Hearing Loss and Tinnitus After COVID-19 Vaccination

In a study of vaccinations in Israel, an association was found between the BNT162b2 mRNA COVID-19 vaccine and Sudden Sensorineural Hearing Loss (SSNHL) as reflected by the high ratio of observed to expected SSNHL cases. 91 cases of SSNHL were reported after the 1st dose (7 males and 10 females aged 16-44, 15 males and 8 females aged 45-64, 21 males and 30 females aged over 65) and 79 cases of SSNHL were reported after the 2nd dose (10 males and 13 females aged 16-44, 8 males and 7 females aged 45-64, 30 males and 24 females aged over 65), There were 170 cases total. 

Overall, 2602557 Clalit Health Services members (46.8 ± 19.6, 51.5% female) received the first dose of the BNT162b2 mRNA COVID-19 vaccine between December 20, 2020, and April30,2021. Of these individuals, 2441719 (age 47.3 ± 19.6) received the second vaccine dose between January10, 2021, and April 30, 2021.

The study is not giving details about these 170 cases, but here's a brief summary of cases from other countries reported in medical literature.  

An 18-year-old male visited Ilsan Hospital in South Korea for sudden hearing loss in the right ear, which had occurred two weeks prior, two days after the second dose of COVID-19 vaccination with Pfizer-BioNTech. Initial hearing threshold with weighted four-frequency average was 89 dB in the right and 13 dB in the left ear on pure tone audiometry (panel C in the figure). He received high-dose oral steroid (prednisolone 60 mg per day for five days, which was tapered for the next five days). Intratympanic steroid injection (dexamethasone 5 mg every third day for five cycles) was administered simultaneously due to severe hearing loss. Temporal magnetic resonance imaging showed normal findings. After treatment with oral and intratympanic steroid, hearing threshold worsened to 100 dB in the right ear on pure tone audiometry.

A 30-year-old male from Italy experienced sudden onset of left tinnitus, hyperacusis and dysacusis approximately one week after the 2nd COVID-19 vaccine dose. He also had fever and sickness as other injection side effects. He reported Hashimoto thyroiditis in his past medical history. He denied any home medical therapy or allergies. He underwent a 10-day course of oral prednisone with tapering regimen, resulting in significant improvement of the auditory phenomena and tinnitus perception.

37-year-old Taiwanese man with a past history of glaucoma but no previous problems associated with tinnitus or hearing loss, received the first dose of the AstraZeneca COVID-19 vaccine at 11 am on 30 April 2021 without any local infection/complication. He started to have intermittent, right ear, high-pitch tinnitus from 4 pm into the night on 30 April 2021 with tinnitus handicap inventory (THI) score as 28. At midnight on April 30th, a high fever with chills and myalgia developed, with a poor response to 500 mg acetaminophen. Therefore, he visited the emergency department, wherein the laboratory data, including CBC/DC, Cre/GPT, PT/aPTT/fibrinogen/D-dimer, creatine kinase, and blood culture, were normal. The intermittent, right ear, high-pitch tinnitus progressed into continuous high-pitch tinnitus and disturbed the normal hearing of the patient. In addition, low-pitch right ear tinnitus also appeared intermittently. Moreover, the THI score increased to 46. He received an otolaryngologic inspection, which revealed no abnormal findings. Under the impression of acute inflammatory cochleopathy, he was treated with one dose of 10 mg intravenous dexamethasone and a 3-day oral 5 mg prednisolone three times per day. His fever and myalgia quickly subsided. In addition, the right ear high-pitch and low-pitch tinnitus completely subsided on 3 May 2021. The subsequent audiometry demonstrated that the patient had recovered well by 5 pm 3 May 2021 with the THI score returning to 0. The COVID-19 real-time polymerase chain reaction (RT-PCR) detection assay revealed negative findings throughout the entire course of treatment.

A 37-year-old previously healthy male from Hong Kong noticed fever and a pain in his right ear, vertigo, tinnitus and loss of hearing two days after his first dose of the Pfizer-BioNTech (BNT162b2) vaccine. He also complained of facial palsy, tongue numbness and dysgeusia. On examination, he had grade 4 right facial nerve palsy of the lower motor neuron type with right sensorineural hearing loss. He was diagnosed with Ramsay Hunt syndrome (RHS) - which is very rare for patients under 60 years old with no previous history of Herpes Zoster. 

A 37-year-old male from Taiwan, with a history of glaucoma but no hearing issues, started to have intermittent, right ear, high-pitch tinnitus 5 hours after his first dose of Astrazeneca vaccine with tinnitus handicap inventory (THI) score as 28. It followed by high fever with chills and myalgia, with a poor response to 500 mg acetaminophen. The intermittent, right ear, high-pitch tinnitus progressed into continuous high-pitch tinnitus and disturbed the normal hearing of the patient. In addition, low-pitch right ear tinnitus also appeared intermittently. Moreover, the THI score increased to 46. He received an otolaryngologic inspection, which revealed no abnormal findings.

A 37-year-old female from Italy experienced sudden onset of right tinnitus 7 hours after her first dose of COVID-19 vaccine.She reported short-term dizziness, but she did not notice hearing loss. Local pain at injection site was reported as another vaccine side effect. Her previous medical history was relevant for glaucoma and undifferentiated connective tissue disease. A 10-day course of oral corticosteroid therapy with tapering regimen slightly improved Tinnitus and THI score, but the patient still complained of tinnitus and an accompanying bilateral ear fullness sensation. 

A 42-year-old Korean male experienced sudden hearing loss in the left ear, which had occurred on the day of the first dose of COVID-19 vaccination with Pfizer-BioNTech. Initial hearing threshold with weighted four-frequency average was 13 dB in the right and 9 dB in the left ear on pure tone audiometry, but there was acute hearing loss at low frequencies in the left ear (40, 45, and 30 dB at 125, 250, and 500 Hz, respectively, panel B in the Figure) He received high-dose oral steroid for five days, which helped to partially restore hearing threshold at low frequencies. Salvage treatment with intratympanic steroid injection (dexamethasone 5 mg every third day for five cycles) helped to improve hearing threshold at low frequencies improved (25, 30, and 10 dB at 125, 250, and 500 Hz, respectively).

A 55-year-old female from USA developed throat fullness, wheezing, tinnitus and severe headache 5 minutes after receiving her first injection of the SARS COV2 Pfizer vaccine. She was treated with epinephrine and admitted for extensive work up and specialist consultations. No significant abnormalities were found and while she improved clinically, her tinnitus has persisted for months despite treatments with corticosteroids, levetiracetam and antibiotics.

A 57-year-old Italian male reported the sudden onset of hearing loss and tinnitus in right ear 2 days after the inoculation of the first shot of AstraZeneca Covid-19 vaccine. He received the first shot on March 14, 2021, started complaining about tinnitus and hearing loss on March 16, 2021 and was admitted in the hospital on March 31, 2021. The patient received an RT-PCR OP/NP swab test, resulted negative for Sars-CoV2 the same day. The patient was healthy, with no history of otological pathology or occupational exposure to noise, no use of medicines and no allergies. Otoscopic examination showed normal external auditory canals and tympanic membranes. Pure tone audiometry (PTA) demonstrated normal hearing threshold in the left ear and a mild hearing loss in the right ear. MRI and autoimmune screenings showed no abnormalities. The patient completed a 12-day cycle of therapy with methylprednisolone, B-vitamin complex and folic acid. On April 13, audiological evaluation showed a clear improvement of right ear's hearing threshold. On May 18, inflammatory markers screening showed all normal values except for slightly increased Fibrinogen. After two months of treatment, the patient was still suffering from tinnitus in right ear, while the Pure tone audiometry remained unchanged.

A 61-year-old female was referred to the Department of Otorhinolaryngology-Head and Neck Surgery in Thessaloniki General Hospital with a four-day history of the right-sided sense of fulness combined with almost complete hearing loss that had started two days after the second dose of Oxford-AstraZeneca COVID-19 vaccine. She did not report any history of earache, trauma, or discharge, did not consume tobacco or alcohol, and did not have tinnitus or vertigo. Pure tone audiometry showed profound right-sided sensorineural hearing loss. Magnetic resonance imaging of the brain and internal auditory canal and magnetic resonance angiography were both normal. The combination of glucocorticoids and acetylsalicylic acid lead to almost full recovery 15 days after deafness. 

A 63-year-old male from Italy experienced sudden onset of left tinnitus 20 hours after the first vaccine dose, associated to hyperacusis and dysacusis. He had a history of SNHL. He refused corticosteroid therapy and experienced spontaneous improvement 7 days later. 

A 64-year-old Korean female experienced sudden hearing loss in the right ear that occurred one day after her first dose of Oxford-AstraZeneca COVID-19 vaccination. Initial hearing threshold with a weighted four-frequency average ([500 Hz + 1000 Hz × 2 + 2000 Hz × 2 + 4000 Hz] / 6) was 86 dB in the right and 17 dB in the left ear on pure tone audiometry (Panel A in the Figure above). She received high-dose oral steroid (prednisolone 60 mg per day for five days, which was tapered for the next five days). Temporal magnetic resonance imaging showed normal findings. After five days of treatment, hearing threshold improved to 30 dB. Salvage treatment with intratympanic steroid injection (dexamethasone 5 mg every third day for three cycles) led to complete recovery.

A US study mentions 30 California patients with new or significantly exacerbated otologic symptoms that began shortly after COVID-19 vaccinationm, 18 after Moderna and 12 after Pfizer vaccine. The mean onset of symptoms was 10± 9 days post-vaccination. Symptoms included 25 patients (83.3%) with hearing loss, 15 (50%) with tinnitus, eight (26.7%) with dizziness, and five (16.7%) with vertigo. Eleven patients had previous otologic diagnoses, including six patients with Menière's disease, two with autoimmune inner ear disease (AIED), and three having both.

Among 555 SNHL incidents reported to VAERS, 305 cases (55.0%) involved the Pfizer-BioNTech vaccine, 222 (40.0%) involved the Moderna vaccine, and 28 (5.0%) involved the Janssen/Johnson & Johnson vaccine. Average age was 55. Among 164 reports in VigiBase (before Feb.2021), most common symptoms co-reported with hearing loss were tinnitus (a subset of 367 submissions that reported tinnitus as a side effect of COVID-19 vaccines), followed by headache, dizziness and nausea, and many patients experienced a quick recovery, although some patients needed steroid treatment. The age in the reported cases ranged from 19 to 93 years with a median of 49. By November 2021, the number of reports about hearing disorders after vaccination dramatically increased, with more than 31,000 reports of tinnitus.

Six cases with otologic symptoms related to the Astra Zeneca COVID-19 vaccine were reported by a Mexico clinic. Ages ranged from 40 to 61. 

Despite all these and many other reports, only one manufacturer - Johnson & Johnson - lists tinnitus as a reported side effect on its COVID-19 vaccine fact sheet.


REFERENCES

Yanir Y, Doweck I, Shibli R, Najjar-Debbiny R, Saliba W. Association Between the BNT162b2 Messenger RNA COVID-19 Vaccine and the Risk of Sudden Sensorineural Hearing Loss. JAMA Otolaryngology–Head & Neck Surgery. 2022.

Tsetsos N, Poutoglidis A, Vlachtsis K, Kilmpasanis A, Gougousis S. Sudden sensorineural hearing loss following the second dose of COVID-19 vaccine. Cureus. 2021 Aug 25;13(8).

Tseng PT, Chen TY, Sun YS, Chen YW, Chen JJ. The reversible tinnitus and cochleopathy followed first-dose AstraZeneca COVID-19 vaccination. QJM: An International Journal of Medicine. 2021 Jul 23.

Jeong J, Choi HS. Sudden sensorineural hearing loss after COVID-19 vaccination. International Journal of Infectious Diseases. 2021 Dec 1;113:341-3.

Formeister EJ, Wu MJ, Chari DA, Meek R, Rauch SD, Remenschneider AK, Quesnel AM, de Venecia R, Lee DJ, Chien W, Stewart CM. Assessment of Sudden Sensorineural Hearing Loss After COVID-19 Vaccination. JAMA Otolaryngology–Head & Neck Surgery. 2022.

Pisani D, Leopardi G, Viola P, Scarpa A, Ricciardiello F, Cerchiai N, Astorina A, Chiarella G. Sudden sensorineural hearing loss after covid-19 vaccine; A possible adverse reaction?. Otolaryngology Case Reports. 2021 Nov 1;21:100384.

Woo CJ, Chou OH, Cheung BM. Ramsay Hunt syndrome following COVID-19 vaccination. Postgraduate medical journal. 2022 Jan 5.

Wichova H, Miller ME, Derebery MJ. Otologic manifestations after COVID-19 vaccination: the house ear clinic experience. Otology & Neurotology. 2021 Oct;42(9):e1213.

Medina MC, Gómez MR. Tinnitus, Sudden Sensorineural Hearing Loss, and Vestibular Neuritis As Complications of the Astra Zeneca COVID-19 Vaccine. Cureus. 2022 Jan 3;14(1).

Tseng PT, Chen TY, Sun YS, Chen YW, Chen JJ. The reversible tinnitus and cochleopathy followed first-dose AstraZeneca COVID-19 vaccination. QJM: An International Journal of Medicine. 2021 Jul 23.

Parrino D, Frosolini A, Gallo C, De Siati RD, Spinato G, de Filippis C. Tinnitus following COVID-19 vaccination: report of three cases. International Journal of Audiology. 2021 Jun 10:1-4.

Ahmed SH, Waseem S, Shaikh TG, Qadir NA, Siddiqui SA, Ullah I, Waris A, Yousaf Z. SARS-CoV-2 vaccine-associated-tinnitus: A review. Annals of Medicine and Surgery. 2022 Jan 25:103293.

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