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Does the new crown pneumonia affect our hearing and vestibule?

 Last Update: 2022-10-20
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Since the "lockdown" of Wuhan in December 2019, the new coronavirus pneumonia (new coronavirus pneumonia, COVID-19) has been familiar to the people of the whole country, and the unprecedented "great escape" and the tragic "retrograde" have remained in the hearts of the
people of Wuhan and the whole country.
In the next 3 years, the new crown pneumonia spread all over the world, swallowing countless lives and leaving endless wounds
.
In addition to common respiratory system injuries, new crown pneumonia can leave "traces"
in the cardiovascular system, digestive system, genitourinary system, mental psychology and other aspects.
Will COVID have an impact on the nervous system, especially hearing and vestibule? We review
through the literature.

Written by Tinyel

This article is authorized by the author to be published by Yimaitong, please do not reprint
without authorization.

Effects of COVID-19 on hearing and vestibular

Judging from the literature, the new crown pneumonia has an impact
on hearing and vestibule.
It can be analyzed
from three aspects: symptoms, etiology/mechanism, and disease.
➤ Auditory - vestibular symptoms tinnitus, hearing loss, vertigo/dizziness, balance disorders
.
In the study of Viola et al.
, 23.
2% of patients with new coronary pneumonia experienced tinnitus, 18.
4% experienced balance disorders, 94.
1% of the latter patients experienced dizziness, and 5.
9%
experienced acute vertigo attacks 。 They believe that viral infections can damage inner ear cells, cause hearing loss, and some even affect the auditory brainstem; The virus is neuroinvasive, and the presence of coronavirus-related neurootological symptoms, such as tinnitus and balance disorders, has been demonstrated, so there is an association between
COVID-19 and auditory-vestibular symptoms.
The effect of the new coronavirus on neuronal tissue may be due to direct infection of the central nervous system by the virus, or related to vascular damage caused by vasculitis and vascular disease, similar to the mechanism of varicella zoster virus (VZV) and human immunodeficiency virus (HIV
).
Primary and secondary vasculitis are often associated with auditory-vestibular symptoms, and dizziness attacks
can occur in primary cardiovascular disease.
In another study of coronavirus and auditory-vestibular pneumonia, tinnitus was the most common auditory-vestibular symptom, with a prevalence of about 14.
8%.

Most studies have reported tinnitus in the early stages of COVID, but some studies have documented tinnitus in the late stages of COVID for days to weeks
, but not persisting.
The types of tinnitus are diverse, some are intermittent, some are continuous, and some are pulsating
.
In the study of Fancello et al.
, hearing loss was the most common auditory-vestibular symptom and could occur in isolation or with tinnitus or vertigo
.
Hearing loss associated with COVID-19 is very similar to the typical sudden sensorineural hearing loss, but conductive hearing loss has also been reported, and hearing loss can occur unilaterally or bilaterally, mild or moderate.

➤ Possible causes/mechanisms It is currently believed that the new coronary pneumonia affects the hearing-vestibular for the following main reasons:

1.
Cochleitis, neuritis

2.
Cross-reactivity

3.
Vascular disease

4.
Immune-mediated

5.
The drugs used in the treatment of new coronary pneumonia are ototoxic

Viral involvement of the inner ear or vestibular cochlear nerve causes cochleitis or neuritis, which can cause vertigo, tinnitus, and hearing loss, so coronavirus can be assumed to have a similar neurotropism
.
Ischemia
is prone to occur due to insufficient blood supply to the collateral branches of the cochlea and semicircular canal.
Microvascular damage can affect the central and peripheral nervous systems, causing a variety of neurological symptoms
such as headaches and dizziness.
Immune-mediated responses such as the production of pre-inflammatory cytokines and vascular events
that may negatively affect the auditory vestibular system.
Cross-reactivity of antibodies or T cells can mistake inner ear antigens for viruses, causing accidental damage
to the inner ear.
Patients with new coronary pneumonia are prone to potentially ototoxic drugs such as hydroxychloroquine and azithromycin
during treatment.
Nearly 12% of new coronavirus patients in Europe take hydroxychloroquine and chloroquine, and azithromycin is included in multiple new coronary pneumonia treatment regimens, and these antiviral drugs have adverse reactions in clinical practice, including tinnitus and hearing loss, which may be misdiagnosed as caused
by new coronary pneumonia.
➤Common diseases Currently reported vestibular diseases related to new coronary pneumonia are vestibular neuritis (VN) and benign paroxysmal positional vertigo (BPPV).

Mat et al.
reported a case of
new coronary pneumonia with VN as a clinical manifestation.
The patient is a 13-year-old female presenting with sudden persistent rotational vertigo and severe vomiting without fever
.
The patient has no hearing loss, tinnitus, earache, or headache, and has no prior history of
vertigo.
Physical examination reveals spontaneous horizontal rotational nystagmus on the right side, step-in-place test turns to the left, and vHIT shows decreased VOR gain and saccade tracking in
the left anterior and outer semicircular canals.
Thus, the diagnosis
of VN is clarified.
During her hospitalization, she was diagnosed with COVID because her family was diagnosed with COVID and tested positive on a nasal swab
.
Jeong reported a case of acute vertigo episode diagnosed with VN
in a 54-year-old man who was vaccinated against new coronavirus.
The patient developed vertigo
2 days after receiving the first dose of the Pfizer-BioNTech vaccine.
The patient has no prior history of hearing loss and no recent upper respiratory tract infection
.
Physical examination reveals spontaneous horizontal twisting nystagmus on the right side, and no signs of
central vertigo.
After 3 days of conservative treatment, the left lateral semicircular canal was finally found to have decreased VOR gain without saccade tracking in vHIT, so the diagnosis was made to the upper left VN
.
Inflammation caused by the virus may be the mechanism
by which VN occurs in patients with new coronary pneumonia.
In a study of patients who developed acute vertigo after receiving the new crown vaccine, it was found that all patients with horizontal or rotating nystagmus were diagnosed with BPPV, accounting for 27% of
all patients with acute vertigo.
Some researchers believe that long-term hospitalization in bed may cause otolith detachment, causing BPPV
.
Other reported diseases include unilateral peripheral vestibular disease after vaccination and novel coronavirus pneumonia
manifested by acute labyrinthitis.

Other points of view

A retrospective analysis of 48 recovered patients with new coronary pneumonia found that in individual frequencies, patients with new coronary pneumonia were different from the control group in individual frequencies, and all patients were within the normal range of these frequencies; And in their study, no patients with new coronary pneumonia experienced objective hearing loss
due to new coronary pneumonia.
Therefore, they believe that even if the new crown pneumonia causes damage to the cochlea, it is temporary
.

Due to the need for protective equipment and careful disinfection of all surfaces, it is difficult for people with COVID-19 to have a complete vestibular assessment, and the chance of vomiting during the test increases the risk of infection, so few studies have studied vestibular function tests
in patients with vestibular symptoms.
Some researchers have found that the right anterior tube vHIT gain value of patients with new coronary pneumonia is significantly different from that of the control group, and there is no overt or implicit saccade
.
Therefore, they believe that no clinically relevant signs
of vestibular injury have been found in previous COVID-19 patients.
Whether a patient with COVID has transient vestibular nerve injury that is subsequently fully recovered, and what causes this injury, is unclear, but minor vestibular symptoms such as dizziness and balance disorders may simply be the result of severe weakness and fatigue in COVID patients, or a normal neurological response
to COVID.
Similarly, many scholars believe that the auditory-vestibular symptoms of new crown pneumonia patients may only be caused by anxiety and stress caused by the serious impact of life and work in the context of the pandemic, or the original underlying disease manifests
itself due to anxiety.
The author's comprehensive tertiary hospital is a local designated hospital for new coronary pneumonia, since the beginning of the new crown pneumonia outbreak, it is the only hospital in the province that has never stopped receiving new crown pneumonia patients, from our data, there are very few patients with auditory-vestibular symptoms, perhaps this also reflects that the impact of new coronary pneumonia on hearing-vestibular is uncommon or we focus more on more serious symptoms and ignore hearing and vestibular symptoms
.

References:

1.
HE Qinglin, LIU Fangli, JI Xinxin, et al.
Research progress of complications related to novel coronavirus pneumonia[J].
Journal of Henan University(Health Sciences),2020,39(6):391-396.
)

2.
Fancello V, Hatzopoulos S, Corazzi V, et al.
SARS-CoV-2 (COVID-19) and audiovestibular disorders.
Int J Immunopathol Pharmacol,2021; 35: 20587384211027373.

3.
Gallus R, Melis A, Rizzo D, et al.
Audiovestibular symptoms and sequelae in COVID-19 patients.
J Vestib Res, 2021; 31(5):381-387.

4.
Almufarrij I, Uus K, Munro KJ.
Does coronavirus affect the audio-vestibular system? A rapid systematic review.
Int J Audiol.
2020; 59(7):487-491.

5.
AlJasser A, Alkeridy W, Munro KJ, et al.
Is COVID-19 associated with self-reported audio-vestibular symptoms? Int J Audiol.
2021; 1-9.

6.
Almufarrij I, Munro KJ.
One year on: an updated systematic review of SARS-CoV-2, COVID-19 and audio-vestibular symptoms.
Int J Audio.
2021; 60(12):935-945.

7.
Viola P, Ralli M, Pisani D, et al.
Tinnitus and equilibrium disorders in COVID‑19 patients: preliminary results.
Eur Arch Otorhinolaryngol.
2021; 278(10):3725-3730.

8.
Di Mauro P, La Mantia I, Cocuzza S, et al.
Acute Vertigo After COVID-19 Vaccination: Case Series and Literature Review.
Front.
Med.
2022; 8:790931.

9.
Jeong JH.
Vestibular neuritis after COVID-19 vaccination.
Hum Vaccin Immunother.
2021; 17(12):5126-5128.

10.
Mat Q, Noël A, Loiselet L, et al.
Vestibular Neuritis as Clinical Presentation of COVID-19.
Ear Nose Throat J.
2021; 145561321995021.

11.
Schmid MB, Bächinger D, Pangalu A, Straumann D and Dlugaiczyk J (2022) Acute Unilateral Peripheral Vestibulopathy After COVID-19 Vaccination: Initial Experience in a Tertiary Neurotology Center.
Front.
Neurol.
13:917845.

12.
Perret, M.
; Bernard, A.
; Rahmani, A.
; Manckoundia, P.
; Putot, A.
Acute Labyrinthitis Revealing COVID-19.
Diagnostics 2021, 11, 482.

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