What treatment options are available for tinnitus and hearing loss after Covid-19?

Treatment Options for Tinnitus and Hearing Loss After COVID-19

For post-COVID-19 tinnitus and hearing loss, initiate oral corticosteroids (with or without intratympanic steroids) as the primary treatment, particularly when presenting within the first week of symptom onset, and consider gabapentin for severe tinnitus cases that persist despite conservative management. 1, 2

Initial Assessment and Timing

• Evaluate patients within the first week of symptom onset when possible, as approximately 75% of COVID-19-related sudden sensorineural hearing loss (SSNHL) cases present during this timeframe 1
• Perform comprehensive audiological testing including threshold tonal audiometry, tympanometry, otoacoustic emissions, and auditory brainstem evoked potentials (ABR) 3
• Document specific characteristics: bilateral vs. unilateral involvement, severity of hearing loss, presence of tinnitus, and associated symptoms (anosmia, dizziness, vertigo) 4, 1

Primary Treatment Approach

Corticosteroid Therapy

• Administer oral corticosteroids as first-line treatment for COVID-19-related SSNHL 1
• Consider adding intratympanic steroid injections for cases not responding to oral therapy alone 1
• Treatment with steroids achieved partial improvement in approximately 50% of cases, reducing mean hearing thresholds from 50.91 ± 11.777 dB to 40.24 ± 15.693 dB 1
• Note that treatment outcomes are not significantly affected by duration, laterality, or initial severity of hearing loss 1

Tinnitus-Specific Management

• For severe tinnitus with normal or near-normal hearing thresholds, initiate gabapentin 300 mg twice daily as this may represent a distinct pathophysiological subtype requiring neuromodulation 2
• Implement masking strategies as initial conservative management before pharmacological intervention 2
• Recognize that tinnitus emerging during or after COVID-19 does not differ significantly in characteristics from non-COVID-related tinnitus, suggesting no unique pathophysiological mechanism 5

Clinical Patterns and Prognostic Factors

Hearing Loss Characteristics

• Bilateral involvement (69% of cases) is more common than unilateral, with bilateral symmetrical deafness outnumbering asymmetrical patterns 1
• Sensorineural hearing loss occurs in approximately 65.5% of post-COVID-19 patients reporting hearing impairment 3
• Stapes reflex is absent in nearly 20% of post-COVID-19 patients, indicating middle ear involvement 3
• ABR testing reveals prolonged latencies of waves III and V, and increased I-III and I-V intervals, demonstrating auditory pathway involvement beyond the cochlea 3

Tinnitus Patterns

• New-onset tinnitus occurs in approximately 19.3% of COVID-19 patients 5
• Tinnitus is the most common associated otological symptom, present in 96% of SSNHL cases 1
• Among patients with pre-existing tinnitus, 30.8% report worsening after COVID-19 infection 5
• The overall occurrence rate of tinnitus in COVID-19 patients is approximately 4.5%, though with high variance between studies 4, 5

Pathophysiological Considerations

• COVID-19 causes damage to both the inner ear and the auditory pathway, likely through neuroinflammation, vascular damage from coagulopathy and endothelial dysfunction, and direct neuronal injury 4, 3
• The virus demonstrates affinity for nervous tissue, with prolonged auditory pathway conduction times indicating ongoing neurological involvement as part of long COVID syndrome 3
• Audiovestibular manifestations including tinnitus, hearing loss, and vertigo are recognized features of long COVID neurological symptoms 4

Important Clinical Caveats

• Hearing loss may be the sole presenting symptom of COVID-19 or emerge as a late complication due to postinfectious inflammation of nerve tissue 3
• No significant relationship exists between specific COVID-19 symptoms, pharmacological treatments (including hydroxychloroquine), and tinnitus onset, despite theoretical ototoxicity concerns 5
• The short prescription duration and low doses of potentially ototoxic medications used in COVID-19 treatment likely explain the lack of observed association 5
• Cognitive impairment and other neurological symptoms may coexist and persist for at least 2 years post-infection 4

Follow-Up and Monitoring

• Perform serial audiological assessments to track progression or improvement 3
• Monitor for development of additional long COVID symptoms including cognitive impairment, dysautonomia, and other neurological manifestations 4
• Provide specialist audiological care for all patients reporting hearing symptoms after COVID-19, regardless of initial severity 3
• Reassess treatment response at regular intervals, as outcomes may vary and some patients require prolonged management 1

4, 5, 2, 3, 1