Assessing and managing COVID-19 related tinnitus

In the era of COVID-19, audiologists around the world are answering the call for action and stepping up as leaders in tinnitus care. Here are evidence-based strategies to assess and manage this increasingly common hearing condition.

Tinnitus care is my passion. As an academic with extensive experience in tinnitus treatment, I teach postgraduate audiology students evidence-based clinical approaches in the assessment and management of tinnitus. I am actively involved in tinnitus research, co-authoring health reports with special interest in tinnitus epidemiology. I also host webinars to support audiologists who want to improve their skills and confidence in treating this unique population. As the pandemic continues to impact the quality of life of so many patients worldwide, I believe it is critical to examine the relationship between COVID-19 and tinnitus. What do we know so far and how can we help?

COVID-19 related health problems, beyond the lungs

While most people with coronavirus disease (COVID-19) recover completely within a few weeks, many of them experience long-term health problems that seem unrelated to the pathogen.1 Beyond the lungs, COVID-19 has been shown to damage the heart and brain.1,2 Recent studies among patients who recovered from the disease have also identified disturbances within the audio-vestibular system. 2,3,4

A telephone survey administered to COVID-19 patients eight weeks after discharge from a Manchester Hospital, revealed that 13.3 % of patients described a change in hearing and 8% of patients reported tinnitus.5 Another study found that a group of asymptomatic patients with confirmed COVID-19, had poorer high-frequency pure-tone thresholds and significantly reduced transient evoked otoacoustic emissions amplitude compared to a group of subjects with normal hearing.6 As viral infections often damage nerve tissue (e.g.: cytomegalovirus, measles, mumps), researchers have begun to hypothesize about a post-COVID auditory neuropathy responsible for tinnitus.7,8

Impact of public health measures and noise exposure

Factors other than COVID-19 might also be underlying the spike in tinnitus reported by many patients. Public health measures used to mitigate the spread of the virus such as enforced lockdown, social distancing, face covering, home-schooling of children, and closing of non-essential services (e.g.: hearing clinics) have had a negative impact on patients’ well-being.9 The decrease sound stimulation due to confinement, unemployment, loneliness, and loss of control have undoubtedly amplified the negative impacts of tinnitus.

Tinnitus is also on the rise and especially among young adults daily exposed to high level of sound with personal audio devices such as smartphones. A recent Canadian epidemiological study revealed that an estimated 37% of Canadians had experienced tinnitus in the past year.10 The prevalence of tinnitus in Canada is more than double the previously estimated value of 15%. The COVID-19 pandemic is expected to further increase the number of patients seeking tinnitus care.

Audiologists’ fundamental understanding of the auditory system and exhaustive knowledge in hearing aid technology position them as leaders in tinnitus care. The clinical framework discussed in this article will give audiologists the opportunity to transfer all skills gained in the assessment and management of hearing loss onto the treatment of patients with tinnitus.

Comprehensive guidelines for tinnitus assessment and management

Tinnitus is frequently associated with a host of auditory and non-auditory conditions such as hearing loss, trouble understanding speech-in-noise, hyperacusis, stress, anxiety, depression and insomnia. If left untreated, these comorbidities can exacerbate the distress associated with tinnitus and jeopardize the efficacy of audiological management strategies. It is, therefore, critical to expand the evaluation process across the following three axes:

  • Axis I  – hearing assessment;
  • Axis II – tinnitus assessment;
  • Axis III – emotional well-being screening.

Hearing assessment (Axis I):

A detailed case history provides clinicians with critical information about onset of tinnitus (i.e.: new symptom or pre-existing condition), associated hearing problems, impact on quality of life, maladaptive coping strategies and need for medical intervention(s). Beyond noise exposure and ear diseases, the case history should also include questions specific to health status and medications. For instance, drugs used to treat COVID-19 should be reviewed especially among patients with no previous history of hearing problem(s). Azithromycin, Quinine and Hydroxychloroquine have all been documented to cause tinnitus and hearing loss.11, 12

The hearing assessment also consists of pure tone and speech audiometry, speech-in-noise testing and acoustic immittance measures. Approximately 40% of tinnitus patients may have some degree of hyperacusis. Therefore, audiologists are advised to obtain informed consent prior to assessment as some procedures with high-level of sound stimulation (e.g.: loudness discomfort level and acoustic reflex) might cause discomfort and pain among these patients.13, 14 Extended high frequency audiometry and otoacoustic emission measures are also suggested as they are highly sensitive at detecting early tissue damage among tinnitus patients with clinically normal audiogram. 15, 16

Tinnitus assessment (Axis II):

The tinnitus psychoacoustic evaluation allows clinicians to gain insight on patients’ tinnitus in terms of its “perceived” pitch and loudness. This information is useful when selecting hearing aids for this population. Audiologists want to ensure proper amplification of low-intensity inputs at patients’ hearing thresholds in the frequency regions where tinnitus is perceived.17, 18

The tinnitus assessment also includes the use of standardized questionnaires, such as Tinnitus Handicap Inventory and Tinnitus Functional Index, for assessment of self-perceived difficulty, severity (i.e.: bothersome vs non-bothersome tinnitus) and treatment outcome.19, 20

The Tinnitus and Hearing Survey is also recommended as it allows the screening of patients attributing hearing and communication difficulties to tinnitus.21 Tinnitus is almost always associated with hearing loss. Indeed, it is estimated that 90% of tinnitus patients present with some degree of hearing loss.22, 23 Mandatory face covering has also raised awareness on the importance of having access to speech reading for patients with hearing loss.24 The added communication challenge has unquestionably intensified the emotional distress experienced by some tinnitus patients.

Emotional well-being screening (Axis III):

Tinnitus patients are more prone to anxiety and depression.25 It is, therefore, critical to screen for emotional disturbances in order to avoid unsuccessful treatment with amplification.26 The relationship between tinnitus distress and psychological disorders is well-documented.27 The Hospital Anxiety and Depression Scale and Patient Health Questionnaire (PHQ-9) are used by many clinicians for their ease of administration.28 If a patient scores high on an anxiety or depression questionnaire, a referral to a mental health professional for assessment and treatment takes priority over audiological intervention.

Clinicians should err on the side of caution when discussing patients’ mental health status while reporting scores obtained with these scales. Although it is in an audiologist scope of practice to screen for emotional disturbances, audiologists are not permitted to communicate mental health diagnose such as anxiety and depression.

Tinnitus management strategies

The use of hearing aid for the treatment of tinnitus is not a new idea. However, the efficacy of amplification for tinnitus relief has been systematically reviewed and established over the last decade.29 The benefits include reduction in tinnitus loudness, reduction in tinnitus severity, and improvement in quality of life.30 Sounds like the improvements reported by patients using hearing aids for communication difficulties doesn’t it? In fact, advances in hearing aid technology in terms of frequency bandwidth, built-in sound generator, direct connectivity to smartphones and remote care apps make it easier than ever to provide tinnitus services.

But hearing aid technology alone is not enough. The use of effective communication skills and an ability to empathize with patients’ struggle is crucial in helping them better manage their reactions to tinnitus.31-33 In order to demystify and normalize the experience of tinnitus, audiologists must also educate patients on an array of topics from anatomy and physiology of ear-brain connection, proposed neural mechanisms underlying its development, brain plasticity, effective coping strategies (e.g.: stress management and better sleep hygiene techniques) and realistic expectations with interventions.31, 33, 34. However, research warns about a link between low-level literacy skills and poor health outcomes. One-third of patients have difficulty understanding basic explanations related to diagnosis and recommendations.35 Anxiety can also reduce patients’ ability to process health information even for those with high-level literacy skills.36 Clinicians gain in using plain and concrete language rather than jargon and technical terms while counseling patients about tinnitus and treatment(s).

Finally, it can be challenging to recommend amplification as an effective treatment option for patients lumping all their hearing problems to tinnitus. The use of hearing aid demos is the best way to get this point across. Experiencing a noticeable change in tinnitus loudness with hearing aids, right at the initial consult, is often all that is needed to get them on board with amplification.

In the era of COVID-19, audiologists around the world are answering the call for action and stepping up as leaders in tinnitus care!

To learn more on tinnitus epidemiology, assessment protocols, management strategies and need for ongoing research, I invite you to read the Canadian Academy of Audiology scientific publication published last year titled, “Tinnitus in Canada: A Call for Action”.

 

References:

  1. Mayo Clinic Staff. COVID-19 (coronavirus): Long-term effects. Mayo Clinic. https://www.mayoclinic.org/diseases-conditions/coronavirus/in-depth/coronavirus-long-term-effects/art-20490351. Published August 18, 2020.
  2. Mao, L., Jin, M., Wang, Y., Hu, S., Chen, Q., He, J., Chang, C., Hong, Y., Zhou, D., Wang, X., Miao, Y., Li, Y., & Hu, Bo. (2020). Neurologic manifestations of hospitalized patients with coronavirus disease 19 in Wuhan, China. JAMA: 77(6); 683-690.
  3. Karimi-Galougahi, M., Naeini, A.S., Raad, N., Mikaniki, N., & Ghorbani, J. (2020). Vertigo and hearing loss during the COVID-19 pandemic – is there an association [Letter to the editor]? Acta Otorhinolaryngolica Italica: 1-3.
  4. Almufarrij, I., Uus, K., & Munro, K.J. (2020). Does coronavirus affect the audio-vestibular system? A rapid systematic review. International Journal of Audiology: 59 (7); 487-453.
  5. Munro, K.J., Uus, K., Almufarrij, M., Chaudhuri, N. & Yioe, V. (2020). Persistent self-reported changes in hearing and tinnitus in post-hospitalization COVID-19 Cases. International Journal of Audiology.
  6. Mustafa, M.W.M. (2020). Audiological profile of asymptomatic COVID-19 PCR- Positive cases. American Journal of Otolaryngology.
  7. Young, Y.H. (2020). Contemporary review of the causes and differential diagnosis of sudden hearing loss. International Journal of Audiology: 59 (4): 243-253
  8. Cohen, B.E., Durstenfeld, & A., Roehm, P.C. (2014). Viral causes of hearing loss: A review for hearing health professionals. Trends in Hearing; 1-17.
  9. Vindegaard, N. & Benros, M.E. (2020). COVID-19 pandemic and mental health consequences: Systematic review of the current evidence. Brain behavior and Immunity; 1-12.
  10. Ramage-Morin, P., Banks, R., Pineault, D. & Atrach, M. (2019). Tinnitus in Canada. Statistics Canada Health Reports.
  11. Prayuenyong, P., Kasbekar, A.V. & Baguley, D.M. (2020). Clinical implications of Chloroquine and Hydroxychloroquine ototoxicity for COVID-19 treatment: A mini-review. Frontiers in Public Health; 8(252).
  12. Ress, B.D. & Gross, E.M. (2000). Irreversible sensorineural hearing loss as a result of Azithromycin ototoxicity: A case report. Annals of Otology, Rhinology and Laryngology; 109(4):435-7.
  13. Baguley, D.M. (2003). Hyperacusis.Journal of Royal Society of Medicine; 96(12): 582–585.
  14. Aazh, H., & Moore, B.C.I. (2017). Incidence of discomfort during pure-tone audiometry and measurement of uncomfortable loudness levels among people seeking help for tinnitus and/or hyperacusis. American Journal of Audiology: 26; 226–232.
  15. Vielsmeier, V., Lehner, A., Strutz, J., Steffens, T., Kreuzer, P.M., Schecklmann, M., Landgrebe, M., Langguth, B. & Kleinjung, T. (2015). The Relevance of the high frequency audiometry in tinnitus patients with normal hearing in conventional pure-tone audiometry. BioMed Research International; 2015: 1-5.
  16. Gentil, F., Meireles, S., Roza, T., Santos, C., Parente, M., Almeida, E. & Natal, R. (2015). Comparison of otoacoustic emissions in patients with tinnitus having normal hearing versus mild hearing loss. International Tinnitus Journal; 19 (2): 39-46.
  17. McNeill, C., Tavora-Vieira, D., Alnafjan, F., Searchfield, G.D. & Welch, D. (2012). Tinnitus pitch, masking, and the effectiveness of hearing aids for tinnitus therapy. International Journal of Audiology; 51: 914-919.
  18. Araujo Tde, M. & Iorio, M.C. (2015). Effects of sound amplification in self-perception of tinnitus and hearing loss in the elderly. Brazilian Journal of Otorhinolaryngology; 82(3):289-296.
  19. Newman, C.W., Sandridge,, S.A. & Jacobson, G.P. (1998). Psychometric adequacy of the Tinnitus Handicap Inventory (THI) for evaluating treatment outcome. Journal of American Academy of Audiology; 9(2):153-60.
  20. Meikle, M.B,, Henry, J.A., Griest, S.E., Stewart, B.J., Abrams, H.B. et al. (2012). The Tinnitus Functional Index: development of a new clinical measure for chronic intrusive tinnitus. Ear and Hearing; 33: 153–76.
  21. Henry, J.A., Griest, S., Zaugg, T.L., Thielman, E., Kaelin, C., Galvez, G. & Carlson, K.F. (2015). Tinnitus and hearing survey: A screening tool to differentiate bothersome tinnitus from hearing difficulties. American Journal of Audiology; 24(1): 66-77.
  22. Davis, A. & Rafaie, E.A. (2000). Epidemiology of tinnitus. In: Tyler R.S., editor. Tinnitus Handbook. Singular; San Diego, CA.
  23. Roberts, L.E., et al. (2010). Ringing ears: the neuroscience of tinnitus. J Neurosci; 30(45):14972–9.
  24. Weinstein, B. (2020, May 28). The masking dilemma revisited. Phonak Audiology Blog [Clinical Practice]. Retrieved from https://audiologyblog.phonakpro.com/the-masking-dilemma-revisited/.
  25. Lin, C.E., Chen, L.F., Chou, P.H. & Chung, C.H. (2018). Increased prevalence and risk of anxiety disorders in adults with tinnitus: a population-based study in Taiwan. General Hospital Psychiatry; 131-136.
  26. Ziai, K., Moshtaghi, O., Mahboubi, H. & Djalilian, H.R. (2017). Tinnitus patients suffering from anxiety and depression: A review. International Tinnitus Journal; 21(1): 68-73.
  27. Bhatt, J.M., Bhattacharyya, N. & Lin, H.W. (2017). Relationship between tinnitus and the prevalence of anxiety and depression. The Laryngoscope; 127(20): 466-469.
  28. Zigmond, A.S., & Snaith, R.P. (1983). The Hospital Anxiety and Depression Scale. Acta Psychiatrica Scandinavica; 67(6):361-370.
  29. Hoare, D.J., Edmondson-Jones, M., Sereda, M., Akeroyd, M.A & Hall, D. (2012). Amplification with hearing aids for patients with tinnitus and co-existing hearing loss. Cochrane Database of Systematic Review; 1-10.
  30. Henry, J.A., McMillan, G., Dann, S., Bennett, K., Griest, S., Theodoroff, S., Pei Silverman, S., Whichard, S. & Saunders, G. (2020). Tinnitus management: randomized controlled trial comparing extended-wear hearing aids, conventional hearing aids, and combination instruments. Journal of American Academy of Audiology.
  31. Tunkel, D.E., Bauer, C.A., Sun, G.H., et al. (2014). Clinical practice guideline: tinnitus. Otolaryngol Head Neck Surg; 151(2 Suppl): S1–S40.
  32. Jastreboff, P.J., & Jastreboff, M.M. (2000). Tinnitus retraining therapy (TRT) as a method for treatment of tinnitus and hyperacusis patients. J Am Acad Audiol; 11; 162-177.
  33. Henry, J.A., Zaugg, T.L., Kendall, K.J., Myers, P.J., & Turbin, M.B. (2009). Principles and application of educational counseling used in progressive audiologic tinnitus management. Noise & Health; 11(42): 33-48.
  34. Hussain, F.T., Gander, P.E., Jansen, J.N., & Shen, S. (2018). Expectations for tinnitus treatment and outcomes: A survey study of Audiologists and patients. J Am Acad Audiol; 29(4): 313-336.
  35. Graham, S,, & Brookey, J. (2008). Do patients understand? The Permanent Journal 2008; 12(2):67-69.
  36. Berkman, N., Sheridan, S.L., Donahue, K.E., Halpern, D.J. & Crotty, K. (2011). Low health literacy and health outcomes: An updated systemic review. Annals of Internal Medicine.