The Connection Between Long COVID and Tinnitus

Many of my tinnitus patients relay their experiences to me about how either COVID infection, the COVID vaccine, and long COVID has aggravated their tinnitus. Here I review the topic of long COVID and tinnitus, covering these key points:

• What is long COVID?
• What are the common long COVID symptoms?
• What causes long COVID?
• Why does COVID cause tinnitus?
• Can the COVID vaccine cause tinnitus?
• How can you treat long COVID-related tinnitus?

Intro to Long COVID and Tinnitus

The connection between long COVID and tinnitus is now becoming more clear. While most studies report the prevalence of tinnitus in long COVID patients to be between 20-40%, a recent study of 990 people with long COVID showed that up to 73% report tinnitus as a chronic symptom [1]. 

Researchers are discovering that nerve hyperexcitability during periods of brain inflammation, such as with viral infections or trauma, may cause the development or worsening of tinnitus [2]. Since acute COVID infection involves a period of brain inflammation, this may be the reason why COVID-related tinnitus is so prevalent. 

Here, I’d like to explore the relationship between long COVID and tinnitus. I’ll first present some general information on long COVID and how it’s related to prolonged brain inflammation. I’ll then explain how this relates to the onset and exacerbation of tinnitus. Finally, I’ll cover the techniques I use in my practice to treat long COVID tinnitus.

What is Long COVID?

Not long after the first waves of COVID infections had passed, doctors began to note that certain patients were having prolonged symptoms. We now refer to this collection of lingering symptoms as long COVID. 

There are several other names used in the research literature for long COVID, including long-haul COVID, chronic COVID, post-COVID syndrome (PCS), or post-acute sequelae of SARS CoV-2 infection (PASC).

What is the definition of Long COVID?

The World Health Organization (WHO) drafted a consensus statement that defines long COVID (which they call “post COVID condition”). Here are the WHO diagnostic elements:

• A history of SARS-CoV-2 infection, with
• Post-infection symptoms that persist for three or more months, and
• Where these symptoms last for at least 2 months, and
• Where these symptoms cannot be explained by another diagnosis [3].

Estimates of the prevalence of long COVID are evolving, but the Centers for Disease Control (CDC) estimates that 1 in 5 people infected with the SARS-CoV-2 virus will develop long COVID [4].

The WHO/CDC definition of long COVID requires that people have symptoms for multiple months after getting infected.  However, this may underestimate the problem. A meta-analysis pooling global data from 1.6 million patients showed that 43% of people infected with COVID-19 had prolonged symptoms lasting greater than 28 days [5].

Is Long COVID a Disability?

The Department of Health and Human Services (HHS) has designated long COVID as a disability under the Americans with Disabilities Act (ADA) if it substantially limits major life activities [5]. 

Furthermore, health insurance reimbursement for long COVID conditions is also now possible, as the International Classification of Diseases (ICD-10) created the U09.9 code for “Post-COVID conditions, unspecified” as a billable code. This is important as it formally recognizes long COVID as a bona fide medical condition. 

How common is long COVID?

Long COVID prevalence appears to be associated with the degree of neuroinflammation or severity from the original infection. For instance, in one meta-analysis of 10,945 cases of severe COVID-19 cases, approximately 64% developed a long COVID diagnosis [7].  However, in cases of asymptomatic COVID-19 infection, prolonged symptoms are much more rare, with an approximate 80% reduced risk of long COVID [8]. This demonstrates the strong link between neuroinflammation and the development of long COVID, which will be discussed further below.

What are the common long COVID symptoms?

Long COVID can affect many different systems in the body. Here are some of the most common symptoms, grouped by bodily system and estimated prevalence (Table 1):

Table 1: Long COVID symptoms by system with estimated prevalence [9-12].

System	Symptom
General	Fatigue  (23-53%)
	Malaise  (20%)
	Joint or Muscle Pain  (10-32%)
Respiratory	Shortness of breath  (14-26%)
	Difficulty breathing  (14-35%)
	Cough  (5-40%)
Cardiovascular	Chest tightness  (48%)
	Palpitations  (5-44%)
Gastrointestinal	Diarrhea  (3-21%)
	Abdominal pain  (4-10%)
	Loss of appetite  (6-14%)
Neurologic	Cognitive impairment  (9-50%)
	Headache  (5-33%)
	Impaired memory  (14-19%)
Ear, Nose	Dizziness/imbalance  (4-60%)
	Tinnitus  (10-30%)
	Decreased sense of smell  (6-36%)
Psychological	Anxiety  (8-24%)
	Depression  (7-23%)
	Post-traumatic stress  (15-18%)

This list is not exhaustive, as people also can experience problems in their immune system, kidneys, skin, and other areas. Long COVID that affects the heart and lungs can be particularly serious, requiring specialist care with a cardiologist or pulmonologist.

Brain Fog, ADHD, And Tinnitus

It's interesting that brain fog and tinnitus are often seen together in long COVID. We're now learning that brain fog is essentially the same clinical entity as inattentive-type ADHD. We expect to do more research in this area soon.

What causes long COVID?

The cause of long COVID is a matter currently being debated. Some are now framing long COVID as being a form of chronic pain syndrome. For instance, in long COVID, chronic pain, fatigue, headache, and cognitive impairment are among the most common symptoms [12].

This constellation of symptoms is very similar to those seen in other chronic multi-symptom conditions, such as migraine, fibromyalgia, chronic fatigue syndrome, ADHD, and post-concussion syndrome. 

Long COVID and Central Sensitization

The common mechanism that long COVID and similar chronic conditions share is “central sensitization”. This process is involved in an atypical form of migraine where patients may not experience headaches, but rather a number of symptoms including dizziness, tinnitus, mental fogginess, blurring of vision, neck stiffness, head or ear pressure, among others. There is increasing consensus that long COVID is a form of “central sensitization syndrome” [13], [14]. 

Central sensitization is also seen in the setting of prolonged neuroinflammation. It describes a neurological process characterized by heightened sensitivity in the central nervous system which leads to an exaggerated reaction to stimuli, creating a self-sustaining cycle. This cycle results in a hypersensitive nervous system that amplifies signals and responds excessively to stimuli that would not typically be perceived as painful or bothersome.

As central sensitization advances, it leads to persistent adverse symptoms. Beyond physical effects like pain, vertigo, or tinnitus, individuals may experience cognitive and emotional shifts, including problems like “brain fog”, memory issues, and mood disturbances. 

Stress and emotional states, such as anxiety and catastrophizing, significantly contribute to reinforcing the neuroplastic changes associated with central sensitization. Therefore, when treating central sensitization syndromes, addressing stress and regulating mood becomes crucial.

In addition, sleep disturbance and diet have major effects on central sensitization and persistence of symptoms. Improving sleep and adjusting the diet is critical in correcting the underlying central sensitization.

Are long COVID and tinnitus related?

Long COVID and tinnitus are related, with estimates of the prevalence of long COVID-related tinnitus varying between 30% and 73% [1]. In fact, tinnitus as a symptom of long COVID is underestimated because researchers look for new symptoms, not necessarily worsening of existing symptoms. To illustrate this point, in a survey of people who had tinnitus before the pandemic, 40% reported that their tinnitus was worse after being infected with COVID-19 [15].

Why does COVID cause tinnitus?

There are several possible explanations for why COVID-19 infection might cause tinnitus. The initial injury to the hearing organ (the cochlea) is similar to other viral infections that affect the ear.

Inflammatory molecules called cytokines are significantly elevated in COVID-19 infection (called a “cytokine storm”). These elevated levels of cytokines may impact synaptic plasticity and contribute to auditory disorders linked to neuroinflammation. 

Specific to COVID-19 infections, the SARS-CoV-2 spike protein has been shown to interact with certain receptors in the cochlea, showing that the inner ear is directly vulnerable to COVID-19 infection [16]. 

Central Sensitization, Long COVID, and Tinnitus

Following the initial impact from infection, the progression toward chronic tinnitus or exacerbation of existing tinnitus is more likely attributed to central sensitization-related processes. 

As noted above, central sensitization is heightened by influences from the emotional and stress-related regions of the brain, sleep, and diet. When these factors coincide with tinnitus, they reinforce the formation of new neural pathways that affect tinnitus severity. 

Central sensitization increases the brain’s attention to the tinnitus, which increases the perception of tinnitus. The activation of migraine in these patients can lead to the development of cochlear migraine, a form of migraine that can cause de novo tinnitus or lead to increased loudness of pre-existing tinnitus.

Can the COVID vaccine cause tinnitus?

All vaccinations cause inflammation. This is how they work. They trigger an immune response so your body knows what to fight. This inflammation can often trigger the migraine process, and therefore, can trigger tinnitus.

Since the vaccines were of a new type for COVID-19, there was some concern about their effect on tinnitus. As of September 14, 2021, the Vaccine Adverse Events Reporting System (VAERS) has documented 12,247 cases of post-vaccination tinnitus related to the coronavirus vaccine [17]. 

However, when put in the context of large populations, the reported cases of new onset tinnitus after COVID-19 vaccinations is very low (less than 0.5%) [18]. In fact, these rates are lower than other commonly administered vaccines, such as the influenza vaccine.  

Can active COVID cause hearing loss?

New onset hearing loss is commonly linked to viral infections. There is growing literature on the association between “sudden sensorineural hearing loss” (when hearing loss is sudden) and COVID infections. In one study of over 3700 people infected with COVID, between 5.1-6.4% responded that they experienced hearing loss 3 months or more after infection [10]. 

Some patients experience difficulty with word understanding in long COVID. This likely occurs because of the brain fog that long COVID causes, which decreases the brain’s ability to concentrate, especially in noisy environments. As noted above, this may be related to an ADHD-type process in the brain.

When people do have hearing loss with COVID, it’s frequently accompanied by tinnitus as well. In a case series of patients with COVID-related hearing loss, 61% also developed tinnitus [19].  

Does long COVID cause vertigo?

Long COVID commonly comes with balance disorders, including vertigo. This correlation is expected, given the similarity in the tissues of the inner ear organs that are responsible for balance and for hearing. 

A meta-analysis of long COVID symptoms found that vertigo, dizziness, or balance disorders were present in 27-42% of patients [10]. In another survey, 60% reported having either vertigo or dizziness as a symptom and 25% reported having both vertigo/dizziness and tinnitus together [1].

A likely cause of dizziness and vertigo in patients with long COVID is the activation of the migraine process. In this atypical form of migraine, patients may never experience headaches and the only manifestation of the migraine may be vertigo. This condition (termed “vestibular migraine”) may become chronic due to other factors such as stress, poor sleep, diet, visual motion stimulation, etc.

How can you treat long COVID-related tinnitus?

By viewing long COVID-related tinnitus as a central sensitization phenomenon, new avenues for treatment become possible for achieving sustained relief from tinnitus. The “biopsychosocial” approach to treating central sensitization conditions involves addressing the interconnected influences of biological, psychological, and social factors on an individual's health.

• Bio: Interventions may target neuroinflammation, pain pathways, and other physiological aspects. Treating sleep problems and following a diet low in specific molecules that trigger and maintain central sensitization.
• Psycho: Addressing stress, anxiety, and mood regulation is crucial, as emotional states significantly impact central sensitization.
• Social: Understanding the patient's environment, support systems, and lifestyle factors is essential for comprehensive care.

This holistic approach recognizes that effective management requires a combination of medical, psychological, and social interventions tailored to the individual's specific condition and circumstances.

How do you treat Long COVID Tinnitus?

When the biopsychosocial approach is applied to tinnitus, several strategies become apparent. Here are some commonly recommended interventions, along with their rationale, as they fit into the biopsychosocial model (Table 2).

Table 2. Elements of the biopsychosocial model applied to treatments for long COVID-related tinnitus.

Intervention	Description and Rationale
Bio-Nutraceuticals	Certain nutraceuticals are very helpful in calming the brain inflammation associated with long COVID.  They can also aid in promoting synaptic plasticity and regulating neurotransmitters.
Bio-Pharmaceuticals	Pharmaceutical medications like nortriptyline or topiramate (Topamax) may be employed to restore a balance in neurotransmitters, facilitating positive neuroplastic changes and alleviating tinnitus.
Bio- Tinnitus Masking	This is a standard intervention for tinnitus, but it makes sense in the context of long COVID. If you give your brain a chance to rest from the constant presence of tinnitus, new healthy neural networks have a chance of being created.
Bio- Exercise	Exercise helps with central sensitization by reducing nervous system hypersensitivity and promoting neuroplastic changes that contribute to alleviating chronic symptoms.
Bio- Diet Changes	A neuroprotective diet should be adopted in long COVID. You can reduce neuroinflammation with anti-inflammatory foods while minimizing processed foods, trans fats, and added sugars. The diet includes elimination of certain neurotransmitters that are contained in some foods.
Psycho- CBT	Cognitive behavioral therapy (CBT) for tinnitus involves identifying and modifying maladaptive thought patterns, developing coping strategies, and reducing catastrophizing behavior.
Psycho- Mindfulness	Practicing mindfulness can play a pivotal role in reducing tinnitus severity by specifically targeting the stress input from brain regions associated with tinnitus generation.
Psycho- Sleep Hygiene	Prioritizing sleep hygiene is essential for reducing long-COVID related tinnitus, as it supports neurological well-being and may alleviate symptom severity over time.
Social- Coaching	Coaching aids in tinnitus treatment by providing support, motivation, and guidance, addressing not only the physical aspects of the condition but also the emotional and social realms.

The best approach is to combine these various elements and tailor them to an individual’s personal needs. This multimodal approach, combining pharmacologic, physical, and holistic interventions, enhances the chances of success in long COVID tinnitus recovery by addressing the diverse factors that contribute to its pathology.

Summary: Long COVID tinnitus is treatable.

Tinnitus in the context of long COVID begins with initial inflammation, but it is the process of central sensitization that solidifies these symptoms into a chronic state. By comprehending the role of central sensitization in the establishment of long COVID symptoms, a broader range of interventions can be considered to alleviate tinnitus. 

In my practice and at NeuroMed, we use a multimodal strategy incorporating pharmacologic, physical, and natural approaches. This offers the most promising chances of success in addressing the complex nature of long COVID tinnitus.

Long COVID and Tinnitus References

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7. “Guidance on ‘Long COVID’ as a Disability Under the ADA, Section | HHS.gov.” Accessed: Dec. 05, 2023. [Online]. Available: https://www.hhs.gov/civil-rights/for-providers/civil-rights-covid19/guidance-long-covid-disability/index.html
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16. E. W. Beukes et al., “Changes in Tinnitus Experiences During the COVID-19 Pandemic,” Front. Public Health, vol. 8, p. 592878, Nov. 2020, doi: 10.3389/fpubh.2020.592878.
17. T. Uranaka et al., “Expression of ACE2, TMPRSS2, and Furin in Mouse Ear Tissue, and the Implications for SARS-CoV-2 Infection,” The Laryngoscope, vol. 131, no. 6, pp. E2013–E2017, Jun. 2021, doi: 10.1002/lary.29324.
18. S. H. Ahmed et al., “SARS-CoV-2 vaccine-associated-tinnitus: A review,” Ann. Med. Surg. 2012, vol. 75, p. 103293, Mar. 2022, doi: 10.1016/j.amsu.2022.103293.
19. I. Dorney, L. Bobak, T. Otteson, and D. C. Kaelber, “Prevalence of New-Onset Tinnitus after COVID-19 Vaccination with Comparison to Other Vaccinations,” The Laryngoscope, vol. 133, no. 7, pp. 1722–1725, Jul. 2023, doi: 10.1002/lary.30395.
20. X. Meng, J. Wang, J. Sun, and K. Zhu, “COVID-19 and Sudden Sensorineural Hearing Loss: A Systematic Review,” Front. Neurol., vol. 13, p. 883749, Apr. 2022, doi: 10.3389/fneur.2022.883749.