|Year : 2022 | Volume
| Issue : 2 | Page : 186-188
Sudden sensorineural hearing loss in coronavirus disease-2019: Our experience
Meng Hon Lye1, Carren Teh Sui Lin2, Nik Adilah Binti Nik Othman3
1 Department of Otorhinolaryngology-Head and Neck Surgery, School of Medical Sciences, Universiti Sains Malaysia, Health Campus, Kelantan; Department of Otorhinolaryngology-Head and Neck Surgery, Hospital Sungai Buloh, Jalan Hospital, Selangor, Malaysia
2 Department of Otorhinolaryngology-Head and Neck Surgery, Hospital Sungai Buloh, Jalan Hospital, Selangor, Malaysia
3 Department of Otorhinolaryngology-Head and Neck Surgery, School of Medical Sciences, Universiti Sains Malaysia, Health Campus, Kelantan, Malaysia
|Date of Submission||16-Jan-2022|
|Date of Acceptance||06-Mar-2022|
|Date of Web Publication||21-Sep-2022|
Dr. Nik Adilah Binti Nik Othman
Department of Otorhinolaryngology-Head and Neck Surgery, School of Medical Sciences, Universiti Sains Malaysia, Health Campus, Kubang Kerian, Kelantan - 16150
Source of Support: None, Conflict of Interest: None
Coronavirus disease-2019 (COVID-19) is an ongoing global pandemic exerting considerable strain on the health-care system. Sudden-onset sensorineural hearing loss (SSNHL) among patients with COVID-19 had been reported sparingly in the literature. Hearing loss can be easily overlooked in intensive care settings and establishing diagnosis can also be challenging. Proposed causes include injury to inner ear structures, cochlear nerve, or auditory brainstem. Prompt diagnosis and treatment is recommended to avoid long-term morbidity. All patients presenting with sudden-onset hearing loss should be screened for COVID-19. Here, we report a case of COVID-19 patient with SSNHL and how the hearing level is determined.
Keywords: Auditory brainstem response, coronavirus disease-2019, pure tone audiometry, sudden-onset sensorineural hearing loss
|How to cite this article:|
Lye MH, Lin CT, Othman NA. Sudden sensorineural hearing loss in coronavirus disease-2019: Our experience. Indian J Otol 2022;28:186-8
| Introduction|| |
The coronavirus disease-2019 (COVID-19) is a highly contagious disease caused by the severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2). It is responsible for strained healthcare worldwide and is declared a pandemic since March 2020., Most patients do not require hospitalization. The most common otolaryngologic symptoms reported were cough, anosmia, and sore throat.
Sudden-onset sensorineural hearing loss (SSNHL) among patients with COVID-19 had been reported sparingly in the literature., Viral infections may cause of SSNHL by damaging inner ear structures directly or indirectly. Here, we present a case of SSNHL following diagnosis of COVID-19 infection in our center.
| Case Report|| |
A 55-year-old female with underlying chronic end-stage renal failure (ESRF) requiring regular hemodialysis, hypertension, and type-II diabetes mellitus was tested positive for SARS-CoV-2 antigen after close contact with a COVID-19 patient. She was admitted and treated for category three COVID-19 with risk factors. On admission, the patient was asymptomatic, but pneumonic changes were evident from the chest X-ray. She was started on oral favipiravir 1800 mg loading dose followed by 800 mg BD.
On day four of admission, patient-reported sudden onset of deafness in both ears after completion of hemodialysis with blood transfusion. Hearing loss was also noticed by allied health-care personnel as the patient had difficulty with verbal communication. She denied recent head trauma or prior history of fluctuating hearing loss. The patient had no otalgia, otorrhea, or vertigo and did not display any other neurological deficit. Otoscopic findings were unremarkable and bedside free-field voice testing revealed bilateral severe to profound hearing loss. Tuning fork tests were not done as the patient was unable to understand verbal commands. Laboratory tests for connective tissue diseases showed elevated C-reactive protein (CRP) and deranged renal profile but otherwise unremarkable.
Hearing loss was confirmed with bedside auditory brainstem response (ABR) test that showed peak waves demonstrable up to 80dB on the right while no response was seen up to 90 dB on the left ear, corresponding to left profound and right severe hearing loss. The test was carried out promptly in the isolation ward by audiologist and physician in full personal protective equipment (PPE) with portable ABR equipment wrapped in clear plastic film. The equipment and probes were fully sanitized with 70% isopropyl alcohol and the plastic wrapping was discarded after use to prevent cross-contamination [Figure 1]. Favipiravir was withheld, due to suspicion of ototoxicity. The patient was started on oral prednisolone at 1 mg/kg and tapered off for 2 weeks. Imaging study was not done due to restrictions on COVID-19 patients.
|Figure 1: Clear plastic film wrapping over auditory brainstem response equipment|
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Patient-reported improvement in her hearing after commencement of oral corticosteroid. She was discharged after 14 days of hospital admission. The patient was given outpatient appointment for hearing monitoring. However, she was briefly lost to follow-up due to repeated hospitalization for complications of ESRF. Eventually, the patient was seen in the ORL clinic after 3 months. Pure-tone audiometry showed right moderate to severe and left severe to profound sensorineural hearing loss with right type A and left type As tympanometry [Figure 2]. The patient was counseled for hearing aid to cope with her hearing loss.
|Figure 2: Follow-up pure tone audiometry 3 months after the onset of symptoms|
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| Discussion|| |
SSNHL is defined as a sensorineural hearing loss of at least 30 dB in at least three consecutive frequencies that has developed within 72 hours (3 days). Viral infection is strongly linked as one of the causes of idiopathic SSNHL. Proposed mechanisms of injury encompass direct damage to the labyrinth or cochlear nerve, reactivation of latent virus within spiral ganglion and immune-mediated mechanism in systemic viral infection. Viral infections may also cause injury to the auditory brainstem. Typically, virus-induced hearing loss is sensorineural in nature ranging from mild to profound and either unilateral or bilateral.
Reports of hearing loss in patients with COVID-19 are limited. A study by Mustafa on asymptomatic COVID-19 patients showed decline in high-frequency pure-tone thresholds, as well as the transient, evoked otoacoustic emissions amplitudes which indicate deterioration in the outer hair cells function. The study also demonstrated that the absence of major respiratory symptoms does not preclude damage to hearing. A recent report suggested an association between COVID-19 infection and encephalopathy. Virus-induced inflammation of the meninges with subsequent spread to the cochlear might lead to acute hearing loss. Chern et al. attributed intralabyrinthine hemorrhage secondary to COVID-19 associated coagulopathy as a mechanism of hearing loss.
Favipiravir is an antiviral prodrug with active metabolite that inhibits viral replication by arresting RNA polymerase. It is the first oral antiviral drug approved for mild to moderate COVID-19 infection. Favipiravir has an established safety profile. No hearing loss was reported as one of the adverse drug events for its use in COVID-19 treatment.
SSNHL is an acute otologic disorder which demands urgent management. The American Academy of Otolaryngology-Head and Neck Surgery clinical practice guideline recommends a course of oral steroids within 2 weeks of symptoms presentation. Intertympanic steroid injection should be offered for patients with incomplete recovery after two to 6 weeks. However, this can be challenging, as presently there is little consensus on how to approach hearing disorder in patients infected with COVID-19. This is made even more difficult as patients had problems acknowledging hearing loss in the noisy intensive care unit setting. Intertympanic steroid injection was not administered for our patient due to loss to follow-up.
In the limited numbers of reported cases, treatment with oral and intertympanic steroids for patients with COVID-19 and SSNHL yielded variable clinical outcomes.,,, However, caution and discretion are needed when prescribing steroids, especially among COVID-19 patients with underlying diabetes. All patients should be monitored closely for complications of immunosuppression such as invasive mucormycosis.
| Conclusion|| |
The patient presenting with sudden-onset hearing loss should be screened for COVID-19 preferably with reverse transcriptase-polymerase chain reaction (RT-PCR) testing for better test accuracy and audiological diagnostic tests should be carried out as soon as possible. Treatment with steroids should be started promptly with close monitoring for the best clinical outcome. Much research is required to fully understand the impact of COVID-19 infection on the auditory system.
Declaration of patient consent
The authors certify that they have obtained all appropriate patient consent forms. In the form, the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.
The authors would like to thank the patient for his permission and cooperation in writing this case report.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
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