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Prevalence and prognosis of tinnitus in post-COVID-19 patients: a cross-sectional survey

Medicine and Health

Prevalence and prognosis of tinnitus in post-COVID-19 patients: a cross-sectional survey

S. Mao, D. Gu, et al.

Nearly 28% of 1331 COVID-19 survivors reported tinnitus — and greater severity meant worse recovery and links to long-term hearing loss, anxiety, and emotional disorders. This research was conducted by Authors present in <Authors> tag. Listen to the audio to learn how severity, prior tinnitus, and prognosis shape post‑COVID ear health.

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~3 min • Beginner • English
Introduction
Tinnitus, the perception of sound without an external source, affects 10–15% of the global population and has been frequently reported during and after COVID-19 infection. While COVID-19 predominantly affects the respiratory system, neurological and otological manifestations, including tinnitus and dizziness, are common and may persist as part of long COVID. Proposed mechanisms linking COVID-19 to tinnitus include inflammation or direct viral effects on the auditory system and pandemic-related stress and anxiety exacerbating tinnitus. Despite growing documentation of symptom presence and duration, prognosis remains underexplored. This study investigates the prevalence, severity, and prognosis of tinnitus following COVID-19, and examines associations with other long-term COVID-19 symptoms and psychological factors to inform management and treatment strategies.
Literature Review
Prior work reports variable tinnitus prevalence during/after COVID-19, influenced by differences in patient populations, disease severity, and measurement methods, with estimates ranging from low single digits up to 67%. Some longitudinal surveys suggest tinnitus prevalence and severity can increase over time among those with prolonged symptoms, while others observed improvement as patients recover. Hypothesized mechanisms include viral-induced inner ear involvement and inflammatory responses, as well as psychosocial stressors of the pandemic exacerbating tinnitus. Studies also highlight the importance of detailed audiological evaluation in COVID-19 patients reporting tinnitus and hearing loss. In the general population, tinnitus severity distributions (e.g., via THI) differ from those observed post-COVID-19, where relatively higher proportions of slight and severe tinnitus have been noted.
Methodology
Design: Cross-sectional study using an anonymous nationwide online questionnaire. Sampling and participants: Convenience sampling recruited individuals with confirmed COVID-19 via nucleic acid or antigen testing, with first infections dated between 12/01/2022 and 01/31/2023. The survey was open 01/19/2023–02/11/2023. Inclusion required age ≥18 and complete key demographics. Exclusions: inconsistent responses (e.g., reporting symptoms without prognosis; reporting no symptoms yet indicating treatment), missing key data (gender, age, height, weight, infection date), and age <18. Of 1366 respondents, 1331 were included; 371 reported post-COVID-19 tinnitus. Ethics: Conducted per the Declaration of Helsinki and Chinese ethical guidelines; approved by the Eye & ENT Hospital of Fudan University Ethics Panel (No. 2022127). Informed consent obtained online; data anonymized. Measures: - Primary outcomes: Prevalence of tinnitus post-COVID-19 and prognosis. Tinnitus severity assessed using the Biesinger tinnitus severity questionnaire (3 items; Grades I–IV). Prognosis categorized as: untreated and self-healed, full remission, relief, or failure. - Secondary outcomes: Cognitive impairment and emotional status assessed using the Health Utilities Index Mark 3 (HUI3) cognition and emotion attributes (6 cognition levels; 5 emotion levels). Anxiety and depression screened via GAD-2 and PHQ-2 (scores ≥3 indicating anxiety/depression). Pre-existing ENT-related conditions (tinnitus, hearing loss, loss of taste/smell) before COVID-19 were recorded. Questionnaire content: 52 items covering demographics, infection date, tinnitus symptoms and outcomes, prior ENT history, and comorbidities; formats included single/multiple choice and free text. Questionnaire developed by otolaryngology and public health experts. Link: https://www.wjx.cn/vm/exOmDok.aspx. Statistical analysis: Non-normally distributed continuous variables summarized as median (IQR) and compared with Wilcoxon rank-sum. Categorical variables as counts (%) compared with chi-square or Fisher's exact tests. Univariate logistic regression assessed associations with treatment effect; multivariate logistic regression identified independent predictors and generated forest plots. Relative risks for cumulative exposures were calculated to estimate absolute risk reduction. Statistical significance at p<0.05. Analyses performed in RStudio (version 2023.06.1+524).
Key Findings
- Sample: 1331 participants (18% male, 82% female), median age 34 (IQR 28–42). Of these, 371 (27.9%) reported post-COVID-19 tinnitus; bilateral tinnitus reported by 51.2%. - Tinnitus severity distribution among 371 cases: Grade I 25.3% (n=94), Grade II 19.4% (n=72), Grade III 22.1% (n=82), Grade IV 33.2% (n=123). Prior tinnitus history: 16.7%. - Prognosis overall (n=371): self-healed 151; full remission 12; relief 24; failure 184. - Prognosis by severity: • Grade I (n=94): self-healed 76.6% (n=72); relief 1.1% (n=1); failure 22.3% (n=21); full remission 0%. • Grade II (n=72): self-healed 44.4% (n=32); full remission 1.4% (n=1); relief 2.8% (n=2); failure 51.4% (n=37). • Grade III (n=82): self-healed 39.0% (n=32); full remission 2.4% (n=2); relief 6.1% (n=5); failure 52.4% (n=43). • Grade IV (n=123): self-healed 12.2% (n=15); full remission 7.3% (n=9); relief 13.0% (n=16); failure 67.5% (n=83). Increasing severity was associated with decreasing self-recovery and increasing persistence of symptoms (p<0.001). - Logistic regression (worse outcomes vs Grade I reference): Grade II OR 3.68 (95% CI 1.89–7.32; p=0.002); Grade III OR 3.70 (1.94–7.22; p<0.001); Grade IV OR 6.83 (3.73–12.91; p<0.001). Prior tinnitus history OR 1.96 (1.08–3.64; p=0.03). - Associations with long-term COVID-19 symptoms: • Hearing loss increased with severity: 19.1% (Grade I) to 50.4% (Grade IV); Grades III–IV significantly higher risk (p<0.001). • Earache: higher risk in Grade IV (p<0.0001). • Cognitive impairment: no significant difference across grades (p=0.517). • Anxiety and emotional disorder: higher with greater tinnitus severity (both p<0.001). Depression showed a smaller association (p=0.024). - Demographics/comorbidities: Significant differences observed for height, weight, and BMI between sexes; no significant differences in most other demographics/comorbidities across prognosis groups.
Discussion
The study addresses the gap in understanding prognosis of post-COVID-19 tinnitus by linking severity at presentation to recovery likelihood. A substantial prevalence (27.9%) of tinnitus was observed among previously infected individuals, higher than typical general-population estimates, suggesting potential COVID-19-related otological effects and/or sampling enrichment. Severity grading was strongly predictive of poorer outcomes: patients with moderate to severe tinnitus were several times more likely to experience no improvement after treatment compared with those with slight tinnitus. The findings also demonstrate that higher tinnitus severity is associated with greater risk of concurrent hearing loss and earache, as well as anxiety and emotional disturbances—key components of long COVID symptomatology—whereas cognitive impairment did not vary significantly by tinnitus severity. Clinically, these results suggest severity-based risk stratification for follow-up, recommending prompt evaluation and targeted management for patients with higher-grade tinnitus or prior tinnitus history to mitigate long-term impacts, including potential hearing loss and psychological burden.
Conclusion
Post-COVID-19 tinnitus varies in severity, with about one-quarter of cases being slight and most of these recovering spontaneously. By contrast, higher severity grades have markedly lower self-healing and overall recovery rates. Compared with slight tinnitus, mild, moderate, and especially severe cases show significantly less favorable treatment responses and a higher likelihood of persistent symptoms. Given the associations with hearing loss and psychological symptoms, early, proactive intervention and close monitoring are recommended for patients with higher-grade tinnitus or a prior tinnitus history.
Limitations
- Selection and sampling bias: Recruitment via an online survey associated with a specialized eye and ENT hospital may enrich for individuals with persistent ENT complaints; the prevalence may therefore exceed that of the general population. - Gender imbalance: The sample included 82% females, potentially biasing estimates and limiting generalizability; sex-specific analyses are warranted. - Self-report and measurement limitations: Tinnitus presence, severity, and prognosis were self-reported without objective audiological confirmation, introducing potential misclassification and recall bias. - Cross-sectional design: Limits causal inference and temporal resolution of symptom trajectories. - Generalizability: Convenience sampling and online participation may underrepresent individuals less likely to respond (e.g., those with milder symptoms seeking no care), affecting external validity.
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