protocol effectiveness (olfactory training group alone showed a mean threshold difference of 2.9, P < .001; Olfactory training + Topical Corticosteroid showed a mean threshold difference of 4, P = .006; Olfactory training + Topical Corticosteroid + Vitamin B complex showed a mean threshold difference of 4.4, P = .006; Olfactory training + Intranasal Vitamin A and E showed a mean threshold difference of 4.4, P < .001). Olfactory training alone showed lower mean olfactory threshold improvement, when compared to patients undergoing olfactory training + adjuvant therapy (olfactory training alone mean improvement 2.9 ± 2.3 vs olfactory training + adjuvants mean improvement 4.3 ± 2.458, P = .03). CONCLUSIONS This is one of the first studies to demonstrate results in the treatment of post-COVID-19 persistent olfactory impairment. A customized approach based on endoscopy findings and patient's preferences may be a valid option for the management of persistent post-COVID-19 olfactory disorder. Adjuvant therapy could be considered in addition to olfactory training, but further studies are needed in order to confirm their effectiveness in this setting. LEVEL OF EVIDENCE 2c (outcomes research).
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Affiliation(s)
- Francisco Alves de Sousa
- Serviço de Otorrinolaringologia e Cirurgia da Cabeça e Pescoço (Otorhinolaryngology and Head & Neck Surgery), Centro Hospitalar Universitário do Porto, Porto, Portugal
| | - André Sousa Machado
- Serviço de Otorrinolaringologia e Cirurgia da Cabeça e Pescoço (Otorhinolaryngology and Head & Neck Surgery), Centro Hospitalar Universitário do Porto, Porto, Portugal
| | - Joana Carvalho da Costa
- Serviço de Otorrinolaringologia e Cirurgia da Cabeça e Pescoço (Otorhinolaryngology and Head & Neck Surgery), Centro Hospitalar Universitário do Porto, Porto, Portugal
| | - Ana Costa Silva
- Serviço de Otorrinolaringologia e Cirurgia da Cabeça e Pescoço (Otorhinolaryngology and Head & Neck Surgery), Centro Hospitalar Universitário do Porto, Porto, Portugal
| | - Ana Nóbrega Pinto
- Serviço de Otorrinolaringologia e Cirurgia da Cabeça e Pescoço (Otorhinolaryngology and Head & Neck Surgery), Centro Hospitalar Universitário do Porto, Porto, Portugal
| | - Miguel Bebiano Coutinho
- Serviço de Otorrinolaringologia e Cirurgia da Cabeça e Pescoço (Otorhinolaryngology and Head & Neck Surgery), Centro Hospitalar Universitário do Porto, Porto, Portugal
| | - Luís Meireles
- Serviço de Otorrinolaringologia e Cirurgia da Cabeça e Pescoço (Otorhinolaryngology and Head & Neck Surgery), Centro Hospitalar Universitário do Porto, Porto, Portugal
| | - Cecília Almeida E Sousa
- Serviço de Otorrinolaringologia e Cirurgia da Cabeça e Pescoço (Otorhinolaryngology and Head & Neck Surgery), Centro Hospitalar Universitário do Porto, Porto, Portugal
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15
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Maleki M, Maarefvand M, Nazeri AR, Akbarzadeh Baghban AR, Borna A. Audio-Vestibular Profile of COVID-19; Systematic Review and Meta-analysis. IRANIAN JOURNAL OF OTORHINOLARYNGOLOGY 2022; 34:145-155. [PMID: 36035653 PMCID: PMC9393004 DOI: 10.22038/ijorl.2022.60404.3079] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 10/14/2021] [Accepted: 05/16/2022] [Indexed: 11/06/2022]
Abstract
Introduction After more than a year of the COVID-19 pandemic, audio-vestibular problems have been reported as consequences. Several limited case report studies with different methodologies were published. This study aimed to describe the impact of COVID-19 on the auditory-vestibular system and communication problems in subjects with hearing impairment. Materials and Methods The current systematic review was performed based on the Preferred Reporting Items for Systematic Reviews and Meta-Analysis (PRISMA) guideline. PubMed, Web of Science, and Google Scholar were searched to find relevant articles using combined keywords. Results Out of 26 final studies, 20 studies dealt with the effects of COVID-19 on the auditory and vestibular system, and six articles examined the COVID-19 effects on hearing-impaired people and patients. In these studies, dizziness (17.8%), tinnitus (8.1%), and vertigo (2.8%) were common symptoms. Most studies were case reports (42.30%), and in terms of quality, nine studies (34.61%) were in the suitable quality group. Conclusions COVID-19 might cause auditory-vestibular system problems by directly affecting the structures or functions of the inner ear or by weakening the immune system. The need for taking preventive measures during the COVID-19 pandemic has caused communication and social challenges, particularly for people with hearing loss.
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Affiliation(s)
- Mehri Maleki
- Student Research Committee, Iran University of Medical Sciences, Tehran, Iran.
| | - Mohammad Maarefvand
- Department of Audiology, School of Rehabilitation Sciences, Iran University of Medical Sciences, Tehran, Iran.
| | - Ahmad Reza Nazeri
- Department of Audiology, School of Rehabilitation Sciences, Shahid Beheshti University of Medical Sciences, Tehran, Iran.
| | - Ali Reza Akbarzadeh Baghban
- Proteomic Research Center Department of Biostatistics, School of Allied Medical Sciences, Shahid Beheshti University of Medical Sciences, Tehran, Iran.
| | - Azadeh Borna
- Student Research Committee, Iran University of Medical Sciences, Tehran, Iran.,Corresponding Author: School of Rehabilitation Sciences, Iran University of Medical Sciences, Maddadkaran St., Shahid Nazari St., Mother Square, Mirdamad Blvd, School of Rehabilitation Sciences, Iran University of Medical Sciences, Tehran, Iran. E-mail:
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16
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Sensorineural Hearing Loss Post-COVID-19 Infection: An Update. Audiol Res 2022; 12:307-315. [PMID: 35735365 PMCID: PMC9219889 DOI: 10.3390/audiolres12030032] [Citation(s) in RCA: 11] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/04/2022] [Revised: 05/27/2022] [Accepted: 05/30/2022] [Indexed: 11/17/2022] Open
Abstract
The course of COVID-19 infection may be complicated by a variety of neurological manifestations. Since the inner ear is vulnerable to viruses, sensorineural hearing loss (SNHL) has been reported to occur following the SARS-CoV-2 infection, often resulting in long-term morbidity and worsening the quality of life. The interest in how the virus affects the inner ear has gradually increased since the pandemic’s spread, but little is still known about the SNHL potentially caused by SARS-CoV-2. The aim of this paper is to evaluate the possible association between SNHL and COVID-19 infection, through a systematic literature review. Currently available data suggest that SARS-CoV-2 may hamper cochlear function; however, available reports are still limited. Large cohort and prospective studies are necessary to evaluate the long-term effects of this viral infection in the inner ear.
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17
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Öztürk B, Kavruk H, Aykul A. Audiological findings in individuals diagnosed with COVID-19. Am J Otolaryngol 2022; 43:103428. [PMID: 35405495 PMCID: PMC8983074 DOI: 10.1016/j.amjoto.2022.103428] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/30/2021] [Revised: 02/17/2022] [Accepted: 04/02/2022] [Indexed: 01/08/2023]
Abstract
Purpose It is thought that COVID-19 may cause hearing loss, but its effects on the hearing system are not clear. This study aimed to reveal the effects of COVID-19 on the auditory system by using various audiological measurement methods in individuals diagnosed with COVID-19. Methods Thirty individuals between the ages of 18–45, who were diagnosed with COVID-19 by PCR at least one month ago, and had no pre-COVID-19 hearing loss complaints, constituted the test group. Thirty individuals aged between 18 and 30 years and who had no history of hearing loss constituted the control group. Audiological evaluations of all participants were made with pure-tone audiometry, high-frequency audiometry, transient-evoked otoacoustic emission (TEOAE), distortion product otoacoustic emission (DPOAE), and auditory brainstem response (ABR) measurements. Results A significant difference was found between the groups at all high frequencies between 4 and 14 kHz (p < 0.05). TEOAE amplitudes at 1500 Hz, 2000 Hz and 4000 Hz frequencies and DPOAE amplitudes at 4003 Hz and higher frequencies were significantly lower in the test group (p < 0.05). While there was a significant difference between the I, III and V absolute latencies between the groups (p < 0.05), there was no significant difference between the I-III, III-V and I-V interpeak latencies (p > 0.05) as a result of the ABR test. Conclusion This study showed that COVID-19 can cause cochlear damage, especially at high frequencies. More studies are needed to determine the effects of COVID-19 on the auditory system.
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18
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Meng X, Wang J, Sun J, Zhu K. COVID-19 and Sudden Sensorineural Hearing Loss: A Systematic Review. Front Neurol 2022; 13:883749. [PMID: 35572936 PMCID: PMC9096262 DOI: 10.3389/fneur.2022.883749] [Citation(s) in RCA: 21] [Impact Index Per Article: 10.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/25/2022] [Accepted: 03/30/2022] [Indexed: 12/23/2022] Open
Abstract
A growing body of evidence suggests that patients with the 2019 Coronavirus disease (COVID-19) have a risk of developing sudden sensorineural hearing loss (SSNHL). The pathogenesis of COVID-19-related SSNHL remains unclear. This systematic review examined whether COVID-19 causes an increased incidence of SSNHL and the clinical characteristics of patients with COVID-19-related SSNHL according to the Preferred Reporting Items for Systematic reviews and Meta-Analyses (PRISMA) guidelines. SSNHL usually developed between a few days and 2 months after the diagnosis of COVID-19, and a proportion of patients developed it before the diagnosis of COVID-19. The literature is inconsistent regarding whether COVID-19 causes an increased incidence of SSNHL, and this matter remains unclear. This review included 23 patients with COVID-19-related SSNHL, all adult patients with an average age of 43.1 years. Of these patients, 60.9% had accompanying tinnitus symptoms. Glucocorticoids are the preferred medication to treat COVID-19-related SSNHL. Intratympanic administration may be considered to reduce the side effects of the drug. Hearing tests are suggested when hearing loss is suspected in COVID-19 individuals, and if SSNHL is detected, prompt and aggressive treatment is vital. Large-scale, multicenter research on the pathophysiology, treatment, and prognosis of COVID-19- related SSNHL should be conducted in the future.
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Affiliation(s)
- Xiangming Meng
- Department of Otolaryngology, Wuxi Huishan District People's Hospital, Wuxi, China
- *Correspondence: Xiangming Meng
| | - Jing Wang
- Department of Otolaryngology, Huadong Sanatorium, Wuxi, China
| | - Jian Sun
- Department of Rheumatology and Immunology, Affiliated Hospital of Jiangnan University, Wuxi, China
| | - Kangxu Zhu
- Department of Otolaryngology, Wuxi Huishan District People's Hospital, Wuxi, China
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19
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Neuro-otological Symptoms: An Atypical Aspect of COVID-19 Disease. Indian J Otolaryngol Head Neck Surg 2022; 74:3273-3282. [PMID: 35465132 PMCID: PMC9012049 DOI: 10.1007/s12070-022-03088-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/05/2022] [Accepted: 01/12/2022] [Indexed: 01/08/2023] Open
Abstract
This study aimed to evaluate the various neuro-otological symptoms experienced by patients with COVID-19 disease. This is a retrospective study conducted from September 2020 to August 2021. Patients with positive RTPCR tests for COVID-19, aged between 18 and 60 years were included in the study. The patients were assessed for neuro-otological symptoms, the type, frequency, and character of these symptoms, their relation with age, gender and COVID-19 disease. Of the 286 patients, 64 (22.3%) had neuro-otological symptoms. The mean age of the patients was 36.3 ± 8.1 years. The frequency of neuro-otological symptoms was higher in females than males and was more frequent in the age group of 18–30 years as compared with other age groups. Of these 64 patients, 29 had vertigo (10.1%), 21 (7.3%) tinnitus, 16 (5.5%) experienced hearing loss. Like many viral diseases, apart from its typical prodromal symptoms, COVID-19 can also cause symptoms like tinnitus, hearing loss, and vertigo.
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20
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Ong KMC, Cruz TLG. Otologic and vestibular symptoms in COVID-19: A scoping review. World J Otorhinolaryngol Head Neck Surg 2022; 8:WJO257. [PMID: 35599837 PMCID: PMC9111077 DOI: 10.1002/wjo2.57] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/07/2021] [Accepted: 01/17/2022] [Indexed: 12/23/2022] Open
Abstract
Background Otologic and vestibular symptoms have been seen in patients confirmed to have COVID-19 disease. Further discussion of these symptoms may provide insight into short- and long-term management for these patients. Objective The aim of this review was to describe the otologic and vestibular symptoms that present in patients with COVID-19. The primary outcomes of this review were onset, duration and clinical outcomes of these symptoms. Sources of Evidence Pub Med, APAMed Central, Herdin, CINAHL, Scopus, Springer Link, ProQuest Coronavirus Research Database, and Google Scholar were searched for the articles to be included. Eligibility Criteria Studies included were those involving adult patients diagnosed with COVID-19 who experienced hearing loss, ear pain, ear discharge, otitis media, vertigo, or tinnitus. Studies were eligible for inclusion if there was a description of the otologic dysfunction, specifically onset, duration, or clinical outcomes. Results The majority of patients who experienced hearing loss (68%), tinnitus (88%), vertigo/dizziness (30%), ear pain (8%), and discharge (100%) did so within a month of experiencing the typical symptoms of COVID-19. A majority also experienced complete resolution of their symptoms within 2 weeks. Standard treatment for COVID-19 was usually provided but when specific diagnoses are made for these symptoms (e.g., sudden sensorineural hearing loss, otitis media, vestibular neuritis), they are treated in the same manner as one would for non-COVID-19 cases, in addition to the management for COVID-19. In certain cases, there may be a need for additional work-up to rule out other causes. Conclusions Otologic and vestibular symptoms were present in COVID-19 patients, majority as part of the systemic nature of the disease. The onset, duration, and course were consistent with the natural history of a systemic viral infection. COVID-19 should be considered in any patient with a new-onset hearing loss, tinnitus, or vertigo/dizziness, even in the absence of infectious or respiratory symptoms.
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Affiliation(s)
- Kimberly Mae C. Ong
- Philippine National Ear Institute, National Institutes of HealthUniversity of the Philippines ManilaManilaPhilippines
- College of MedicineUniversity of the Philippines ManilaManilaPhilippines
| | - Teresa Luisa G. Cruz
- Philippine National Ear Institute, National Institutes of HealthUniversity of the Philippines ManilaManilaPhilippines
- College of MedicineUniversity of the Philippines ManilaManilaPhilippines
- Department of OtorhinolaryngologyUniversity of the Philippines‐Philippine General HospitalManilaPhilippines
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21
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Almishaal AA, Alrushaidan AA. Short- and Long-Term Self-Reported Audiovestibular Symptoms of SARS-CoV-2 Infection in Hospitalized and Nonhospitalized Patients. Audiol Neurootol 2022; 27:297-311. [PMID: 35240596 PMCID: PMC9059062 DOI: 10.1159/000521963] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/10/2021] [Accepted: 12/16/2021] [Indexed: 12/11/2022] Open
Abstract
BACKGROUND Audiovestibular symptoms during the acute stage have been reported in patients with severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), while very few studies investigated the long-term audiovestibular manifestations of SARS-CoV-2. OBJECTIVE The objective of this study was to examine the occurrence of short- and long-term audiovestibular symptoms associated with SARS-CoV-2 infection. METHOD In this cross-sectional study, a questionnaire was distributed to severe hospitalized cases and nonhospitalized patients with mild disease, all with confirmed SARS-CoV-2 test results. Participants were inquired to report audiovestibular symptoms during the acute phase and at 6-month follow-up after contracting SARS-CoV-2. RESULTS A total of 301 participants completed the questionnaire. Auditory symptoms were reported by 21.9% and 1.99% of patients during the acute phase and 6 months post SARS-CoV-2 infection, respectively. During the acute phase of SARS-CoV-2 infection, aural fullness represents the most common symptoms (18.94%) followed by tinnitus (9.97%) and hearing loss (6.31%). Vestibular symptoms were reported by 34% during the acute phase; most commonly was dizziness (29.9%) followed by vertigo (24.25%) and unsteadiness (8.31%). Long-term and persistent vestibular problems were reported by 3.99% patients. There were no statistically significant differences in self-reported audiovestibular symptoms between patients with severe SARS-CoV-2 disease compared to those with mild disease. CONCLUSION The current study showed that audiovestibular symptoms are common among SARS-CoV-2 infected patients during the acute phase of the disease. However, these symptoms are mostly temporary and showed complete spontaneous recovery during the first 2 weeks postinfection.
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Affiliation(s)
- Ali A. Almishaal
- College of Applied Medical Sciences, University of Hail, Hail, Saudi Arabia
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22
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Jafari Z, Kolb BE, Mohajerani MH. Hearing Loss, Tinnitus, and Dizziness in COVID-19: A Systematic Review and Meta-Analysis. Can J Neurol Sci 2022; 49:184-195. [PMID: 33843530 PMCID: PMC8267343 DOI: 10.1017/cjn.2021.63] [Citation(s) in RCA: 72] [Impact Index Per Article: 36.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/01/2020] [Revised: 03/30/2021] [Accepted: 04/01/2021] [Indexed: 12/17/2022]
Abstract
OBJECTIVES Extensive studies indicate that severe acute respiratory syndrome coronavirus (SARS-CoV-2) involves human sensory systems. A lack of discussion, however, exists given the auditory-vestibular system involvement in CoV disease 2019 (COVID-19). The present systematic review and meta-analysis were performed to determine the event rate (ER) of hearing loss, tinnitus, and dizziness caused by SARS-CoV-2. METHODS Databases (PubMed, ScienceDirect, Wiley) and World Health Organization updates were searched using combined keywords: 'COVID-19,' 'SARS-CoV-2,' 'pandemic,' 'auditory dysfunction,' 'hearing loss,' 'tinnitus,' 'vestibular dysfunction,' 'dizziness,' 'vertigo,' and 'otologic symptoms.' RESULTS Twelve papers met the eligibility criteria and were included in the study. These papers were single group prospective, cross-sectional, or retrospective studies on otolaryngologic, neurologic, or general clinical symptoms of COVID-19 and had used subjective assessments for data collection (case histories/medical records). The results of the meta-analysis demonstrate that the ER of hearing loss (3.1%, CIs: 0.01-0.09), tinnitus (4.5%, CIs: 0.012-0.153), and dizziness (12.2%, CIs: 0.070-0.204) is statistically significant in patients with COVID-19 (Z ≤ -4.469, p ≤ 0.001). CONCLUSIONS COVID-19 can cause hearing loss, tinnitus, and dizziness. These findings, however, should be interpreted with caution given insufficient evidence and heterogeneity among studies. Well-designed studies and follow-up assessments on otologic symptoms of SARS-CoV-2 using standard objective tests are recommended.
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Affiliation(s)
- Zahra Jafari
- Department of Neuroscience, Canadian Centre for Behavioural Neuroscience, University of Lethbridge, Lethbridge, Canada
| | - Bryan E. Kolb
- Department of Neuroscience, Canadian Centre for Behavioural Neuroscience, University of Lethbridge, Lethbridge, Canada
| | - Majid H. Mohajerani
- Department of Neuroscience, Canadian Centre for Behavioural Neuroscience, University of Lethbridge, Lethbridge, Canada
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Canales Medina M, Ramirez Gómez M. Tinnitus, Sudden Sensorineural Hearing Loss, and Vestibular Neuritis As Complications of the Astra Zeneca COVID-19 Vaccine. Cureus 2022; 14:e20906. [PMID: 35145810 PMCID: PMC8810281 DOI: 10.7759/cureus.20906] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/03/2022] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND Sudden sensorineural hearing loss is most commonly defined as a sensorineural hearing loss of 30dB or greater over at least three contiguous audiometric frequencies occurring within a 72-hr period. The Astra Zeneca COVID-19 vaccine is suspicious of causing thrombotic complications following its administration, and could theoretically induce hearing loss by damaging the hearing organs through this mechanism, as well as vestibular damage through similar mechanisms. MATERIAL AND METHODS We reviewed the files of patients with otological symptoms after exposure to the Astra Zeneca COVID-19 vaccine during the year 2021. CASE SERIES We studied a total of six cases with otologic symptoms temporally related to the Astra Zeneca COVID-19 vaccine. We report four cases of patients presenting with hearing loss and tinnitus a few days after the second dose of the Astra Zeneca vaccine, and one case with the same symptoms after the first dose. Four cases were successfully treated with steroids; however, one case presented to the office two months after the onset of symptoms and did not improve with treatment. We also report the first case of vestibular neuritis temporally related to the administration of the first dose of the vaccine, which also had a good outcome after medical treatment. CONCLUSIONS Prompt treatment in the present cases was a factor associated with a good prognosis.
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Bento RF, Campos TV. Hearing Loss, Tinnitus, and Dizziness and their Relation with Covid-19: what is the Current Evidence? Int Arch Otorhinolaryngol 2022; 26:e001-e002. [PMID: 35096151 PMCID: PMC8789497 DOI: 10.1055/s-0042-1742353] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/13/2023] Open
Affiliation(s)
- Ricardo Ferreira Bento
- Department of Ophthalmology and Otorhinolaryngology, Hospital das Clínicas, Faculty of Medicine, University of São Paulo, São Paulo, Brazil
| | - Tatiane Vacaro Campos
- Department of Ophthalmology and Otorhinolaryngology, Hospital das Clínicas, Faculty of Medicine, University of São Paulo, São Paulo, Brazil
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Di Mauro P, La Mantia I, Cocuzza S, Sciancalepore PI, Rasà D, Maniaci A, Ferlito S, Tundo I, Anzivino R. Acute Vertigo After COVID-19 Vaccination: Case Series and Literature Review. Front Med (Lausanne) 2022; 8:790931. [PMID: 35071270 PMCID: PMC8770332 DOI: 10.3389/fmed.2021.790931] [Citation(s) in RCA: 19] [Impact Index Per Article: 9.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/07/2021] [Accepted: 12/06/2021] [Indexed: 12/13/2022] Open
Abstract
Objective: The aim of this study was to present some cases of acute vertigo potentially related to the coronavirus disease 2019 (COVID-19) vaccine and review the available literature about cochleovestibular dysfunction after the COVID-19 vaccination. Methods: In the period from May to July 2021, we evaluated 33 patients (mean age 54.3 ± 14.1) with “acute vertigo” post COVID-19 vaccination. A detailed medical history was taken on comorbidities, types of vaccines received, and symptoms associated. All patients underwent otoneurological evaluation, such as head impulse test, nystagmus evaluation, test of skew (HINTS) examination. Head shaking test-induced nystagmus, hyperventilation-induced nystagmus, and parossistic positional nystagmus were studied to search for vestibular impairment. Results: Symptoms included 16 patients (48.5%) with objective vertigo, 14 patients (42.4%) with subjective vertigo, and 3 patients (9.1%) with dizziness. Of the associated ear, nose, and throat (ENT) symptoms, the most expressed was tinnitus (18.2%). Bedside examination showed absent nystagmus in 7 patients (21.2%), 9 patients (27.3%) had horizontal or rotatory nystagmus, 17 patients (51.5%) had a vertical or oblique nystagmus, negative HST, or “central HINTS.” Discussion and Conclusions: The 9 patients had an evoked nystagmus pathognomonic for benign paroxysmal positional vertigo; in the remaining 17 cases, peripheral vestibular dysfunction could be excluded and central disorder may be suggested. Due to the prevalence of nystagmus of non-peripheral origin, a central nervous system involvement could not be excluded. However, due to the small sample size, a definite cause–effect relationship between vaccination and vertigo cannot be inferred. In light of expected third dose, large-scale and well-designed studies are needed to better define possible adverse reactions of the COVID-19 vaccine.
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Affiliation(s)
- Paola Di Mauro
- Department of Medical and Surgical Sciences and Advanced Technologies "G.F. Ingrassia", ENT Section, A.O.U. Policlinico "G.Rodolico-San Marco", University of Catania, Catania, Italy
| | - Ignazio La Mantia
- Department of Medical and Surgical Sciences and Advanced Technologies "G.F. Ingrassia", ENT Section, A.O.U. Policlinico "G.Rodolico-San Marco", University of Catania, Catania, Italy
| | - Salvatore Cocuzza
- Department of Medical and Surgical Sciences and Advanced Technologies "G.F. Ingrassia", ENT Section, A.O.U. Policlinico "G.Rodolico-San Marco", University of Catania, Catania, Italy
| | - Pasqua Irene Sciancalepore
- Centre of Phoniatry and Rehabilitation of Communication Disorders - Azienda Sanitaria Locale Lecce, Lecce, Italy
| | - Deborak Rasà
- Department of Medical and Surgical Sciences and Advanced Technologies "G.F. Ingrassia", ENT Section, A.O.U. Policlinico "G.Rodolico-San Marco", University of Catania, Catania, Italy
| | - Antonino Maniaci
- Department of Medical and Surgical Sciences and Advanced Technologies "G.F. Ingrassia", ENT Section, A.O.U. Policlinico "G.Rodolico-San Marco", University of Catania, Catania, Italy
| | - Salvatore Ferlito
- Department of Medical and Surgical Sciences and Advanced Technologies "G.F. Ingrassia", ENT Section, A.O.U. Policlinico "G.Rodolico-San Marco", University of Catania, Catania, Italy
| | - Isabella Tundo
- Department of Medical and Surgical Sciences and Advanced Technologies "G.F. Ingrassia", ENT Section, A.O.U. Policlinico "G.Rodolico-San Marco", University of Catania, Catania, Italy
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Özel T, Erdem N, Ünal A, Yalçın A, İnan D, Ilhanli N, Uysal H. Neurological manifestations and mortality in hospitalized coronavirus disease 2019 patients. NEUROL SCI NEUROPHYS 2022. [DOI: 10.4103/nsn.nsn_117_21] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
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McIntyre KM, Favre NM, Kuo CC, Carr MM. Systematic Review of Sensorineural Hearing Loss Associated With COVID-19 Infection. Cureus 2021; 13:e19757. [PMID: 34938632 PMCID: PMC8684886 DOI: 10.7759/cureus.19757] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/19/2021] [Indexed: 12/23/2022] Open
Abstract
Our objective is to identify novel coronavirus disease 2019 (COVID-19) patients with a diagnosis of sudden sensorineural hearing loss (SSNHL) with an aim to describe possible mechanisms. A systematic review was conducted using PubMed and Google Scholar. Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines were followed. Our search terms included: "Sensorineural Hearing Loss" + "COVID-19" or "Sensorineural Hearing Loss" + "SARS-CoV-2" or "Sensorineural Hearing Loss" + "Coronavirus". Studies that adhered to the inclusion and exclusion criteria were included in the review. Of the 20 articles identified in the initial search, five met the inclusion criteria. The included articles consisted of four case studies and one letter to the editor, with seven total patients analyzed. All patients were COVID-19 positive and exhibited SSNHL, either unilateral or bilateral. Four patients reported tinnitus and two patients experienced vertigo. One patient was treated with hydroxychloroquine and one patient was treated with a variety of medications. Four patients were treated with intravenous and/or oral steroids intended to treat the SSNHL. The current literature describing SSNHL in COVID-19 patients is insufficient to characterize the pattern of hearing loss or advise about the treatment or outcomes. Future studies require a larger database or population study.
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Affiliation(s)
- Kelcy M McIntyre
- Otolaryngology, University at Buffalo Jacobs School of Medicine and Biomedical Sciences, Buffalo, USA
| | - Nicole M Favre
- Otolaryngology, University at Buffalo Jacobs School of Medicine and Biomedical Sciences, Buffalo, USA
| | - Cathleen C Kuo
- Otolaryngology, University at Buffalo Jacobs School of Medicine and Biomedical Sciences, Buffalo, USA
| | - Michele M Carr
- Otolaryngology, University at Buffalo Jacobs School of Medicine and Biomedical Sciences, Buffalo, USA
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Chang CWD, McCoul ED, Briggs SE, Guardiani EA, Durand ML, Hadlock TA, Hillel AT, Kattar N, Openshaw PJM, Osazuwa-Peters N, Poetker DM, Shin JJ, Chandrasekhar SS, Bradford CR, Brenner MJ. Corticosteroid Use in Otolaryngology: Current Considerations During the COVID-19 Era. Otolaryngol Head Neck Surg 2021; 167:803-820. [PMID: 34874793 DOI: 10.1177/01945998211064275] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
OBJECTIVE To offer pragmatic, evidence-informed advice on administering corticosteroids in otolaryngology during the coronavirus disease 2019 (COVID-19) pandemic, considering therapeutic efficacy, potential adverse effects, susceptibility to COVID-19, and potential effects on efficacy of vaccination against SARS-CoV-2, which causes COVID-19. DATA SOURCES PubMed, Cochrane Library, EMBASE, CINAHL, and guideline databases. REVIEW METHODS Guideline search strategies, supplemented by database searches on sudden sensorineural hearing loss (SSNHL), idiopathic facial nerve paralysis (Bell's palsy), sinonasal polyposis, laryngotracheal disorders, head and neck oncology, and pediatric otolaryngology, prioritizing systematic reviews, randomized controlled trials, and COVID-19-specific findings. CONCLUSIONS Systemic corticosteroids (SCSs) reduce long-term morbidity in individuals with SSNHL and Bell's palsy, reduce acute laryngotracheal edema, and have benefit in perioperative management for some procedures. Topical or locally injected corticosteroids are preferable for most other otolaryngologic indications. SCSs have not shown long-term benefit for sinonasal disorders. SCSs are not a contraindication to vaccination with COVID-19 vaccines approved by the US Food and Drug Administration. The Centers for Disease Control and Prevention noted that these vaccines are safe for immunocompromised patients. IMPLICATIONS FOR PRACTICE SCS use for SSNHL, Bell's palsy, laryngotracheal edema, and perioperative care should follow prepandemic standards. Local or topical corticosteroids are preferable for most other otolaryngologic indications. Whether SCSs attenuate response to vaccination against COVID-19 or increase susceptibility to SARS-CoV-2 infection is unknown. Immunosuppression may lower vaccine efficacy, so immunocompromised patients should adhere to recommended infection control practices. COVID-19 vaccination with Pfizer-BioNTech, Moderna, or Johnson & Johnson vaccines is safe for immunocompromised patients.
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Affiliation(s)
- C W David Chang
- Department of Otolaryngology-Head and Neck Surgery, University of Missouri, Columbia, Missouri, USA
| | - Edward D McCoul
- Department of Otorhinolaryngology, Ochsner Clinic, New Orleans, Louisiana, USA
| | - Selena E Briggs
- Department of Otolaryngology-Head and Neck Surgery, Georgetown University, Washington, DC, USA
| | - Elizabeth A Guardiani
- Department of Otolaryngology-Head and Neck Surgery, University of Maryland, Baltimore, Maryland, USA
| | - Marlene L Durand
- Division of Infectious Diseases, Department of Medicine, Massachusetts General Hospital, and Infectious Disease Service, Massachusetts Eye and Ear Infirmary and Harvard Medical School, Boston, Massachusetts, USA
| | - Tessa A Hadlock
- Department of Otolaryngology-Head and Neck Surgery, Massachusetts Eye and Ear Infirmary and Harvard Medical School, Boston, Massachusetts, USA
| | - Alexander T Hillel
- Department of Otolaryngology-Head and Neck Surgery, Johns Hopkins University, Baltimore, Maryland, USA
| | - Nrusheel Kattar
- Department of Surgery, Louisiana State University, Shreveport, Louisiana, USA
| | | | - Nosayaba Osazuwa-Peters
- Department of Head and Neck Surgery and Communication Sciences, Duke University, Durham, North Carolina, USA
| | - David M Poetker
- Department of Otolaryngology and Communication Sciences, Medical College of Wisconsin, Milwaukee, Wisconsin, USA
| | - Jennifer J Shin
- Department of Otolaryngology-Head and Neck Surgery, Massachusetts Eye and Ear Infirmary and Harvard Medical School, Boston, Massachusetts, USA
| | | | - Carol R Bradford
- Department of Otolaryngology-Head and Neck Surgery, The Ohio State University, Columbus, Ohio, USA
| | - Michael J Brenner
- Department of Otolaryngology-Head and Neck Surgery, University of Michigan Medical School, Ann Arbor, Michigan, USA
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Direct SARS-CoV-2 infection of the human inner ear may underlie COVID-19-associated audiovestibular dysfunction. COMMUNICATIONS MEDICINE 2021; 1:44. [PMID: 34870285 PMCID: PMC8633908 DOI: 10.1038/s43856-021-00044-w] [Citation(s) in RCA: 51] [Impact Index Per Article: 17.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/10/2021] [Accepted: 10/05/2021] [Indexed: 02/07/2023] Open
Abstract
Background COVID-19 is a pandemic respiratory and vascular disease caused by SARS-CoV-2 virus. There is a growing number of sensory deficits associated with COVID-19 and molecular mechanisms underlying these deficits are incompletely understood. Methods We report a series of ten COVID-19 patients with audiovestibular symptoms such as hearing loss, vestibular dysfunction and tinnitus. To investigate the causal relationship between SARS-CoV-2 and audiovestibular dysfunction, we examine human inner ear tissue, human inner ear in vitro cellular models, and mouse inner ear tissue. Results We demonstrate that adult human inner ear tissue co-expresses the angiotensin-converting enzyme 2 (ACE2) receptor for SARS-CoV-2 virus, and the transmembrane protease serine 2 (TMPRSS2) and FURIN cofactors required for virus entry. Furthermore, hair cells and Schwann cells in explanted human vestibular tissue can be infected by SARS-CoV-2, as demonstrated by confocal microscopy. We establish three human induced pluripotent stem cell (hiPSC)-derived in vitro models of the inner ear for infection: two-dimensional otic prosensory cells (OPCs) and Schwann cell precursors (SCPs), and three-dimensional inner ear organoids. Both OPCs and SCPs express ACE2, TMPRSS2, and FURIN, with lower ACE2 and FURIN expression in SCPs. OPCs are permissive to SARS-CoV-2 infection; lower infection rates exist in isogenic SCPs. The inner ear organoids show that hair cells express ACE2 and are targets for SARS-CoV-2. Conclusions Our results provide mechanistic explanations of audiovestibular dysfunction in COVID-19 patients and introduce hiPSC-derived systems for studying infectious human otologic disease.
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No lasting impact of Covid-19 on the auditory system: a prospective cohort study. The Journal of Laryngology & Otology 2021. [PMCID: PMC8576134 DOI: 10.1017/s002221512100267x] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 01/02/2023]
Abstract
Objective Otological complications are considered early symptoms of severe acute respiratory syndrome coronavirus-2; however, it is unknown how long these symptoms last and whether the virus leaves any hearing disorders post-recovery. Methods This prospective cohort study comprised 31 mild or moderate confirmed coronavirus disease 2019 patients and 26 age-matched control peers (21–50 years old). Patients were questioned about their otological symptoms, and their hearing status was assessed during one month post-diagnosis. Results Patients showed a significantly higher rate of otological symptoms (hearing loss, ear fullness, ear pain, dizziness or vertigo, communication difficulties, and hyperacusis) versus the control group (p ≤ 0.022). The symptoms resolved early, between 2 and 8 days after their appearance. No significant differences were observed between the two groups in pure tone and extended high-frequency audiometry, transient evoked otoacoustic emissions, distortion product otoacoustic emissions, or auditory brainstem response following recovery. Conclusion The findings indicate that, in mild to moderate coronavirus disease 2019 cases, otological symptoms resolve within a week, and the virus has no lasting impact on the auditory system.
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Tufatulin GS, Boboshko MY, Garbaruk ES, Artyushkin SA, Alieva DI, Kreisman MV, Tsytsorina IA, Vasilyeva EN, Myazina YA, Samoylova EV. [Hearing function in children after new coronavirus infection (COVID-19)]. Vestn Otorinolaringol 2021; 86:28-34. [PMID: 34783470 DOI: 10.17116/otorino20218605128] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
The information about hearing status of patients who have had a COVID-19 is scattered. There are no studies among children population. OBJECTIVE To evaluate hearing function in children after coronavirus infection. MATERIAL AND METHODS 87 children aged from 5 months to 17 years who have had a new coronavirus infection were examined in three cities of Russia (St. Petersburg, Novosibirsk and Surgut). Audiologic examination depended on the age and included: otoscopy, TEOAE and DPOAE, ABR, impedansometry, pure tone audiometry, speech audiometry in quiet and noise. Fisher, LittlEARS and PEACH questionnaires were used as well. An evaluation of central auditory processing was performed in case of indications. RESULTS In 80 children (92%) otoscopy didn't revealed any problems. All children had type A tympanogram. Acoustic reflex was registered in 49 children (56%), wasn't registered on 1-2 frequencies in 27 (31%) children, was registered on only 1 frequency or wasn't registered at all in 11 (13%) children. OAE was present in 83 (95%) children. Audiometric thresholds in all children were within a normal range. Speech intelligibility in quiet and noise in most cases was normal. 7 children with poor speech intelligibility or low Fisher questionnaire results got an extended examination. Binaural fusion speech test, dichotic test, RuMatrix test, gap detection test data showed no signs of central auditory processing disorders. CONCLUSION There are no cases of hearing loss or central auditory processing disorders were found in children after new coronavirus infection. Due to variety of symptoms and long-term consequences of COVID-19 further hearing examination is required in this group of patients.
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Affiliation(s)
- G Sh Tufatulin
- Center of the Pediatric Audiology, St. Petersburg, Russia,Mechnikov North-Western State Medical University, St. Petersburg, Russia
| | - M Yu Boboshko
- Mechnikov North-Western State Medical University, St. Petersburg, Russia,Pavlov First St. Petersburg State Medical University, St. Petersburg, Russia
| | - E S Garbaruk
- Pavlov First St. Petersburg State Medical University, St. Petersburg, Russia,St. Petersburg State Pediatric Medical University, St. Petersburg, Russia
| | - S A Artyushkin
- Mechnikov North-Western State Medical University, St. Petersburg, Russia
| | - D I Alieva
- Center of the Pediatric Audiology, St. Petersburg, Russia
| | - M V Kreisman
- City Clinical Polyclinic No. 7, Novosibirsk, Russia,Novosibirsk State Medical University, Novosibirsk, Russia
| | - I A Tsytsorina
- Novosibirsk State Medical University, Novosibirsk, Russia
| | | | - Yu A Myazina
- Surgut District Clinical Hospital, Surgut, Russia
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Resumption of Cochlear Implant Surgery under COVID-19 Pandemic Conditions. Life (Basel) 2021; 11:life11090929. [PMID: 34575078 PMCID: PMC8466866 DOI: 10.3390/life11090929] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/03/2021] [Revised: 09/03/2021] [Accepted: 09/04/2021] [Indexed: 12/15/2022] Open
Abstract
(1) Background: The novel coronavirus COVID-19 has been recognized by the World Health Organization as a public health emergency of international concern and has caused cancellation of elective cochlear implantation in many countries. This article sets out our experience with resuming cochlear implant (CI) surgery under COVID-19 conditions over a period of 3 months. In addition, early results of hearing preservation (HP) after CI surgery are presented; (2) Methods: We adopted epidemic management policies and procedures according to the National Consultant for Infectious Diseases recommendations. During preoperative visits, all patients were tested for COVID-19 with a RT-PCR test. One month postoperatively, HP values in the Partial Deafness Treatment (PDT) group of patients was established using the HEARRING group formula; (3) Results: Between January and March 2021, we performed 312 CI procedures in adult and pediatric patients. Of these, none were subsequently re-admitted to hospital and found to be COVID-19 positive. Postoperative audiometric results showed that complete or partial HP was achieved in more than half the PDT patients; (4) Conclusion: Cochlear implantation during the coronavirus disease pandemic is essential and, with careful planning, is perfectly feasible.
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De Luca P, Scarpa A, Ralli M, Tassone D, Simone M, De Campora L, Cassandro C, Di Stadio A. Auditory Disturbances and SARS-CoV-2 Infection: Brain Inflammation or Cochlear Affection? Systematic Review and Discussion of Potential Pathogenesis. Front Neurol 2021; 12:707207. [PMID: 34421805 PMCID: PMC8373381 DOI: 10.3389/fneur.2021.707207] [Citation(s) in RCA: 21] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/09/2021] [Accepted: 06/28/2021] [Indexed: 12/23/2022] Open
Abstract
Patients affected by COVID-19 present a series of different symptoms; despite some of these are common, other less likely appear. Auditory symptoms seem to be less frequent, maybe because rarer or, alternatively, because they are underestimated during the clinical investigation. The hearing impairment might be related to the central or peripheral involvement of the auditory pathways; in particular, the likelihood of thrombosis might be one of the causes. To date, the prevalence of auditory symptoms such as sudden or progressive sensorineural hearing loss and tinnitus is unclear in COVID-19 patients. However, their presence might be an early sign of thrombosis or spread of the infection into the brain. In this systematic review of the literature we investigated the presence of auditory symptoms in COVID-19 patients and discussed their potential origin and causal relationship with SARS-CoV-2. Results showed that, despite rarely, auditory impairment can appear in patients with COVID-19 and should always be investigated for an early treatment and potential indicator of involvement of the central nervous system.
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Affiliation(s)
- Pietro De Luca
- Department of Medicine, Surgery and Dentistry, University of Salerno, Salerno, Italy
| | - Alfonso Scarpa
- Department of Medicine, Surgery and Dentistry, University of Salerno, Salerno, Italy
| | - Massimo Ralli
- Department of Sense Organs, Sapienza University of Rome, Rome, Italy
| | - Domenico Tassone
- Otolaryngology Unit, San Giovanni Addolorata Hospital, Rome, Italy
| | - Matteo Simone
- Otolaryngology Unit, San Giovanni Addolorata Hospital, Rome, Italy
| | - Luca De Campora
- Otolaryngology Unit, San Giovanni Addolorata Hospital, Rome, Italy
| | | | - Arianna Di Stadio
- Department of Surgery and Biomedical Sciences, Section of Otorhinolaryngology, "Santa Maria della Misericordia" University Hospital, Perugia, Italy
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35
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Bhatta S, Sharma S, Sharma D, Maharjan L, Bhattachan S, Sah MK, Singhal A, Ghanpur AD, Ganesuni D. Study of Hearing Status in COVID-19 Patients: A Multicentered Review. Indian J Otolaryngol Head Neck Surg 2021; 74:3036-3042. [PMID: 34277385 PMCID: PMC8274964 DOI: 10.1007/s12070-021-02710-w] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/26/2021] [Accepted: 06/20/2021] [Indexed: 12/25/2022] Open
Abstract
To evaluate the hearing status of COVID-19 patients and compare with control group. Prospective study carried out in 9 institutes. The pure tone audiogram and impedance audiometry of COVID-19 patients performed initially and at 3 months follow up. The control group consisted COVID-19 negative individuals with no history of ear related diseases. The average of air and bone conduction threshold (AC and BC) were compared between the COVID-19 patients and control group using independent t-test with a p value of less than 0.05 considered significant. Total of 331 patients, age 32 ± 4.3 years, 66.7% males and 33.3% females were included in the study. There were 80 individuals in the control group. Aural symptoms were, tinnitus in 1.8%, aural fullness in 1.4%, hearing loss in 3. 9%, and ear ache in 1.8% were present initially, resolved at 3 months follow up. The impedance audiometry demonstrated type B and type C curve in 5.1% and 1.15% ears, and out of these 64.7% and 40% improved at 3 months follow up respectively. No significant difference observed between the average AC and BC of the COVID-19 patients and control group. The COVID-19 infection may present with aural symptoms; however, it was concluded that there was no significant difference in the hearing status of the COVID-19 positive patients in comparison to the control group. The presence of some changes in the normal functioning of the eustachian tube and middle ear in the COVID-19 infection was also highlighted.
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Affiliation(s)
| | | | - Dibya Sharma
- Indira Gandhi Memorial Hospital, Male', Maldives
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Umashankar A, Prakash P, Prabhu P. Sudden Sensorineural Hearing Loss Post Coronavirus Disease: A Systematic Review of Case Reports. Indian J Otolaryngol Head Neck Surg 2021; 74:3028-3035. [PMID: 34277383 PMCID: PMC8271291 DOI: 10.1007/s12070-021-02756-w] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/24/2021] [Accepted: 07/04/2021] [Indexed: 02/08/2023] Open
Abstract
The coronavirus disease of 2019 is a global pandemic disease severely affecting the upper respiratory tract that can be fatal in some instances. The virus most commonly affects the respiratory system. However, in certain cases it affects the other systems, including cardiovascular, renal, gastrointestinal, neurological, and auditory. Concerning the hearing and balance system, the microcirculation supply to the inner ear is hampered thus causing audiovestibular symptoms. Several case studies have reported sudden sensorineural hearing loss post-coronavirus disease and its detrimental impact on overall hearing. As both sudden sensorineural hearing loss and coronavirus disease deals with an emergency situation, there is a need to document case studies on how these individuals have been assessed and treated. The article has systematically reviewed these case reports involving a search strategy in databases like PubMed, PubMed Central, science direct, J-GATE, Google Scholar, and a manual Google Search.
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Affiliation(s)
- Abishek Umashankar
- All India Institute of Speech and Hearing, Mysore, Karnataka 570006 India
| | - Praveen Prakash
- All India Institute of Speech and Hearing, Mysore, Karnataka 570006 India
| | - Prashanth Prabhu
- All India Institute of Speech and Hearing, Mysore, Karnataka 570006 India
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Ricciardiello F, Pisani D, Viola P, Cristiano E, Scarpa A, Giannone A, Longo G, Russo G, Bocchetti M, Coppola C, Perrella M, Oliva F, Chiarella G. Sudden Sensorineural Hearing Loss in Mild COVID-19: Case Series and Analysis of the Literature. Audiol Res 2021; 11:313-326. [PMID: 34287226 PMCID: PMC8293051 DOI: 10.3390/audiolres11030029] [Citation(s) in RCA: 25] [Impact Index Per Article: 8.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/15/2021] [Revised: 05/06/2021] [Accepted: 06/28/2021] [Indexed: 12/23/2022] Open
Abstract
Background: There is growing evidence of otoneurological involvement of SARS-CoV-2, such as tinnitus and balance disorders and smell and taste disorders, but HL in COVID-19 patients has still been marginally studied. Investigating the role of SARS-CoV-2 as an aetiological factor of Sudden Sensorineural Hearing Loss (SSNHL) may offer the opportunity to address treatment strategies to maximize clinical recovery and avoid side effects. Methods and results: For this purpose, we will present case studies of five patients who experienced SSNHL during COVID-19. Patients were selected from COVID-19 positive adult subjects with mild clinical presentation, admitted to the outpatient Ear Nose and Throat Department of Cardarelli Hospital due to the onset of SSNHL during the infection. All underwent a complete audio-vestibular investigation before and after SSNHL treatment protocol. Each patient is described with a detailed analysis. Conclusions: SSNHL could be an occasional symptom of COVID-19, even in mild manifestations of the disease. Our experience leads us to underline the value of promptly recognizing and addressing this and other uncommon symptoms, giving patients the opportunity to receive early treatment.
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Affiliation(s)
- Filippo Ricciardiello
- ENT Department, AORN Cardarelli, 80131 Napoli, Italy; (F.R.); (E.C.); (A.G.); (F.O.)
| | - Davide Pisani
- Unit of Audiology, Department of Experimental and Clinical Medicine, Magna Graecia University, 88100 Catanzaro, Italy; (P.V.); (G.C.)
- Correspondence: ; Tel.: +39-096-1364-7124
| | - Pasquale Viola
- Unit of Audiology, Department of Experimental and Clinical Medicine, Magna Graecia University, 88100 Catanzaro, Italy; (P.V.); (G.C.)
| | - Elisabetta Cristiano
- ENT Department, AORN Cardarelli, 80131 Napoli, Italy; (F.R.); (E.C.); (A.G.); (F.O.)
| | - Alfonso Scarpa
- Department of Medicine and Surgery, University of Salerno, 84084 Fisciano, Italy;
| | - Antonio Giannone
- ENT Department, AORN Cardarelli, 80131 Napoli, Italy; (F.R.); (E.C.); (A.G.); (F.O.)
| | | | - Giuseppe Russo
- Health Management AORN Cardarelli, 80131 Napoli, Italy; (G.R.); (C.C.)
| | - Marco Bocchetti
- Biogem Scarl, Molecular Oncology and Precision Medicine Laboratory, 83031 Irpino, Italy;
| | - Ciro Coppola
- Health Management AORN Cardarelli, 80131 Napoli, Italy; (G.R.); (C.C.)
| | - Marco Perrella
- Anesthesiology and Reanimation Department AORN Cardarelli, 80100 Napoli, Italy;
| | - Flavia Oliva
- ENT Department, AORN Cardarelli, 80131 Napoli, Italy; (F.R.); (E.C.); (A.G.); (F.O.)
| | - Giuseppe Chiarella
- Unit of Audiology, Department of Experimental and Clinical Medicine, Magna Graecia University, 88100 Catanzaro, Italy; (P.V.); (G.C.)
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Narozny W, Tretiakow D, Skorek A. In Reference to The Challenges of Pharmacotherapy of SARS-CoV-2 Infection in Patients With Sudden Sensorineural Hearing Loss Due to COVID-19. Laryngoscope 2021; 131:E2335. [PMID: 33729578 PMCID: PMC8251197 DOI: 10.1002/lary.29514] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/30/2021] [Accepted: 02/01/2021] [Indexed: 12/23/2022]
Affiliation(s)
- Waldemar Narozny
- Department of OtolaryngologyGdansk Medical UniversityGdanskPoland
| | - Dmitry Tretiakow
- Department of OtolaryngologyGdansk Medical UniversityGdanskPoland
| | - Andrzej Skorek
- Department of OtolaryngologyGdansk Medical UniversityGdanskPoland
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Beukes E, Ulep AJ, Eubank T, Manchaiah V. The Impact of COVID-19 and the Pandemic on Tinnitus: A Systematic Review. J Clin Med 2021; 10:2763. [PMID: 34201831 PMCID: PMC8268057 DOI: 10.3390/jcm10132763] [Citation(s) in RCA: 17] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/03/2021] [Revised: 06/17/2021] [Accepted: 06/20/2021] [Indexed: 01/08/2023] Open
Abstract
This review aimed to systematically review what has been published regarding tinnitus during the coronavirus disease 2019 (COVID-19) pandemic up to March 2021 by performing both narrative and quantitative meta-analyses. Of the 181 records identified, 33 met the inclusion criteria, which generally had a fair risk of overall bias. In the included, 28 studies focused on the impact of the COVID-19 virus on tinnitus and 5 studies focused on the impact of the pandemic on tinnitus. From the studies identifying the impact of COVID-19 on tinnitus, there were 17 cross-sectional studies (n = 8913) and 11 case series or case report studies (n = 35). There were 2 cross-sectional studies (n = 3232) and 3 pre-post-test design studies (n = 326) focusing on the impact of the pandemic on tinnitus. No consistent patterns were found regarding the presentation of the tinnitus or additional factors that could have tinnitus developing in the disease impact studies. For the pandemic impact studies, the associated stress and anxiety of the pandemic were consistently suggested to contribute to tinnitus experiences. The pooled estimated prevalence of tinnitus post COVID-19 was 8% (CI: 5 to 13%). Medical professionals should be aware that tinnitus might be more problematic following the pandemic or after having COVID-19.
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Affiliation(s)
- Eldre Beukes
- Department of Speech and Hearing Sciences, Lamar University, Beaumont, TX 77710, USA; (A.J.U.); (T.E.); (V.M.)
- Vision and Hearing Sciences Research Centre, Faculty of Science and Engineering, Anglia Ruskin University, Cambridge CB1 1TP, UK
| | - Alyssa Jade Ulep
- Department of Speech and Hearing Sciences, Lamar University, Beaumont, TX 77710, USA; (A.J.U.); (T.E.); (V.M.)
| | - Taylor Eubank
- Department of Speech and Hearing Sciences, Lamar University, Beaumont, TX 77710, USA; (A.J.U.); (T.E.); (V.M.)
| | - Vinaya Manchaiah
- Department of Speech and Hearing Sciences, Lamar University, Beaumont, TX 77710, USA; (A.J.U.); (T.E.); (V.M.)
- Department of Speech and Hearing, School of Allied Health Sciences, Manipal University, Karnataka 576104, India
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Gheorghe DC, Niculescu AG, Bîrcă AC, Grumezescu AM. Nanoparticles for the Treatment of Inner Ear Infections. NANOMATERIALS (BASEL, SWITZERLAND) 2021; 11:1311. [PMID: 34067544 PMCID: PMC8156593 DOI: 10.3390/nano11051311] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 04/15/2021] [Revised: 05/12/2021] [Accepted: 05/13/2021] [Indexed: 12/13/2022]
Abstract
The inner ear is sensitive to various infections of viral, bacterial, or fungal origin, which, if left untreated, may lead to hearing loss or progress through the temporal bone and cause intracranial infectious complications. Due to its isolated location, the inner ear is difficult to treat, imposing an acute need for improving current therapeutic approaches. A solution for enhancing antimicrobial treatment performance is the use of nanoparticles. Different inorganic, lipidic, and polymeric-based such particles have been designed, tested, and proven successful in the controlled delivery of medication, improving drug internalization by the targeted cells while reducing the systemic side effects. This paper makes a general presentation of common inner ear infections and therapeutics administration routes, further focusing on newly developed nanoparticle-mediated treatments.
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Affiliation(s)
- Dan Cristian Gheorghe
- “Carol Davila” University of Medicine and Pharmacy, 050474 Bucharest, Romania;
- “M.S. Curie” Clinical Emergency Hospital for Children, 050474 Bucharest, Romania
| | - Adelina-Gabriela Niculescu
- Faculty of Engineering in Foreign Languages, University Politehnica of Bucharest, 060042 Bucharest, Romania;
| | - Alexandra Cătălina Bîrcă
- Faculty of Applied Chemistry and Materials Science, University Politehnica of Bucharest, 060042 Bucharest, Romania;
| | - Alexandru Mihai Grumezescu
- Faculty of Applied Chemistry and Materials Science, University Politehnica of Bucharest, 060042 Bucharest, Romania;
- Research Institute of the University of Bucharest—ICUB, University of Bucharest, 050657 Bucharest, Romania
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Sudden hearing loss and coronavirus disease 2019: the role of corticosteroid intra-tympanic injection in hearing improvement. The Journal of Laryngology & Otology 2021; 135:464-466. [PMID: 33913413 DOI: 10.1017/s0022215121001080] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/23/2022]
Abstract
BACKGROUND Coronavirus disease 2019 was first seen in December 2019. Due to the insidious and complex nature of the disease, the list of symptoms is rapidly expanding. So far, few studies have reported sudden sensorineural hearing loss as a possible symptom of coronavirus disease 2019. CASE REPORT A 60-year-old woman with a complaint of sudden sensorineural hearing loss and subjective severe tinnitus presented to the ENT clinic. Coronavirus disease 2019 was subsequently confirmed with a polymerase chain reaction test. At the time of presentation, she was treated with intra-tympanic dexamethasone. Improvements in hearing threshold and speech perception, and a subjective reduction in tinnitus, were observed after treatment. CONCLUSION This case report supports evidence from other case reports of a possible association between coronavirus disease 2019 and sudden sensorineural hearing loss. Sudden sensorineural hearing loss may be a symptom of this disease that behaves as an underlying aggravating factor. Intra-tympanic injection of corticosteroids is recommended for managing these patients during the pandemic.
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Beckers E, Chouvel P, Cassetto V, Mustin V. Sudden sensorineural hearing loss in COVID-19: A case report and literature review. Clin Case Rep 2021; 9:2300-2304. [PMID: 33936683 PMCID: PMC8077296 DOI: 10.1002/ccr3.4019] [Citation(s) in RCA: 21] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/22/2020] [Revised: 02/02/2021] [Accepted: 02/21/2021] [Indexed: 12/23/2022] Open
Abstract
We encourage SARS-CoV-2 polymerase chain reaction in the diagnostic workup of patients currently presenting with sudden sensorineural hearing loss.
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Affiliation(s)
- Eline Beckers
- Department of Otorhinolaryngology‐Head and Neck SurgeryCliniques de l’EuropeBrusselsBelgium
| | - Pascale Chouvel
- Department of Otorhinolaryngology‐Head and Neck SurgeryCliniques de l’EuropeBrusselsBelgium
| | | | - Vincent Mustin
- Department of Otorhinolaryngology‐Head and Neck SurgeryCliniques de l’EuropeBrusselsBelgium
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43
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Almufarrij I, Munro KJ. One year on: an updated systematic review of SARS-CoV-2, COVID-19 and audio-vestibular symptoms. Int J Audiol 2021; 60:935-945. [PMID: 33750252 DOI: 10.1080/14992027.2021.1896793] [Citation(s) in RCA: 65] [Impact Index Per Article: 21.7] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
Abstract
OBJECTIVE The aim was to systematically review the literature to December 2020, in order to provide a timely summary of evidence on SARS-CoV-2, COVID-19 and audio-vestibular symptoms. DESIGN The protocol was registered in the International Prospective Register of Systematic Reviews. The methods were developed in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-analyses guidelines. Risk of bias was assessed using the National Institutes of Heath quality assessment tools. STUDY SAMPLE After rejecting 850 records, 28 case reports/series and 28 cross-sectional studies met the inclusion criteria. RESULTS There are multiple reports of hearing loss (e.g. sudden sensorineural), tinnitus and rotatory vertigo in adults having a wide range of COVID-19 symptom severity. The pooled estimate of prevalence based primarily on retrospective recall of symptoms, was 7.6% (CI: 2.5-15.1), 14.8% (CI: 6.3-26.1) and 7.2% (CI: 0.01-26.4), for hearing loss, tinnitus and rotatory vertigo, respectively. However, these could be an over-estimate because it was not always clear that studies report a change in symptom. CONCLUSION There are multiple reports of audio-vestibular symptoms associated with COVID-19. However, there is a dearth of high-quality studies comparing COVID-19 cases and controls. REVIEW REGISTRATION Prospective Register of Systematic Reviews (PROSPERO); registration number CRD42020227038).
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Affiliation(s)
- Ibrahim Almufarrij
- Manchester Centre for Audiology and Deafness, School of Health Sciences, University of Manchester, Manchester, UK.,Department of Rehabilitation Sciences, College of Applied Medical Sciences, King Saud University, Riyadh, Kingdom of Saudi Arabia
| | - Kevin J Munro
- Manchester Centre for Audiology and Deafness, School of Health Sciences, University of Manchester, Manchester, UK.,Manchester University Hospitals NHS Foundation Trust, Manchester Academic Health Science Centre, Manchester, UK
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Ferreira RJDS, Barboza HN, Araújo ALDLES, Paiva SFD, Rosa MRDD. Auditory and vestibular symptoms after COVID-19 infection: a preliminary Brazilian report. REVISTA CEFAC 2021. [DOI: 10.1590/1982-0216/20212368121] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022] Open
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45
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Fancello V, Hatzopoulos S, Corazzi V, Bianchini C, Skarżyńska MB, Pelucchi S, Skarżyński PH, Ciorba A. SARS-CoV-2 (COVID-19) and audio-vestibular disorders. Int J Immunopathol Pharmacol 2021; 35:20587384211027373. [PMID: 34142589 PMCID: PMC8216371 DOI: 10.1177/20587384211027373] [Citation(s) in RCA: 40] [Impact Index Per Article: 13.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/23/2021] [Accepted: 06/03/2021] [Indexed: 12/23/2022] Open
Abstract
To describe the audio-vestibular disorders related to the newly SARS-CoV-2 infection, including the possible ototoxicity side-effects related to the use of drugs included in the SARS-CoV-2 treatment protocols. A systematic review was performed according to the PRISMA protocol. The Medline and Embase databases were searched from March 1, 2020 to April 9, 2021. Initially the search yielded 400 manuscripts, which were reduced to 15, upon the application of inclusion criteria. Sensorineural hearing loss (SNHL) is the most frequent audio-vestibular symptom described, occurring alone or in association with tinnitus and vertigo. The etiopathogenesis of the inner ear disorders related to COVID-19 infection is still poorly understood. The number of reports of COVID-19 infections associated to audio-vestibular disorders is increasing; even if the quality of the studies available is often insufficient, audio-vestibular disorders should be considered as possible manifestations to be included among the symptoms of this infection.
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Affiliation(s)
- Virginia Fancello
- ENT and Audiology Unit, Department of Neuroscience and Rehabilitation, University Hospital of Ferrara, Ferrara, Italy
| | - Stavros Hatzopoulos
- ENT and Audiology Unit, Department of Neuroscience and Rehabilitation, University Hospital of Ferrara, Ferrara, Italy
| | - Virginia Corazzi
- ENT and Audiology Unit, Department of Neuroscience and Rehabilitation, University Hospital of Ferrara, Ferrara, Italy
| | - Chiara Bianchini
- ENT and Audiology Unit, Department of Neuroscience and Rehabilitation, University Hospital of Ferrara, Ferrara, Italy
| | - Magdalena B Skarżyńska
- Institute of Sensory Organs, Kajetany, Poland
- Institute of Physiology and Pathology of Hearing, Warsaw, Poland
| | - Stefano Pelucchi
- ENT and Audiology Unit, Department of Neuroscience and Rehabilitation, University Hospital of Ferrara, Ferrara, Italy
| | - Piotr Henryk Skarżyński
- Institute of Sensory Organs, Kajetany, Poland
- Institute of Physiology and Pathology of Hearing, Warsaw, Poland
- Department of Heart Failure and Cardiac Rehabilitation, Medical University of Warsaw, Warsaw, Poland
| | - Andrea Ciorba
- ENT and Audiology Unit, Department of Neuroscience and Rehabilitation, University Hospital of Ferrara, Ferrara, Italy
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