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 Table of Contents  
Year : 2022  |  Volume : 9  |  Issue : 1  |  Page : 66-71

Hearing loss and tinnitus among pediatric patients with COVID-19 infection: our experience

1 Department of Otorhinolaryngology and Head and Neck Surgery, Institute of Medical Sciences and SUM Hospital, Siksha “O” Anusandhan University, Bhubaneswar, Odisha, India
2 Department of Microbiology, Institute of Medical Sciences and SUM Hospital, Siksha “O” Anusandhan University, Bhubaneswar, Odisha, India

Date of Submission16-Aug-2021
Date of Acceptance11-Jan-2022
Date of Web Publication23-Mar-2022

Correspondence Address:
Dr. Santosh Kumar Swain
Department of Otorhinolaryngology and Head and Neck Surgery, Institute of Medical Sciences and SUM Hospital, Siksha “O” Anusandhan University, K8, Kalinga Nagar, Bhubaneswar 751003, Odisha.
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/mgmj.mgmj_61_21

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Background: Hearing impairment and tinnitus are common otological manifestations found in the outpatient Department of Otorhinolaryngology. Hearing loss and tinnitus have been documented among coronavirus disease-2019 (COVID-19) patients. However, these clinical manifestations were rarely investigated among pediatric patients with COVID-19 infections. Objective: This study aims to evaluate the prevalence of hearing impairment and tinnitus among children with COVID-19 infection at a teaching hospital. Materials and Methods: This is a prospective and descriptive study where 192 children with COVID-19 infections were evaluated for hearing loss and tinnitus. There were 44 (22.91%) children with COVID-19 infections presenting with hearing loss and tinnitus. All of the children were confirmed as COVID-19 infection with the help of reverse transcription-polymerase chain reaction of the nasopharyngeal swab. Detailed history taking and clinical examination of the ear were done for the assessment of hearing loss and tinnitus and its outcome was analyzed. Results: Out of 44 children, 20 (45.45%) were presented with tinnitus, 16 (36.36%) were presented with hearing loss, and 8 (18.18%) were presented with both hearing loss and tinnitus. Out of 44 pediatric patients with hearing loss and/or tinnitus, 26 (59.09%) were males and 18 (40.90%) were females with a male child to female child ratio of 1.44:1. The mean age of the participants was 9.16 years with an age range from 5 to 18 years. The sporadic type of tinnitus is more common than any other type. Conclusion: This study showed that the presence of subjective neurological features like hearing loss and tinnitus can be found in children with COVID-19 infection. More studies are required to confirm the exact pathophysiology mechanism underlying this subjective symptom in pediatric patients with COVID-19 infection.

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

How to cite this article:
Swain SK, Panda S, Jena PP. Hearing loss and tinnitus among pediatric patients with COVID-19 infection: our experience. MGM J Med Sci 2022;9:66-71

How to cite this URL:
Swain SK, Panda S, Jena PP. Hearing loss and tinnitus among pediatric patients with COVID-19 infection: our experience. MGM J Med Sci [serial online] 2022 [cited 2022 May 17];9:66-71. Available from: http://www.mgmjms.com/text.asp?2022/9/1/66/340588

  Introduction Top

Hearing loss and tinnitus are regarded as intangible hindrances for those who suffer from them, and they are linked to psychological solitary confinement.[1] Coronavirus disease-2019 (COVID-19) infection was more common in adults than pediatric age groups in the initial period of a pandemic. COVID-19 infections are later discovered in the pediatric age group in many parts of the world.[2] Because younger children are unable to wear masks and have not taken any additional precautions, the number of youngsters infected with severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) has increased dramatically, necessitating special attention.[2] The clinical manifestations of the patients with COVID-19 infection vary from mild upper respiratory tract symptoms to acute respiratory distress syndrome (ARDS) along with body ache, fever, cough, olfactory dysfunction, and taste disorder.[3] COVID-19 pediatric patients may also manifest neurological symptoms along with respiratory problems. The neurological symptoms may be seen in around 30% of individuals with SARS-CoV-2 infections.[4] The neurotropic nature of COVID-19 infections is still being investigated. COVID-19 individuals have reported neurological problems such as headaches, loss of consciousness, and dizziness.[5] Olfactory dysfunctions and taste disorders are also two important neurological manifestations found in COVID-19 infections.[6] In addition to different neurological symptoms, some COVID-19 patients show neuro-otological symptoms such as hearing loss, tinnitus, dizziness, and otalgia.[7] Although hearing impairment and tinnitus are common clinical manifestations encountered in the outpatient department of otorhinolaryngology and often happen due to otological etiology, but also reported in a few cases of COVID-19 patients.[8] Persistent hearing impairment and tinnitus in patients with COVID-19 infection result in a disturbing quality of life and often hinder the routine work of a person including a high impact on the speech development of the children.[9] Parents, caretakers, and healthcare professionals are often concerned for children with COVID-19 infections suffering from hearing loss and tinnitus, however, the neuro-otological symptoms like hearing loss and tinnitus have been only partially investigated in the current pandemic specifically the pediatric age group. Here, we study the details of the hearing impairment and tinnitus among children with COVID-19 infection at a teaching hospital in the eastern part of India.

  Materials and methods Top

Between May 2020 and June 2021, a prospective and descriptive study was undertaken at a tertiary care teaching hospital. The Institutional Ethical Committee approved this study. All participants underwent a detailed medical examination and relevant history was documented such as age, sex, duration, patients of COVID-19 infection with their severity, and place where patient stayed for isolation/treatment. The parents/caregivers of the children who took part in the study gave their informed consent to be participated in the study and to the use of anonymized data from the questionnaire responses [Table 1]. Those pediatric patients who recovered from proven COVID-19 infection and complained of hearing impairment and tinnitus were enrolled in this study. This study included children with a history of a positive nasopharyngeal swab for SARS-CoV-2, independent of the severity of the disease or the need for oxygen assistance during therapy. The recovery was defined as a negative report of reverse transcription-polymerase chain reaction. The children who enrolled in this study were under the age of 18 years. The exclusion criteria included children of COVID-19 infections with subjective intensive care in hospital by severe infection with SARS-CoV-2, history of acoustic/noise trauma or noise exposure for a prolonged period, known otological diseases before confirmation of COVID-19 infection or history of ear surgery, psychiatry disorder, cardiovascular diseases, or vascular comorbidities, or medical treatment with hydroxychloroquine/chloroquine. The risk factors like hypertension, diabetes mellitus, and if any steroid taken by the patient during the treatment period were documented. All participants were also asked for any loss of smell and taste sensation during or after the treatment of COVID-19 infections. Otoscopic examinations and tuning fork tests for hearing assessment of the participants were done with the use of appropriate protective measures. Using Telephonics TDH39 earphones, pure tone audiometry was performed at 250, 500, 1000, 2000, 4000, and 8000 Hz. The audiometric evaluation was carried out in a sound-proofed room with a GSI 61 clinical audiometer. The average hearing threshold was calculated at 500 Hz, 1000 Hz, and 2000 Hz. Hearing loss was defined as a pure tone average of more than 25 dB. To rule out middle ear pathology, tympanometry was performed using a plaid 775 middle ear analyzer. Those children not cooperated in pure tone audiometry, their hearing was tested with a tuning form test with the use of 256, 512, and 1024 Hz tuning forks. The Madsen Capella Analyzer was used to record transient evoked otoacoustic emissions (TEOAEs) in all of the patients. The stimuli in TEOAEs were a nonlinear click in the external auditory canal at roughly 80 db SPL. To avoid the ringing sound of the input stimuli, the spectrum analyzer was activated 4 ms after the stimuli were presented, and the temporal window was set at 20 ms. Magnetic resonance imaging (MRI) was done in all cases with unilateral tinnitus and or unilateral sensorineural hearing loss (SNHL) to rule out any cerebellopontine angle lesions.
Table 1: Questionnaire for evaluation tinnitus among COVID-19 patients

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Statistical Packages for Social Sciences (SPSS), version 23, SPSS Inc., Chicago, IL, USA, was used for the statistical analysis.

  Results Top

During the current COVID-19 epidemic, 192 pediatric patients with positive nasopharyngeal/oropharyngeal swabs for SARS-CoV-2 were tested for hearing loss and tinnitus. All were under 18 years of age. Out of 192 children, 44 were presented with hearing loss and tinnitus. The age range of the pediatric COVID-19 patients with tinnitus was 5–18 years with a mean age of 9.16 (standard deviation [SD] ± 12; median 9). There were 19 children in the age range of 5–10 years whereas 25 children in the age range of 11–18 years. Out of 44 children of COVID-19 infection with hearing loss and tinnitus, 26 were males and 18 were females with a male to female ratio of 1.44:1. Among 44, there were 33 (75%) children with COVID-19 infections home quarantined with medical treatment whereas 11 (25%) were hospitalized. Sixteen children presented with only hearing loss, 20 presented with only tinnitus, and 8 presented with both hearing loss and tinnitus [Table 2]. All 16 children presented with hearing impairment were confirmed as SNHL by a tuning fork test and pure tone audiometry. There were 23 (52.27%) children who developed the decreased sensation of smell and 20 (45.45%) had decreased taste sensation out of 44 COVID-19 pediatric patients with hearing loss and tinnitus. Five children developed balance problems/vertigo out of 44 patients. There were 20 (64.28%) pediatric COVID-19 patients who described tinnitus alone and eight presented with tinnitus along with hearing loss. Out of 28 patients with tinnitus, 13 presented with the recurrent type of tinnitus whereas 15 presented with the occasional or sporadic type of tinnitus. Out of 28 COVID-19 children with tinnitus, 14 described tinnitus of fluctuating intensity in nature, 8 described persistently but changing the intensity of tinnitus in nature, 4 described continuous/persistent with same intensity tinnitus, and 2 (7.14%) described the pulsatile type of tinnitus [Table 3]. Sixteen COVID-19 children were diagnosed with SNHL solely, while eight were diagnosed with hearing loss plus tinnitus. Out of 24 children with SNHL, 17 presented with bilateral SNHL, and 7 presented with bilateral SNHL [Table 4]. Out of 24 patients, 17 presented with reduced TEOAE.
Table 2: Clinical profile COVID-19 pediatric patients

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Table 3: Tinnitus characteristics in COVID-19 patients

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Table 4: Hearing profile of the pediatric patients with COVID-19 infections

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Out of 44 COVID-19 children with hearing loss, 5 had a history of migraine, 11 had taken steroids during the treatment period of SARS-CoV-2 infection, 2 had diabetes mellitus, and nobody had a history of hypertension [Table 5].
Table 5: Clinical profile of COVID-19 pediatric patients with hearing loss and tinnitus

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  Discussion Top

Hearing loss and tinnitus are commonly described complaints among patients at the outpatient Department of Otolaryngology. Hearing loss in the pediatric age usually affects speech and hampers communication in daily life.[10] Tinnitus is a sound perception that occurs when there is no external or internal source of sound and significantly affects the quality of life of a patient.[11] Tinnitus and SNHL are often caused by a viral infection and viral infections typically affect/damage the labyrinthine hair cells; however, some viruses can involve the auditory brainstem.[12] COVID-19 infection is a highly contagious disease caused by a novel virus called SARS-CoV-2. COVID-19 infections cause otoneurological symptoms like tinnitus and hearing loss.[13] The neurotrophic and neuroinvasive properties are the typical features of COVID-19 infections.[14] Coronavirus can involve the brain and result in possibly neuroauditory impairment.[15] There may be direct involvement of the central nervous system or result in vascular injury causing vasculitis by SARS-CoV-2 similar to the mechanism of the human immunodeficiency virus (HIV) and varicella-zoster. The vasculopathy by the SARAS-CoV-2 infection can be the direct result of hypercoagulability.[16] The treatment of COVID-19 infection at the beginning of the pandemic by chloroquine or hydroxychloroquine is also known to cause inner ear damage and result in tinnitus and SNHL.[17] COVID-19 infection has been shown to have negative effects on the outer hair cells of the cochlea in one study.[18] The mechanism of viral injury to the peripheral auditory system, including direct damage to the organ of Corti, stria vascularis, or spiral ganglion, injury mediated by the patients’ immune system against virally expressed proteins (cytomegalovirus), and immunocompromise leading to secondary bacterial infections of the inner ear (HIV and measles).19] Diabetes mellitus is often acted as aggravating factor for causing sensorineural and hearing loss.[20] In this study, 4.54% of cases were diagnosed with diabetes mellitus whereas no children were not known cases of hypertensive. One study on juvenile insulin-dependent diabetes mellitus showed 21% hearing loss and all of them suffered from SNHL and affected all frequencies.[21]

The cochleovestibular system involvement by a viral infection such as SARS-CoV-2 and stress of patients during the current pandemic are causes of more cochlear symptoms like tinnitus.[22] During the infection period, the COVID-19 patient usually stays in quarantine in-home or stay in the hospital, so they are socially isolated, lonely, and with poor sleep which makes them at risk for developing increasing severity of tinnitus. As the COVID-19 pandemic is expected to stay for a longer time, so emotional, social, and health implications may continue for some time. COVID-19 patients with hearing loss and tinnitus often complain that they are neglected by health care professionals by not understanding their difficulties because of their morbid symptoms.[23] In this study, 25% of pediatric COVID-19 patients with hearing loss and tinnitus were hospitalized whereas 75% of them were home quarantined with appropriate treatment. One study showed 21.9% required hospitalization whereas 78.1% underwent home isolation.[24]

Fever, tiredness, cough, gastrointestinal symptoms, sore throat, headache, olfactory, and taste dysfunctions are some of the clinical signs of COVID-19 individuals.[25] Females and younger age groups experience significantly more cochlear symptoms during the COVID-19 pandemic.[12] COVID-19 patients may present with olfactory and taste dysfunction along with the presence of hearing impairment and tinnitus as there is a common mechanism of the neuroinvasive nature of the SARS-CoV-2 virus. A cochlear symptom like tinnitus is usually exacerbated by self-isolation, experiencing loneliness, decreased or poor quality of sleep, and reduced levels of physical exercise.[26] The tinnitus may be recurrent, sporadic, fluctuating, or persistent. In this study, 46.42% of cases of pediatric patients of COVID-19 infections with cochlear symptoms present recurrent tinnitus whereas 53.57% present with sporadic tinnitus. Depression, anxiety, irritability, and financial worries in the current pandemic period further contribute to more bothersome tinnitus.[27] Even though the majority of the young patients in this study were asymptomatic to mildly symptomatic, COVID-19 infections hurt cochlear functioning. In this study 44 (22.91%) patients out of 192 study groups presented with cochlear symptoms such as SNHL and tinnitus. In the pediatric age, hearing loss has a vital role in communication and interaction, leading to an invisible handicap of the affected children and also causing psychological impairment. There is a paucity of literature related to SNHL and tinnitus of children diagnosed with COVID-19 infection. Female and younger age patients experience greater cochlear symptoms during the COVID-19 pandemic.[12] In this study, cochlear symptoms were more in the 11–18 years of age group and male to female ratio of 1.44:1.

Medical history data is an important part of investigating COVID-19 patients with hearing loss and tinnitus. Proper history taking must be needed in survivors of COVID-19 patients who those undertaken treatments with chloroquine or hydroxychloroquine as these may be associated with a high chance of developing hearing loss and tinnitus.[28] Complete audiological assessments are required for patients with hearing loss and tinnitus which include tuning fork test, pure tone audiometry, and tympanometry.[29] Pure tone audiometry testing and tympanometry are important audiological tests which usually performed in a soundproof room. Pure tone audiometry assesses the degree and type of hearing impairment whereas tympanometry evaluates middle ear pathology and eustachian tube function. In tympanometry, type-A suggests normal middle ear, type-C indicates eustachian tube dysfunction and type-B indicates fluids in the middle ear. An otoacoustic emission (OAE) is a form of energy produced by the cochlea’s outer hair cells. OAE may be spontaneous (SOAE) type, evoked type induced by transient stimuli such as clicks or tone bursts (TEOAEs). TOAEs are not invasive tests and so can be performed easily. This test requires lesser time, lesser cost, and higher sensitivity.[10] TOAE amplitude decreases, indicating modest degradation of the cochlea’s outer hair cells. As SARS-CoV-2 virus has deleterious effects on the outer hair cells of the cochlea, may affect the low-frequency threshold of pure tone audiogram, and also has an impact on TOAE and DPOAE low-frequency amplitudes. Any injury in the outer hair cells of the cochlea is seen by the reduced amplitude of TEOAEs and DPOAEs. MRI is useful to rule out any lesions in the brain and inner ear.

The effective management of the COVID-19 infection is still under investigation. It is often challenging for clinicians to detect the exact etiology for cochlear symptoms in COVID-19 patients and to start appropriate treatment for getting maximum clinical recovery from hearing loss and tinnitus. For managing hearing loss and tinnitus, evaluation of hypertension, diabetes mellitus, thyroid function test, lipid profile, allergies, and factors aggravating tinnitus such as stress, nicotine, caffeine, and aspirin intake must be taken into consideration and managed.[30] Pharmacological drugs such as lidocaine, antidepressants, benzodiazepines, and caroverine may be useful for tinnitus and give some benefit to the patients. Gingko Biloba is a common alternative herbal medicine prescribed by many clinicians for the treatment of tinnitus and sensorineural hearing impairment.[31] Hearing aids, tinnitus retraining treatment (TRT), masking, amplification, and limiting triggering chemicals, as well as specific environmental conditions, are all nonpharmacological treatments. For the treatment of hearing loss and tinnitus, masking usually covers or partially covers the tinnitus with an external sound. TRT, which combines counseling and sound generator therapy, is a more effective treatment for tinnitus in the current COVID-19 pandemic than masking.

  Conclusion Top

Children with COVID-19 infections have a higher risk of tinnitus and hearing impairment, particularly sensorineural type. Pathogenesis of sensorineural hearing impairment and tinnitus among children infected with SARS-CoV-2 is not well defined. The etiopathogenesis, clinical symptoms such as hearing loss and tinnitus, and human transmission of this disease are all poorly understood. To ensure a thorough grasp of this inner ear etiology, pediatric COVID-19 patients should have their cochlear symptoms monitored regularly. Routine hearing loss and tinnitus screening with tuning fork tests, pure tone audiometry, and otoacoustic emission should be advised among COVID-19 positive children patients for early diagnosis and suitable rehabilitation. In the current pandemic, raising awareness of hearing loss and tinnitus among COVID-19 pediatric patients is critical. The incidence of SNHL and tinnitus can be reduced by early detection of cochlear symptoms and early beginning of focused treatment for pediatric patients.

Financial support and sponsorship


Conflicts of interest

There are no conflicts of interest

Ethical consideration

This study was approved by the Institutional Ethical Committee (IEC) with reference number IEC/IMS/SOAU//36/12.04.2020.

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  [Table 1], [Table 2], [Table 3], [Table 4], [Table 5]


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