key: cord-0716556-oo5oc6ro authors: Maharaj, Shivesh; Bello Alvarez, Martha; Mungul, Sheetal; Hari, Kapila title: Otologic dysfunction in patients with COVID‐19: A systematic review date: 2020-11-17 journal: Laryngoscope Investig Otolaryngol DOI: 10.1002/lio2.498 sha: 0e78b20e110adbcd822ec607ba3a408d04acb4e4 doc_id: 716556 cord_uid: oo5oc6ro OBJECTIVE: To describe otologic dysfunction in patients with the novel SARS‐CoV‐2. REVIEW METHODS: Search strategies acquired for each database included keywords. The keywords use were—Otologic OR Vestibular OR Audiologic and COVID‐19 OR Coronavirus OR SARS‐CoV‐2. Resulting articles were imported into a systematic review software and screened for appropriateness. To be eligible for inclusion in the analysis, the studies and case reports should have met the following criteria: i. Description of otologic dysfunction in COVID‐19 patients; ii. peer review. Studies were excluded if: i. the description of the specific dysfunction was inadequate; ii. there were no original case descriptions. Data that met the inclusion criteria was extracted and analyzed. RESULTS: A total of 62 articles were identified and screened, seven articles met the inclusion criteria and were analyzed. The articles were mainly case reports (5) with 2 case series. There were 28 patients in total identified with the largest study comprising 20 patients. All patients presented with hearing loss, 27 of whom had audiometry. Three patients had associated vestibular symptoms (vertigo, otalgia, and tinnitus). CONCLUSION: SARS‐CoV‐2 is a probable cause of middle ear infections and sensorineural hearing loss, secondary to spread of the novel virus into the middle ear and related neural structures. Coronaviruses are large enveloped nonsegmented positive-sense RNA viruses. 1 These viruses usually cause mild respiratory illnesses in animals and humans but have been implicated in significant epidemics. Two outbreaks in recent memory that is, severe acute respiratory syndrome CoV (SARS-CoV) and Middle East respiratory syndrome CoV (MERS-CoV) highlighted their proclivity for worldwide spread and fatalities. There are no reports of any inner ear or vestibulocochlear nerve disorders specifically linked to these outbreaks, despite the neuroinvasive properties of the coronaviruses. 2, 3 In December 2019, a report emerged from China of a case series of patients with pneumonia due to an unknown cause. The causative organism was later identified as severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2). 4 The disease itself was termed novel coronavirus disease-2019 (COVID- 19) and declared a global pandemic by the Director General of the World Health Organisation (WHO) on March 11, 2020. 5 Viral upper respiratory tract infections have long been causally linked to new cases of otitis media. 6 There is some controversy regarding the significance of individual viral species, but the human corona virus has been isolated from middle ear fluid and linked to otitis media in children. 7 Recent reports have implicated SARS-CoV-2. [8] [9] [10] [11] Most patients affected by SARS-CoV-2 are asymptomatic or experience mild symptoms. 12 The common symptoms including fever, cough, fatigue and gastrointestinal disorders have been well documented. 13 Unusual presentations of the disease including tinnitus and hearing loss are emerging in the literature. 14 We did a systematic review in accordance with the PRISMA guidelines. 16 We searched PubMed, Embase, Web of Science, Scopus, BMJ best practice, Google scholar and Cochrane Database of Systematic Reviews (July 2020) for relevant articles without date or language restrictions. The following PICOS (Participants, Interventions, Comparisons, Outcomes, and Study design) criteria were utilized: The selected studies were ranked using the ROBINS-1 tool for assessing risk of bias in non-randomized studies of interventions. Each reviewer then compiled a descriptive narrative of each study (Table 1) . Relevant studies were assessed based on the following categories; study type, aim, participant characteristics, definition of otologic dysfunction or synonymous terms used, sensitivity, specificity, positive and negative findings as well as the respective author comments and opinions. These findings were systematically tabulated ( Table 2 ). Data extraction was done by two independent reviewers (SM and KRH) and compared, with disagreements resolved by discussion. We The studies were mainly mostly case reports. Follow-up was variable and ranged from 3 days to 10 months (Table 2 ). All of the studies had human participants. The patient population was adults with an equal number of males to female. The age at presentation varied between 20 and 60 years of age. The total number of subjects across all studies was 28 patients. The largest study had 20 participants while the smallest included manuscript had 1 subject. Amongst the seven studies, two were from Turkey and one study each from China, Egypt, Iran, Germany and Thailand. All patients presented with hearing loss (n-28). Three patients presented with otalgia, vertigo and tinnitus. There is no established treatment protocol for COVID19 otologic dysfunction based on the included studies. Hearing loss, both asymptomatic and symptomatic has been reported in patients with COVID-19. In a recent study, the audiograms of twenty COVID-19 positive patients were examined. 19 These patients were asymptomatic for all known symptoms of SARS-CoV-2. The ages of the participants were kept between 20 and 50 years to avoid age related hearing deficits. Hearing thresholds for high frequency pure tones were found to be significantly decreased in com- has been documented. The presumed mechanism of hearing loss in this case was a middle ear effusion secondary to an ascending nasopharyngeal infection. 9 There have been six case reports of sensorineural hearing loss (SNHL), four of which were documented to be sudden in onset (SSNHL) ( Table 1) . Viruses, most notably herpes simplex have been implicated in cases of SSNHL. 15 The pathogenesis of the hearing loss has not been One of the main strengths of this review is that it is the first review focusing on the novel coronavirus and otologic dysfunction of the search strategy. Our review has been able to identify a number of studies published since then. Our review includes 7 studies of a total of 28 patients. The limitations include that there is still much research that needs to be done in this field with larger study populations. There is growing evidence suggesting that otologic disorders, specifically hearing loss can be part of the clinical spectrum of COVID-19 and may in some cases signal the onset of the disease. It is of utmost importance to appreciate the rare presentations of SARS-CoV-2 in ENT patients as these will not only facilitate the diagnosis, especially in early presentations of the disease but also help protect and decrease the exposure of the ENT surgeon to potential infection risks. More research is needed in the otolaryngology field with regards to SARS-CoV-2 manifestations and prognosis thereof. There is no conflict of interest. https://orcid.org/0000-0002-2118-2400 BIBLIOGRAPHY Mechanisms of host defense following severe acute respiratory syndrome-coronavirus (SARS-CoV) pulmonary infection of mice Vertigo and hearing loss during the COVID-19 pandemic -is there an association? Central nervous system manifestations of COVID-19: a systematic review WHO Official Updates Coronavirus Disease World Health Organization (WHO) Acute otitis media and respiratory virus infections Detection of rhinovirus, respiratory syncytial virus, and coronavirus infections in acute otitis media by reverse transcriptase polymerase chain reaction Risk of acute otitis media in relation to the viral etiology of infections in children New type of corona virus induced acute otitis media in adult, 102487 Hearing loss and COVID-19: a note A novel coronavirus pneumonia case report from an ear, nose and throat clinic The origin, transmission and clinical therapies on coronavirus disease 2019 (COVID-19) outbreak -an update on the status The 2019-2020 Novel Coronavirus (Severe Acute Respiratory Syndrome Coronavirus 2) Pandemic: a Joint American College of Academic International Medicine-World Academic Council of Emergency Medicine Multidisciplinary COVID-19 Working Group Consensus Paper Hearing loss in SARS-CoV-2: What do we know? Viral causes of hearing loss: a review for hearing health professionals COVID-19) treatment guidelines Kappa coefficients for missing data safety recommendations for evaluation and surgery of the head and neck during the COVID-19 pandemic Acute profound sensorineural hearing loss after COVID-19 pneumonia Audiological profile of asymptomatic Covid-19 PCRpositive cases Evidence of the COVID-19 virus targeting the CNS: tissue distribution, host-virus interaction, and proposed neurotropic mechanisms Comment on "hearing loss and COVID-19: a note Could sudden sensorineural hearing loss be the sole manifestation of COVID-19? An investigation into SARS-COV-2 in the aetiology of sudden sensorineural hearing loss Otologic dysfunction in patients with COVID-19: A systematic review