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Federal government websites often end in. The site is secure. Language: English French. Extensive studies indicate that severe acute respiratory syndrome coronavirus SARS-CoV-2 involves human sensory systems.
The present systematic review and meta-analysis were performed to determine the event rate ER of hearing loss, tinnitus, and dizziness caused by SARS-CoV Twelve papers met the eligibility criteria and were included in the study. The results of the meta-analysis demonstrate that the ER of hearing loss 3. COVID can cause hearing loss, tinnitus, and dizziness.
These findings, however, should be interpreted with caution given insufficient evidence and heterogeneity among studies. Well-designed studies and follow-up assessments on otologic symptoms of SARS-CoV-2 using standard objective tests are recommended. Typical signs and symptoms based on confirmed PCR, which generally develop 5—6 d after infection range 1—14 d , consist of fever, dry cough, fatigue, sputum production, shortness of breath, sore throat, headache, dizziness, myalgia or arthralgia, chills, nausea or vomiting, nasal congestion, diarrhea, hemoptysis, and conjunctival congestion.
It is also expressed by many cells, including glial cells and neurons, and can cause neurological involvement through direct or indirect mechanisms. Likewise, the timeline of virus development from initial symptoms to moderate or severe complications, roughly five days, is long enough for the virus to enter and damage the brainstem cranial nerves and nuclei.
The present paper intends to systematically review current evidence regarding hearing loss, tinnitus, and dizziness caused by SARS-CoV-2, as well as determine the occurrence frequency of these symptoms through a meta-analysis. The final papers were included through a three-stage process: title screening, abstract screening, and full-text screening.
In each section, the papers that did not meet the inclusion criteria were excluded. In the cases of uncertainty, first the abstracts and then the full texts were screened. All three stages were independently conducted by two reviewers. If there was any disagreement, the authors discussed to reach a consensus. Overall, there was a complete agreement between the reviewers. The meta-analysis was carried out using Comprehensive Meta-Analysis Version 3. To prevent confounding bias resulting from low sample sizes, the papers with a sample size fewer than 50 were not considered in the analysis.
The database search yielded papers Figure 1. This initial screening resulted in a set of papers, which were evaluated to extract the papers corresponding with the inclusion criteria. Among 18 studies extracted for the full-text review, 6 papers were removed e. The ERs of hearing loss, tinnitus, and dizziness were collected from four, 11 , 22 — 24 six, 11 , 22 — 26 and nine 11 — 13 , 24 , 25 , 27 — 30 papers, respectively.
The reference lists for the selected publications were also hand-searched for any additional related publications. No additional related article, however, was found.
The bias resulted from only searching databases in the English language language bias is acknowledged. According to CCAT recommendations, the scores were reported as both a total score and a percentage. The quality of the studies rated between 50 and None of the studies used objective standard tests to access hearing loss, tinnitus, or dizziness, and the data collection was performed subjectively through using case history forms, questionnaires, or medical records.
Only one study applied standard questionnaires to collect information about hearing loss and tinnitus i. Given the extent of heterogeneity i. The total population was equal to , and the sample size varied between 50 and Figure 2 A. The ER of hearing loss was equal to 0. Forest plot for the event rate of hearing loss in four studies A , tinnitus in six studies B , and dizziness in nine studies C.
The square size indicates the statistical weight for each study. CI, confidence interval. The total population was equivalent to , and the sample size varied between 50 and Figure 2 B. The ER of tinnitus was obtained 0. The total population was equal to , and the sample size varied between 69 and Figure 2 C. The ER of dizziness was obtained 0. In each forest plot in Figure 2 , each horizontal line drawn onto a forest plot demonstrates a separate study being analyzed.
A diamond below each forest plot exhibits the overall point estimate of ER and its CIs obtained by meta-analysis e. The present meta-analysis on four studies 11 , 22 — 24 shows the occurrence rate of 3. This number, however, should be interpreted with precaution because of the low level of evidence e. In descriptive or self-report studies, it is also likely that slight to mild changes in hearing ability are being ignored, especially in patients with a severe condition. In this regard, current publications over the occurrence frequency of olfactory dysfunction in patients with COVID demonstrate a remarkable difference between the results of using standard objective tests compared with subjective data collection e.
Tinnitus is defined as the sensation of sound without any external acoustic source phantom perception of sound. In three questionnaire-based studies on individuals with tinnitus without COVID to examine the pandemic mental burden on tinnitus perception, an increase in tinnitus-related handicap and distress was shown in those who perceived the situation stressful and bothersome Table 4.
The present meta-analysis on nine papers demonstrates the occurrence rate of It has been shown that the inner ear structures are particularly susceptible to ischemia and vascular damage, which can lead to both hearing and balance dysfunction. The disease is clinically diagnosed with vertigo and develops acutely over minutes to hours.
Whereas vestibular neuritis is generally considered to be a monophasic condition, multiple cranial nerve involvement also is likely in viral inflammation.
Auditory and vestibular neural pathways in humans. B Innervation of the cochlea and vestibule i. C The major ascending auditory neural pathways. D Vestibular neural pathways. The afferent fibers from the vestibular labyrinth project to each of the vestibular nuclei located in the rostral medulla and the caudal pons.
Neural fibers from the utricle and saccule terminate in LVN. Some saccular neural fibers project to the IVN. In a recent systematic review and meta-analysis on audiovisual symptoms of COVID, the pooled estimate of the prevalence of hearing loss, tinnitus, and rotatory vertigo was reported as 7.
For instance, Almufarrij and Munro considered no restriction in terms of the diagnostic tool used to detect SARS-CoV-2 and included studies on probable i. But in the present meta-analysis, only studies on patients with confirmed PCR test results were included.
The papers with a sample size less than 50 were also excluded in our study to prevent confounding bias associated with low sample sizes. The auditory and vestibular systems are two sensory systems that are mostly present in the brainstem Figure 3 C and D. Auditory inputs are transferred from the auditory branch of the eighth cranial nerve to the cochlear nuclei, lateral lemniscus, inferior colliculus, and medial geniculate body before projection to the auditory cortex.
Multiple thalamic nuclei contribute to vestibular processing, which contain multisensory neurons and process vestibular, proprioceptive, and visual signals and project to the cortex. Thus, brainstem dysfunction resulting from neuroinflammatory mechanisms triggered by SARS-CoV-2 can produce sensory including auditory and vestibular and motor deficits, cranial nerve palsies, impairment of consciousness, dysautonomia, and respiratory failure.
Inflammation is a natural defense mechanism against pathogens and involves many pathogenic diseases such as microbial and viral infections, as well as autoimmune and chronic diseases. ROS is implicated in the regulation of processes involved in cell homeostasis and functions and is normally produced in limited quantities in the body. Inflammation and oxidative stress are closely associated with pathophysiological processes and are tightly linked to one another. Thus, the activation of both processes is simultaneously found in many pathological conditions, including infection with SARS-CoV Therefore, it can be transported with erythrocytes or vascular endothelium to all the tissues with ACE2 in their structure, including the brain and medulla oblongata that have plenty of ACE2, as well as the auditory system.
Human evidence demonstrates that SARS-CoV-2 can spread throughout the body via the circulation system because of the abundant expression of ACE2 in arterial and venous endothelial cells and arterial smooth muscle cells in many organs.
Remdesivir, ribavirin, and synthetic quinine products chloroquine CQ and hydroxychloroquine HCQ are traditionally used for the treatment of malaria, autoimmune diseases, and systemic erythematosus lupus given their antiviral and anti-inflammatory properties.
For instance, they can cause temporary or permanent auditory toxicity and lead to SNHL and tinnitus in both acute and chronic consumption, which has been reported is irreversible following CQ. Twelve single-group prospective, cross-sectional, or retrospective studies on confirmed patients with COVID were reviewed in this study. Except for four studies on otolaryngologic manifestations of SARS-CoV-2, other studies were more general, over neurological or clinical characteristics of the disease.
Our meta-analysis demonstrates that the occurrence rate of hearing loss 0. But, given the low level of evidence i. Weakness in data collection also may contribute to the magnitude of ERs, especially in cases with mild symptoms or those in a critical condition.
Thus, well-designed studies and follow-up assessments using standard objective tests are necessary, which can provide more precise information given the occurrence frequency, type, and severity of otologic symptoms hearing loss, tinnitus, and dizziness ; the rate of improvement after recovery; and the link between disease severity and the auditory—vestibular involvement. ZJ: conceptualization, design, writing the original draft, review, and editing.
BEK: review and editing. MHM: funding acquisition, review, and editing. Can J Neurol Sci. Published online Apr Zahra Jafari , Bryan E. Kolb , and Majid H. Bryan E. Majid H. Author information Article notes Copyright and License information Disclaimer.
Correspondence to : Majid H. Email: ac.
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