|Ahead of print publication
Deafness in COVID-19
Mahendra Kumar Taneja
Department of ENT, Indian Institute of Ear Diseases, New Delhi, India
|Date of Submission||10-May-2020|
|Date of Acceptance||11-May-2020|
|Date of Web Publication||22-Jun-2020|
Mahendra Kumar Taneja,
Indian Institute of Ear Diseases, E-982 C. R. Park, New Delhi
Source of Support: None, Conflict of Interest: None
COVID-19 is a highly contagious disease caused by RNA virus which is known to cause sensorineural deafness. The evidences are also prompting the risk of deafness in the near future. Respiratory virus, Mumps, measles, and Herpez are known for delayed presentation of deafness with poor prognosis. In the past, nitric oxide has shown evidence-based results in the treatment of coronavirus and respiratory pathologies. Humming enhances (Bhramari Pranayama) the production of nitric oxide. Suitable diet and lifestyle changes along with Tratak (focused concentration) and Bhramari Pranayama along with regular follow-up may be a must step to prevent and rehabilitate the patients with sensorineural deafness.
Keywords: Alkaline diet, Bhramari Pranayama, COVID-19, nitric oxide, RNA virus, sensorineural deafness, Tratak
The coronavirus (2019 – CoV) infection (COVID-19) is highly contagious caused by single-stranded RNA virus (+ssRNA) with nucleocapsid, which spreads widely all across the world. It is responsible for more than 4.2 million morbidity and 0.28 million mortality. CoV has a crown-like appearance as the name derives from Latin “Coronam” termed crown, due to the presence of spike glycoprotein on the envelope. No specific treatment is available till date, and even etiopathology is a matter of research. The clinical symptoms are mainly upper respiratory leading to diffuse viral pneumonia and multiple organ failure involving kidney, liver, and heart along with coagulopathies.
A number of RNA virus can cause respiratory infection presenting similar to CoV and may lead to deafness. The viral infections are known to cause deafness and most of the time, it is sensorineural though we do get some cases of conductive hearing loss as a result of acute otitis media, serous otitis media, otitis media with effusion and viral myringitis. Fortunately, most conductive deafness are curable, and recovery is spontaneous in majority of cases. Most of the viral infection affects the hair cell, organ of corti. The patient usually observe and report late to otolaryngologist or audiologist in case of sensorineural deafness due to herpes Zoster and mumps infection.
Rubella commonly known as German Measles. The virus is + ssRNA. It is also transmitted via respiratory passage through coughing, sneezing, and talking. Maternal rubella infection leads to sensorineural hearing loss sparing the vestibular function, but manifestations are observed apparently late by 6th to 12th months.
The viral infection, specially caused by Cytomegalovirus, is one of the most common causes of congenital deafness. Hearing loss may reverse partially or totally depending on the prompt management including antiviral therapy. Mumps affects stria vascularis, organ of corti, and hair cells, whereas Rubella affects the stria vascularis and organ of corti. Rubella, herpes simplex, and herpes Zoster affect the hair cells. Rubella is also hypothesized to cause otosclerosis via stimulation of abnormal osteoblastic activity. All these prompt including the present study by Mustafa that sensoneural deafness is one of the complications of Covid – 19 symptoms appears late hence investigation and management is delayed leading to poor prognosis.
The mode of invasion is through nose nasopharynx, hence fair chance to attack the organ of corti and hair cells through round window.
The research conducted by Mustafa audiometry reveals high frequency hearing loss as well as on Transitory evoked oto acoustic emission (TEOAE) amplitude were significantly worse. These findings were an evidence of damage to outer hair cells in cochlea. The outdoor hearing acuity was normal. Which synchronized with the past studies.
During 2014 (SARS–CoV) pandemic, the role of nitric oxide (NO) in its management is well demonstrated. NO reversed pulmonary hypertension, improved severe hypoxia, and shortened the stay in intensive care unit and ventilatory support. NO increased the survival rate. The genetic composition of CoV (SARS-CoV) is almost similar to that of COVID-19, thus indicates good chances of effectiveness or enhancement in results by NO along with other modes in the treatment of COVID-19.
As discussed earlier, NO inhibits viral protein and RNA. It has been observed that NO synthase reduces the yield of progeny virus by 82%. Thus, by virtue of its antiviral effect, it reduces the replication of CoV.
NO may also stimulate ciliary motility. Humming increases the production of NO dramatically.
For the replication of CoV, the optimum pH is 5.5 and if we can maintain alkaline pH above 7.0, perhaps we can control and restrict the replication. The NO is a known modality having antiviral and anti-inflammatory properties and that too its release in the middle ear may prevent deafness and help in rehabilitation.
Spiral ganglion cells (neurons) can be protected, preserved, and regenerated by neurotropic factors, antioxidants, electric stimulation, and NO production (Bhramari Pranayama). We know it is almost impossible to regenerate hair cells but certainly injured hair cells can be revoked and spiral ganglion neurons and organ of corti can be regenerated though it is a long-run exercise.
supplementation with alkaline diet, Nitric Oxide booster foods and Bhramari Pranayam which enhances nitric oxide expression may augment the immune system in revoking the hearing in COVID - 19 patients.
Patients with sensorineural deafness usually go under depression, which may lead to dementia. The isolation or stay in home in COVID-19 may further aggravate the depression. Creating positivity and rehabilitation by visual speech perception; learning lip reading; focused concentration (predicting gestures); and activation of nondominant brain and mid-brain by generating alpha brain waves along with suitable diet, lifestyle changes, and Bhramari Pranayama may help in preventing and rehabilitating the sensorineural deafness due to COVID-19.
| Alkaline Diet|| |
Honey/dates/pineapple juice/sprout and raw leafy green vegetables added to diet boost the immune system.
The following are the foods to boost NO expression (rich in dietary nitrates, which the body can convert into NO):
- Beets root
- Dark chocolate
- Leafy greens
- Citrus fruits
- Nuts and seeds
- Red wine.
Addition of beetroot in nondiabetics and neem in diabetics may be considered in selective cases; all patients on antihypertensive may be supplemented with rock salt and relaxation therapy.
Antiviral herbs may be added if project permits. The structure of CoV is composed of a RNA-based protein that contains amino (–NH2) and carboxyl (–COOH); it includes neucleocapsid protein (N-protein) spike protein (S-protein) which affects the gastrointestinal tract and damage other organs. It has been observed that plant extract of hydroxyl group (–OH) chemically deactivates the active component of virus by esterification process. Liquorice (glycerrhiza glabra) can be added as a supplement in holistic management.
Ginger: Zingiber officinale contains gingerols, paradols, sesquiterpenes, and shogaols having anti-inflammatory and antioxidant properties and have shown to be protective in human respiratory syncytial virus (CHRVS). Thus, ginger as a herbal food can be considered to enhance immune power. All the patients should be checked for deficiency of Vitamin D and corrected.
| Bhramari Pranayam|| |
It is a breathing exercise; a humming sound is produced during exhalation with an effort to generate the echo in the ears. It is also quite effective in destressing and in the management of tinnitus. Bhramari releases NO in the body which acts as a vasodilator and increases tissue perfusion.
| Technique|| |
The patient is instructed to take a slow deep abdominal breath, lift the tongue, press on the hard palate in Khechari Mudra, hold the breath in, blow the cheek for better echo, close both ears with the thumbs of both hands keeping them on the concha simultaneously blocking the ears, and close both eyes gently by the index finger. The tip of the index finger should rest on the lateral wall of the nose. Both middle fingers are put on the base of the ala of nose, and the mouth is closed on both sides; upper lip by ring fingers and lower lip by little fingers. Both eyes are focused in Shambhavi Mudra at the Ajna Chakra in between both eyebrows. A constant rhythmic uninterrupted specific frequency sound (mouth closed and jaw relaxed) is generated. Spiritual concentration is focused on Dwarika Dhish (Deity). After complete exhalation, hold the breath out; Vahya Kumbhak is enforced with spiritual focus on Lord Shiva (Deity). Keep holding the breath out as long as possible, give a command to brain that my whole body is revitalizing with improvement in hearing. The exercise can be performed sitting comfortably in calm place, eyes closed, and in a relaxed mood with a smile on the face. A high-pitch sound gives better results. It also helps in regaining better speech recognition. For better results, the whole body, mind, and soul should be relaxed and the eyes are gently closed. You should be able to visualize a faint dusty brown light at solar plexus (Ajna Chakra) matching with the color of the pineal gland. After completing the Bhramari, hold the breath out for maximum comfortable duration. This optimizes the CO2 level in blood, tissue, and cellular level enhancing HCO3 anion, leading to apoptosis and revitalization.
| Conclusion|| |
Sensorineural deafness is a late complication of respiratory virus infection. We have to evaluate every patient of COVID-19 for deafness. All patients suspected or presenting with deafness must be taken care by suitable diet, lifestyle changes, Tratak, and Bhramari Pranayama. All patients must be kept under observation and rehabilitated properly to prevent the incidence of deafness, depression, and dementia and to avoid the forthcoming burden on the society and health-care system.
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Conflicts of interest
There are no conflicts of interest.
| References|| |
Abramovich S, Prasher DK. Electrocochleography and brain stem potentials in hunt syndrome. Arch Otolaryngol Head Neck Surg 1986;112:925-8.
Adler SP. Congenital cytomegalovirus screening. Pediatr Infect Dis J 2005;24:1105-6.
Aleksic SN, Budzilovich GN, Lieberman AN. Herpes zoster oticus and facial paralysis (Ramsay Hunt syndrome). Clinicopathologic study and review of literature. J Neurol Sci 1973;20:149-59.
Mustafa MW. Audiological profile of asymptomatic Covid-19 PCR positive cases Am J Otolryng 2020:102483. doi: 10.1016/j.amjoto.2020.102483.
Akerstrom S, Mousavi-Jazi M, Klingstrom J, Leijon M, Lundkvist A, Mirazimi A. Nitric oxide inhibits the replication cycle of severe acute respiratory syndrome coronavirus. J Virol 2005;79:1966-9.
NIH U.S. National Library of Medicine Nitrous Oxide Inhalation for Severe Acute Respiratory Syndrome in Covid-19 (NOSARSCOVID). Available from: http://clinicaltrials.gov/C+2/result
. [Last accessed on 04 May 2020].
Cinatl J, Morgenstern B, Bauer G, Chandra P, Rabenau H, Doerr HW. Treatment of SARS with human interferons. Lancet 2003;362:293-4.
Jain B, Rubinstein I, Robbins RA, Leise KL, Sisson JH. Modulation of air way Epithelial cell ciliary beat frequency by Nitric Oxide. Biochem Biophys Commune 1993;191:83-6.
Weitzberg E, Lundberg JO. Humming greatly increases nasal nitric oxide. Am J Respir Crit Care Med 2002;166:144-5.
Chang JS, Wang KC, Yeh CF, Shieh DE, Chiang LC. Fresh ginger (Zingiber officinale
) has anti-viral activity against human respiratory syncytial virus in human respiratory tract cell lines. J Ethnopharmacol 2013;145:146-51.
Brochot A, Guilbot A, Haddioui L, Roques C. Antibacterial, antifungal, and antiviral effects of three essential oil blends. MicrobiologyOpen 2017;6:E00459.
Taneja MK, Taneja V. Vitamin d deficiency in E. N.T. patients. Indian J Otolaryngol Head Neck Surg 2013;65:57-60.
Taneja MK. Frequency modulated Bhramari Pranayam in tinnitus and deafness. Indian J Otol 2018;24:209-13. [Full text]
Taneja MK. Improving hearing performance through yoga. J Yoga Physther 2015;3:194.