Q&A: Tinnitus worsening amid pandemic in patients with, without COVID-19

Tinnitus appears to be worsening in patients during the COVID-19 pandemic, including those who were and were not infected with the novel coronavirus, according to research published in Frontiers in Public Health.

Researchers conducted a mixed-methods exploratory cross-sectional study using information gathered from an online survey of people with tinnitus from 48 countries, primarily in North America (49%) and Europe (47%).

The survey focused on reports of tinnitus during the COVID-19 pandemic, and participants were recruited mostly through the social media accounts of professional organizations, including the American Tinnitus Association and the British Tinnitus Association.

Responses from 3,103 participants were included in the study, seven of whom reported that their tinnitus was initiated by COVID-19.

The researchers found that 40% of respondents with COVID-19 symptoms reported that these symptoms significantly exacerbated their tinnitus, while 54% reported no change in tinnitus symptoms, and 6% reported that their tinnitus improved.

Additionally, 32% of participants reported that other factors such as social and emotional effects stemming from the COVID-19 pandemic made their preexisting tinnitus more bothersome.

Healio Primary Care spoke with Eldré W. Beukes, PhD, a post-doctoral researcher and research audiologist at Lamar University in Beaumont, Texas, and Anglia Ruskin University in Cambridge, United Kingdom, to learn more about the findings, what physicians should know about tinnitus in COVID-19 and support they can offer their patients.

Q: What are the long-term health effects associated with tinnitus?

A: Tinnitus is often associated with hearing loss, though often hearing loss comes first and due to that, a lot of people develop tinnitus. Having a hearing loss can lead to lots of additional effects — lots of new research associates untreated hearing loss to dementia, for instance. Due to the communication difficulties experienced, those with a hearing loss often withdraw socially as well. Those with tinnitus are at greater risk for developing psychological conditions such as anxiety and/or depression. It’s hard to know which comes first, but there’s definitely a two-way relationship. It could be a lot of anxiety that causes tinnitus, or the other way around, that the difficulties experienced living with tinnitus may lead to anxiety and depression. Longer-term effects of tinnitus would be more inclined to go with more mental health conditions. Sometimes, tinnitus is a symptom of a medical condition such as Ménière's disease, where you’d have a lot of dizziness, hearing loss and tinnitus associated with it, but tinnitus in itself isn’t necessarily going to result in a long-term health condition.

Q: What factors may lead tinnitus to worsen in patients with or without COVID-19 during the pandemic?

A: There appeared to be various factors leading to tinnitus worsening during the pandemic. Firstly, for those without COVID-19, there were four main reasons, namely, health-related factors, increased emotional stress, changes in lifestyle and restrictions on socializing. For instance, those who were more anxious, depressed or more irritable during the pandemic reported that their tinnitus was worse. Those who were more socially isolated and lonelier were also more inclined to say their tinnitus got worse. Those who were more at risk for developing COVID-19 due to additional health problems or concerns about their health also mentioned noticing their tinnitus worsening. People who were struggling to sleep and those who were more worried about finances than other people had a significant worsening of their tinnitus. Those who weren’t able to exercise to the same level were also affected, which may be that they did not have a means to reduce stress, anxiety and irritation without being able to go out an exercise as easily. It’s hard to tease out exactly which of those factors, in isolation, would do it. But there were lots of factors that seemed to indicate that they were affecting tinnitus.

And then, in those who had COVID-19, a large percentage reported that their tinnitus worsened and we probably need to look into that in more depth. It’s really hard to say from our study exactly why tinnitus worsened. We did ask for reasons, and some reported no knowing. Others said they really did feel very poorly with the virus and thought that their tinnitus was affected by the virus. We know that viral infections can cause hearing loss and in some cases problems like vestibular neuritis or labyrinthitis. It’s also possible that the effect of having the virus increased stress due to related anxieties surrounding being in the hospital, not being close to relatives and worrying about what’s going to happen.

Q: What may be causing patients without preexisting tinnitus to develop the condition after COVID-19 illness?

A: It’s not something a lot of us were considering at the start of COVID-19, and there are more and more reports and research coming out and individual case studies of people developing tinnitus after the virus. Various viral infections such as rubella, measles and mumps are all known to affect the ear, sometimes having a temporary effect and sometimes a more permanent effect. There is also the possibility that the stress associated with being that ill could also contribute. We certainly need more research to see if there is an association and the mechanisms behind this possible association.

Q: A recent case report described irreversible hearing loss in a patient with COVID-19. Does this, combined with your findings, suggest that COVID-19 may lead to long-term effects on hearing?

A: It’s definitely a possibility that cannot be ruled out at this stage. More such findings are being reported, such as that by Kevin Munro, PhD, in the U.K., where they report that some patients developed hearing loss after having COVID-19. To date, it does look like the hearing loss remains after recovering from COVID-19, but we have to monitor these patients longer term to monitor the effect. Quite a few researchers are developing protocols to investigate these possible associations further.

Q: Should physicians be monitoring patients who had COVID-19 more frequently for tinnitus or hearing loss in general?

A: Definitely. We are hearing more and more reports of people saying that after having COVID-19, tinnitus is the only symptom that remained. Their sense of taste and sense of smell came back and their fatigue was getting better, but the tinnitus was still there after many months. Having tinnitus is experienced very differently by everybody. Some people are able to manage it and do not find it bothersome, but there is a cohort that finds it very distressing — and it can severely disrupt their daily living activities. Those who are easily distressed by tinnitus definitely need support. If we as a medical profession aren’t aware of the causation, we won’t be giving them that needed support. Hopefully, that’s something that’s going to come out of this — health care professionals will be more mindful of the possibility of tinnitus when someone has had COVID-19 and that will be one of the questions they ask. We can build up more of a database and find what percentage of patients have tinnitus and hearing loss following COVID-19, but then also direct them to appropriate support services to deal with the effects because there are things that can help manage the tinnitus, but people may need to be directed the most appropriate help.

Q: What kind of support can patients with tinnitus get?

A: At present, there’s no known cure for most people with tinnitus. For a small majority, tinnitus is related to another medical condition, and once the medical condition treated, tinnitus may be less noticeable, but that’s seldom the case. Often, addressing untreated hearing loss can make the tinnitus less noticeable. There are various things those with tinnitus can do to help them learn to manage tinnitus better to such an extent that it becomes less bothersome and they habituate to it, like they do to sounds or other stimuli. To reach this stage, having a toolbox of different strategies can be helpful as different things may work in different situations. It is helpful addressing things that could make tinnitus worse such as stress and anxiety, as when people are feeling less anxious, the tinnitus is often less noticeable. The strategy with the most evidence of effectiveness in tinnitus management to date is the use of cognitive behavioral therapy techniques, as it helps you teach people to reinterpret the tinnitus and think and react differently to it. There are also relaxation techniques and mindfulness, which are both really helpful. For some people, good social support can be very beneficial and having people who understand to speak to about their tinnitus. This may be support from a tinnitus helpline or being part of a tinnitus support group, even an online support group.

References:

• Beukes EW, et al. Front Public Health. 2020;doi:10.3389/fpubh.2020.592878.
• Koumpa SF, et al. BMJ Case Rep. 2020;doi:10.1136/bcr-2020-238419.