10.14639/0392-100X-N0820
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1827-675X
820
6
en
Jahangir Ghorbani
https://creativecommons.org/licenses/by-nc-nd/4.0
ACTA Otorhinolaryngologica Italica
corona virus
Vertigo and hearing loss during the COVID-19 pandemic - is there an association?
Text.Serial.Journal
https://www.actaitalica.it/
40
Letters to the Editor-in-Chief
2020-06-10
2020-05-01
2021-01-21
2021-01-21
463-465
1
Jahangir Ghorbani
2020/06/10
10.14639/0392-100X-N0820
463
Department of Otolaryngology, Iranshahr University of Medical Sciences, Sistan and Baluchestan, Iran
1827-675X
6
corona virus
465
Vertigo and hearing loss during the COVID-19 pandemic - is there an association?
https://www.actaitalica.it/article/download/820/368
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ACTA OTORHINOLARYNGOLOGICA ITALICA 2020;40:463-465; doi: 10.14639/0392-100X-N0820




Letter to the Editor


Vertigo and hearing loss during the COVID-19
pandemic – is there an association?
La vertigine e l’ipoacusia durante la pandemia COVID-19 – esiste un nesso?
Mahboobeh Karimi-Galougahi1,2, Ali Safavi Naeini1,2, Nasim Raad1,2, Narges Mikaniki3, Jahangir Ghorbani1,2
1
 Department of Otolaryngology, Masih Daneshvari Hospital, Tehran, Iran; 2 Chronic Respiratory Disease Research Center, National
Research Institute of Tuberculosis and Lung Diseases, Shahid Beheshti University of Medical Sciences, Tehran, Iran; 3 Department of
Otolaryngology, Iranshahr University of Medical Sciences, Sistan and Baluchestan, Iran


KEY WORDS: vertigo, hearing loss, sensorineural hearing loss, COVID-19, corona virus
PAROLE CHIAVE: vertigine, ipoacusia, ipoacusia neurosensoriale, COVID-19, corona
virus



Dear Editor,
Concurrent with the global outbreak of coronavirus disease-2019 (COVID-19),
exceeding numbers of new cases with smell and taste disorders have been re-
ported from Asia and Europe 1, prompting the possibility of direct neuropathic
effect of severe acute respiratory syndrome-coronavirus-2 (SARS-CoV-2) as               Received: May 1, 2020
the likely underlying mechanism. Post-viral olfactory dysfunction is a well-            Accepted: May 18, 2020
known disease entity caused by several families of viruses, including betac-            Published online: June 10, 2020
oronoviridae 2. Akin to the effects of viruses on neural pathways of olfactory
                                                                                        Correspondence
sense, post-viral vertigo or hearing loss are known sequelae of viruses that can        Jahangir Ghorbani
cause vestibular neuritis or labyrinthitis 3. For instance, the DNA of herpes           Department of Otolaryngology, Masih Daneshvari
simplex virus has been found in the vestibular nerve fibres in patients with            Hospital, Neyavran, Daar Abad, Tehran, Iran
                                                                                        Tel. +98 21 26105242. Fax +98 21 26105242
vertigo secondary to vestibular neuritis 3.                                             E-mail: jghorbani@sbmu.ac.ir
 Whether SARS-CoV-2 can invade the neural pathways involved in the balance
and hearing is not known, but initial observations implicate the possibility.           Funding
A recent study in asymptomatic patients with confirmed COVID-19 revealed                None.

increased high-frequency pure-tone thresholds while transient evoked otoa-              Conflict of interest
coustic emissions were significantly reduced, all in the absence of otologic            The Authors declare no conflict of interest.
symptoms 4. While coronaviruses have neurotropic and neuroinvasive proper-
ties 5,6, after a search in the English literature we found no cases suggestive of        How to cite this article: Karimi-Galougahi
the inner ear or vestibulocochlear nerve involvement during the SARS-CoV or               M, Naeini AS, Raad N, et al. Vertigo and
                                                                                          hearing loss during the COVID-19 pan-
Middle Eastern respiratory syndrome (MERS) outbreak.
                                                                                          demic - is there an association? Acta Otorhi-
Nevertheless, neurologic manifestations spanning the central nervous system,              nolaryngol Ital 2020;40:463-465. https://doi.
peripheral nervous system and skeletal muscles have been recently reported                org/10.14639/0392-100X-N0820
in hospitalised patients with COVID-19 7. Most neurologic manifestations oc-
                                                                                        © Società Italiana di Otorinolaringoiatria
curred early in the illness and neurologic symptoms were the only presenting            e Chirurgia Cervico-Facciale
symptoms in some patients without other typical symptoms of COVID-19 7.
The spectrum of neurologic syndromes known to be caused by COVID-19                                    OPEN ACCESS
encompasses encephalitis, meningitis, demyelination and Guillain-Barre syn-             This is an open access article distributed in accordance with
                                                                                        the CC-BY-NC-ND (Creative Commons Attribution-Non-
drome 7,8. Thus, SARS-CoV-2 neurotropism may make it possible to inflict a              Commercial-NoDerivatives 4.0 International) license. The
wide spectrum of neuropathic effects, potentially including effects on neural           article can be used by giving appropriate credit and mentio-
                                                                                        ning the license, but only for non-commercial purposes and
networks governing hearing and balance.                                                 only in the original version. For further information: https://
In addition to a direct cytopathic effect of the virus, inflammatory response,          creativecommons.org/licenses/by-nc-nd/4.0/deed.en




                                                                                                                                                463
M. Karimi-Galougahi et al.




Table I. Demographic and clinical characteristics of patients with acute hearing loss or vertigo and high clinical suspicion for/or confirmed coronavirus dis-
ease-2019 (COVID-19).
  N         Demographic and clinical             General         Otologic or balance symptoms                  Pure tone audiometry - bone (dB)
                 characteristics                symptoms
         Sex       Age        FH of          PCR                             Tinnitus   Vertigo      Laterality   500      1000     2000     3000    4000     8000
                 (years)     COVD-19                                                                    of
                                                                                                      hearing
                                                                                                       loss
 1         F        34            -        Pending       Dyspnoea,              -       Slight         Right       0        0        0        20       60       90
                                                          Cough
 2        M         22            -            +         Dyspnoea,              -          -            Left       0        0        30       40       60       70
                                                          Cough
 3         F        40            -            +         Dyspnoea,              +          -           Right       50       60       60       60       65       80
                                                          Cough,
                                                          Malaise
 4        M         38            -            -         Dyspnoea,              +          -           Right       40       50       55       60       70       80
                                                          Cough,
                                                           Fever
 5         F        23            +            +         Dyspnoea,              +         +             Left       30       35       35       40       45       45
                                                          Cough
 6         F        35            -            -         Dyspnoea,              +          -           Right       40       40       45       45       50       60
                                                          Cough,
                                                           Fever
dB: decibel, FH: family history, N: number, PCR: polymerase chain reaction



cytokine storm and cerebrovascular events 7,8, especially in                               These recent confirmed cases of COVID-19, the anec-
the posterior circulation 9, and ototoxic drugs like azithromy-                            dotal epidemiological correlations and bio-pathological
cin, hydroxychloroquine being used extensively during the                                  mechanisms call for urgent studies to examine the as-
nascent pandemic as therapeutic agents may also contribute                                 sociation of new onset otologic symptoms with COV-
to hearing or balance disorders associated with COVID-19.                                  ID-19 during the current pandemic. There are several
Anecdotally, during recent weeks, we have frequently en-                                   important issues to address. First priority is in perform-
countered patients without previous otologic or neurologic                                 ing screening PCR tests, which are hoped to become
problems who presented with true vertigo or sensorineural                                  more widely available than during the early phase of the
hearing loss. While initially none of these cases were tested                              pandemic, to establish a link, especially in cases with
for COVID-19 due to the scarcity of the screening tests and                                isolated hearing loss or balance disorder. Absent the
the priority given to the patients with typical symptoms or                                availability of PCR assay, and if the hearing or balance
severe form of COVID-19, some had family members with                                      problems are not associated with respiratory symptoms,
recent history of COVID-19, with the universal concomitant                                 it is debatable whether imaging such as chest computed
presence of symptoms such as fever, cough and dyspnoea,                                    tomography should be considered, although with an in-
pointing to high clinical suspicion for COVID-19 that in                                   creasing number of “clinically silent” cases of pulmo-
some patients (e.g., patient number 6 in Tab. I) led to diagno-                            nary involvement with SARS-CoV-2 being recognised,
sis of COVID-19 on chest computed tomography.                                              this approach may be clinically justifiable. Last, apart
Recently, we have been able to perform polymerase chain                                    from implications on the need for patient isolation,
reaction (PCR) assay to confirm COVID-19 in a number of                                    there are immediate therapeutic dilemmas including the
                                                                                           use of local or systemic steroids and whether empiric
patients with acute-onset hearing loss and/or vertigo (Tab.
                                                                                           antivirals should be considered.
I). Since these young patients (age range 22-40 years) had
no previous relevant medical history and had not received
any ototoxic drugs prior to their presentation, it is highly                               References
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