Category: Tinnitus

A look at what we now know about how COVID-19 has been found to affect the auditory system, based on a review of the literature. By Robert M. DiSogra, AuD It has been five years since the COVID-19 pandemic started in the United States. Each of us has dealt with the impact of COVID-19 personally and professionally. In 2019, there were many unknowns about the virus’s effect on the many parts of the auditory system: hearing, tinnitus, balance, auditory processing, and cognition. Although it was tempting to make early declarations regarding the impact of COVID-19 on these areas, the aggregated peer-reviewed literature points to a more realistic picture. Introduction As of June 17, 2025, the National Library of Medicine (NLM), a division of the National Center for Biotechnology Information (NCBI), part of the National Institutes of Health (NIH), PubMed website had documented 61,991 peer reviewed books, documents, clinical trials, meta-analyses, randomized controlled trials, and reviews (including systematic review) on the topic of COVID-19. Also, as of June 17, 2025, the NIH’s website identifying ongoing clinical trials (www.clinicaltrials.gov), listed only three ongoing studies using the following parameters: COVID-19, Corona virus, Recruiting studies, Phase (Early Phase, Phases 1, 2, 3), and Interventional studies. These studies were taking place in the USA and India. The American Academy of Audiology lists 239 articles when you Search “COVID-19.” This manuscript will summarize what we, as a profession, have learned about COVID-19 and its impact on the auditory system: hearing, balance, auditory processing, and cognition. Details can be found in the referenced literature. Main Sources for Current COVID-19 Information (2025) 1. World Health Organization (WHO): (www.who.net) 2. Centers for Disease Control and Prevention (CDC): www.cdc.gov 3. Food and Drug Administration (FDA): www.fda.gov; Search COVID-19 4. Peer-reviewed COVID research from 2019: www.pubmed.ncbi.nlm.nih.gov COVID-19 Vaccine Information (2025) U.S. Department of Health and Human Services (HHS): www.hhs.gov Centers for Disease Control and Prevention: www.vaccines.gov To report a vaccine adverse reaction: Vaccine Adverse Event Reporting System (VAERS): https://vaers.hhs.gov COVID-19 Dietary Supplements There are no over-the-counter (OTC) dietary supplements for COVID-19 approved by the U.S. Food and Drug Administration (FDA). However, if an adverse reaction occurs from any dietary supplement, it should be reported to the FDA’s VAERS program (https://vaers.hhs.gov). NOTE: VAERS is a voluntary reporting program. https://hearingreview.com/hearing-loss/health-wellness/how-chronic-illnesses-impact-hearing-balance-and-cognition-a-guide-for-hearing-care-professionals COVID-19 As of 1/23/2025, there were three pharmaceuticals that were FDA approved or authorized drugs to reduce the risk of hospitalization or death for patients with mild to moderate COVID-19: Paxlovid (nirmatrelvir and ritonavir), Veklury (remdesivir), Lagevrio (molnupiravir), and Pemgarda. Lagevrioand Pemgarda have been authorized under Emergency Use Authorization (EUA). Additional information about EUA can be found on the FDA’s website (search Emergency Use Authorization). Auditory-Related Vaccine Side Effects (2024) Vaccine adverse effects are published monthly by the National Vaccine Information Center(www.medalerts.org). Table 1 shows the auditory-related adverse events from FDA-approved vaccines and Table 1a lists the top 10 adverse reactions as reported in December 2024. Table 1: Auditory-Vestibular-Cognitive Related Vaccine Side Effects n 2,652,032 (as of 12/27/2024) Symptom1 n Percentage (rounded) Auditory Disorder (unspecified) 225 0.0085 Auditory Hallucination (not specified) 283 0.0107 Auditory Nerve Disorder 21 0.0008 Auditory Neuropathy Spectrum Disorder 1 0.00004 Brain Fog 1,071 0.0404 Central Auditory Processing Disorder 2 0.00008 Cognitive Disorder 2,475 0.0933 Cognitive Linguistic Impairment 10 1.0194 Sudden Sensorineural HL 2,077 0.0783 Deafness2 - total 3,639 0.1372 Bilateral 346 0.0130 Conductive 23 0.0009 Congenital 3 0.0001 Mixed 6 0.0002 Neonatal 2 0.00008 Neurosensory 681 0.0258 Permanent 24 0.0009 Transitory3 114 0.0043 Traumatic 7 0.0003 Unilateral 2,433 0.0917 Dizziness - total 128,201 4.8341 Exertional 189 0.0071 Postural 2,142 0.0808 Persistent postural perceptual 59 0.0022 Procedural 10 0.0004 Hearing Disability 39 0.0015 Otitis Media (includes acute, 245 0.0092 allergic, bacterial, chronic and viral) Tinnitus4 26,063 0.9827 Vertigo - total 17,424 0.6570 CNS Origin 15 0.0005 Cervicogenic 1 0.00004 Labyrinthine 21 0.0008 Phobic postural 17 0.0006 Positional 810 0.0305 Vertigo 16,560 0.6242 Vascular Cognitive Impairment 2 0.00008 1. No formal language requirement exists when reporting auditory impairments (including balance, tinnitus and cognitive disorders 2. It appears that the terms “hearing disability, “deafness,” “conductive deafness” are being used interchangeably with sensorineural (neurosensory) or mixed hearing loss. These were the terms used by those reporting to the VAERS 3. Duration not specified 4. Duration, uni-/bilateral, continuous or pulsatile or description not specified _____________________________________________________________________________ Table 1. The number of auditory-related adverse events from FDA approved vaccines that were voluntarily reported to the Vaccine Adverse Event Reporting System as of 12/27/2024. Table 1a: Top 10 Vaccine Reactions for December 2024 Reaction Reports Dizziness 126,201 Tinnitus 26,063 Vertigo 17,424 Deafness 3,639 Cognitive Disorder 2,475 Sensorineural HL 2,077 Brain Fog 1,071 Auditory Hallucinations* 283 Otitis Media 245 Auditory Disorder* 225 *unspecified __________________________________________________________________ Table 1a. The top 10 adverse reactions as reported in December 2024 from the National Vaccine Information Center. See Table 1 for details. What Is Known About the Impact of COVID-19 on Hearing, Balance, and Cognition The following is a summary of information that the PubMed website identified when the specific search term was used. Cerumen There has been evidence of the COVID-19 virus in cerumen (Hanege, 2021; Celik, 2021). It is recommended that there be an increase in the use of personal protective equipment (PPE); cerumen disposal does not have to be handled any differently, as long as one is following Universal Precautions per the CDC (DiSogra, 2021). CPT Code 99072 can be used for billing for the time spent pre-screening patients before the visit; time spent checking patients for symptoms onsite; PPE for the patient, clinician, and staff; and for cleaning supplies needed for disinfecting equipment and rooms after each encounter. Unfortunately, there is no guarantee of payment depending on the insurance coverage the patient has. Middle Ear Pathology The coronavirus can colonize in the middle ear and mastoid region. The resulting otitis media should be referred to an ENT specialist for intervention (Frazier, 2020). Cochlear Hearing Loss Because the virus is systemic, you can expect bilateral sensorineural hearing loss. Satar (2020) found that COVID-19-associated hearing loss occurs within one month of the diagnosis. Cochlear Hearing Loss – Subjective Testing COVID-19-associated sensorineural hearing loss (SNHL) is usually high frequency ( >4kHz) and often above 8kHz) (Jafari, 2020). Hearing thresholds can recover to pre-COVID levels, but not in all cases (Mustafa, 2020). Cochlear Hearing Loss – Objective Testing Distortion Product Otoacoustic Emission (DPOAE) Testing DPOAE parameters are no different for the COVID patient than for any other patient complaining of hearing loss. Loss of outer hair cells can be identified with this test procedure. Interpretation is the same. A baseline test including all available frequencies above 2000Hz should be established to monitor stability, recovery, or progression of the loss. Auditory Brainstem Response Test (ABR) Early on in the COVID-19 pandemic, neuroauditory problems could not be ruled out as having been caused by the virus (Sriwijitalai and Wiwanitkit, 2020). Therefore, the ABR is an excellent procedure to support the DPOAE test with either the presence or absence of a Wave I. If subsequent waves are absent or the morphology of the response is poor, then the Middle Latency Test (MLR) becomes the test of choice for looking at other areas of the auditorypathway. Middle Latency Response Test (MLR) The MLR test visualizes the electrical activity of the primary auditory cortex, the auditory thalamus-cortical pathways, and the temporal processing of linguistic information (Frizzo,2015). A latency shift and abnormal morphology raises suspicions that the virus has affected cells in the brainstem. NOTE: an abnormal ABR (Waves II - V) and/or MLR (delayed Na wave or smaller Pa wave amplitude) could occur in the presence of a normal pure tone audiogram. Sudden Sensorineural Hearing Loss (SSNHL) SSNHL has been reported after a COVID vaccination, but the incidence has not been shown to be greater than pre-COVID-19 with the general population (Formeister, 2022). Word Recognition Scores There has been no research specifically looking at changes in word recognition scores (WRS) with COVID-19 patients (Mikhail and Perez, 2024). Therefore, WRS remains a dubious test at best, but does appear to be essential as expected based on the degree of SNHL. Tinnitus According to the American Tinnitus Association (2020), pre-existing behavioral conditions could contribute to COVID-19-related tinnitus. These include stress, depression, social isolation, infection, and avoidance. Also, current medication side effects must be considered as possible causes (DiSogra, 2021). Therefore, tinnitus remains a case-by-case situation based on the patient’s medical history, comorbidities, and/or medication use. No changes have been suggested in the current tinnitus assessment or management protocols for patients with COVID-19. NOTE: Additional information about a patient’s medications and known side effects can be obtained from four reliable sources: the patient’s pharmacist, the drug’s manufacturer, and two online websites: www.rxlist.com and www.drugs.com (not an endorsement by the author or publisher). Vestibular Assessment Vestibular complaints can be evaluated and managed using recognized balance assessment tests that would be used for a non-COVID patient. There are no changes in management strategies either. In an unpublished data review (n 250 adults), the most sensitive tests were Bithermal Calorics and the High Frequency Head Shake Test (McClung, 2024). The most common diagnoses in this group were benign paroxysmal positional vertigo (BPPV), labyrinthitis, and vestibular neuronitis. Meniere’s disease has also been reported in COVID-19 patients (Jafari, 2022). Recovery from this condition is similar to that for vestibular pathologies; however, symptoms may persist for more than 70% of the population up to a month post-diagnosis (Aedo-Sanchez (2023). Vestibular Rehabilitation McClung (2024) reports that a “small percentage” of COVID-19 patients are referred to physical therapy for a fall-risk assessment and rehabilitation. Others are given a home-based vestibular rehabilitation therapy (VRT) program for one month. McClung reports a 90% success rate with VRT. Long COVID Long COVID (the most often used term in the literature) is defined as short- and long-term health effects associated with COVID-19 with symptoms that can last for weeks or months after recovery (CDC, 2024). These symptoms include “brain fog,” cognitive issues, and memory loss (Wu, 2022). The Wu study followed 8,000 adults and found 23% still had COVID symptoms at 12 weeks post-diagnosis. The American Academy of Physical Medicine and Rehabilitation estimated 1 in 5 COVID-19 survivors will experience Long COVID (AAPM&R, 2024). The National Center for Health Statistics put the number at 17% (NCHS, 2024). The average age for experiencing Long COVID (n 27,651) for adults is between 35 and 64 years, with women more at risk than men (8.5% and 5.2%, respectively) (Adjaye-Gbewonyo, 2023). In children, the numbers were less (1.3% n 7,463). Hispanic children were at 1.9% compared to Asian and Black children (0.2% and 0.6%, respectively) In a study following 1,502 pregnant women, it was estimated that 10% who had COVID-19 while pregnant will develop Long COVID (Robertson, 2024). Brain Fog Brain fog is a non-medical term that has found its way into the professional literature when describing a patient with the following symptoms: reduced mental acuity, reduced cognition, inability to concentrate, inability to multi-task, and loss of short- and long-term memory. Also, when looking at these behaviors in detail, we see a very similar pattern of behavior consistent with an auditory processing disorder (APD): delays before responding, asking people to repeat what they’ve said, mishearing spoken questions, saying “Huh?” or “What?” or “What did you say?” and becoming easily fatigued while listening (DiSogra, 2022). https://hearingreview.com/hearing-loss/hearing-disorders/apd/covid-19-brain-fog-symptoms-auditory-processing-disorder-related Brain Shrinkage, APD, and Brain Fog In 2021, a significant observation was made by researchers at England’s Biobank Research Center. A group of patients (n 394) who were identified as having a normal MRI study pre-pandemic were later diagnosed with COVID-19 (with hospitalization for high fever and a course of intervention that included oxygen therapy). Patients needing oxygen therapy had reduced gray matter volume in the frontal lobe. Patients who experienced fever also had reduced gray matter volume in the temporal lobe. (Duoaud, 2021) A repeat MRI showed several areas of the brain that play a role in auditory processing had shrunk in some patients after being diagnosed with COVID-19. (See Table 2). Table 2: Anatomical Structure Role in Auditory Processing Cingulate Cortex Dichotic Listening, Attentional Focus, Working Memory Amygdala Rhythm/Music, Startle Response Hippocampus and Limbic/Cortical Area Informational Processing __________________________________________________________________ Table 2. Neural structures that were found to be smaller post-pandemic based on two MRI studies Other structures that are involved with auditory processing that were not looked at specifically (and are in close proximity to the structures that appear in Table 2) are listed in Table 3. Table 3: Anatomical Structure Role in Auditory Processing Corpus Callosum Dichotic listening, Localization Insula Dichotic listening, Rhythm/Music, Speech in Noise Brainstem Nuclei Localization Planum Temporale Sound Decoding Heschl’s Gyrus Audition, Auditory Processing Table 3. Other neural structures that could affect auditory processing not measured in the Duoaud study (2022). Auditory Processing The Duoaud study shed new light on why “brain fog” exists. A case study was published in 2023 (Alexander, 2023) that successfully demonstrated that the traditional auditory processing test battery known as the “Buffalo Battery” (Katz, 2007) is an excellent measure for a post-COVID adult patient whose symptoms align with a diagnosis of “brain fog.” The recommended rehabilitation was followed for three months. Repeat testing (including a post-therapy Hearing Handicap Inventory for Adults - HHIA) showed scores in the normal range for all subtests and a “No handicap” rating on the HHIA. A new screening battery has since been proposed from the University of Pittsburgh that includes the following tests: Words-In-Noise (WIN), Random Dichotic Digits Task (RDDT), and the Quick Speech in Noise (QuickSIN) tests (Cancel, 2023). COVID-19 Additional Tests Knowing that brain shrinkage is a concern that could be causing “brain fog,” the Middle Latency Response Test (see Cochlear Hearing Loss – Objective Testing “C”) in addition to the Time Compressed Sentences test (Dias, 2018) would be able to objectively and subjectively identify any conduction defect along the auditory pathway. Although the rehabilitation plan is individualized based on APD test results, the findings solidify the APD diagnosis (DiSogra, 2024, Alexander, 2023). Cognitive Impairment A cognitive impairment can be defined as having one or more deficits in global cognition, working memory, executive function, verbal fluency, verbal learning, and memory (Miskowiak, 2023). Cognitive problems occurin 1 of 5 COVID patients with symptoms lasting more than three months (sometimes referred to as “long-haulers”). Cognitive problems may resolve over 18-24 months. COVID-19 is also capable of eliciting “persistent measurable neurocognitive alterations” especially in the areas of attention and working memory (Lauria, 2023). COVID-19 cognitive impairment prognosis: 70% recover by 9 months; 30% may not ever recover (Gupta, 2021). Cognitive Screening Cognitive complaints associated with “brain fog” can be screened via cognitive screening tests by audiologists. Beck (2024) reports that when an audiologist performs a cognitive screening, the result helps determine whether the patient’s communication problem is primarily an audiologic issue, or whether a medical referral (based on a positive cognitive screening) is the more prudent recommendation. According to the American Academy of Audiology Scope of Practice, Principle 2, Rule 2b (American Academy of Audiology, 2024), “Individuals shall use available resources, including referrals to other specialists…” Pharmaceutical Management for Cognitive Impairments There are no FDA-approved pharmaceuticals or dietary supplements for cognitive impairments (Mayo Clinic, 2021). Diagnosis Codes for Billing The following ICD-10 Codes can be used for billing. However, payment is not guaranteed by the carrier unless the testing is a covered service. G31.84: Mild Cognitive Impairment H93.25: (Central) Auditory Processing Disorder R41.9: Unspecified symptoms involving cognitive functions and awareness (i.e., “Brain Fog”) U09.9: Post-COVID-19 condition, unspecified Summary For patients who have contracted COVID-19, viral hearing losses (usually high frequency and bilateral) can be confined to the cochlea and auditory pathways, although sometimes middle ear pathology may be present. Vaccine-related auditory/vestibular/cognitive impairments can occur. However, the incidence is very low. Despite this low incidence, the data serves as an excellent counseling tool for both short- and long-term management. There is objective, clinical evidence that the virus affects the size of several brain structures along the auditory pathway (including brainstem and cortical regions) from pre-COVID normal MRI findings and post-COVID abnormal MRI findings on the same patients. "Shrinkage" sheds light on the inaccurate use of the term “brain fog” when the behaviors associated with this subjective, non-medical term fall in direct line with the behaviors associated with an auditory processing disorder. Objective test results (DPOAE, ABR, and MLR) in conjunction with an APD battery of tests will support the diagnosis of an auditory processing disorder/mild cognitive impairment (or as it is sometimes referred to, ‘brain fog’). Acknowledgements Special thanks to the following audiologists who contributed information for this manuscript: Angela Loucks-Alexander, AuD, Auditory Processing Institute, Queensland, Australia; Samuael Atcherson, PhD, University of Arkansas Medical School; Douglas L. Beck, AuD, audiology consultant, San Antonio, TX. Bobby McClung, Valleydale Hearing and Balance Center, Birmingham, AL. Robert M. DiSogra, AuD, is an audiology consultant in Millstone, NJ. He is a board member of The Audiology Project, a non-profit organization that promotes audiology-based diagnosis and treatment for patients with diabetes or other chronic illness (www.theaudiologyproject.com). He was the 2020 recipient of the Clinical Excellence in Audiology Award from the American Academy of Audiology. References Adjaye-Gbewonyo D, et al. (2023) Long COVID in adults: United States, 2022. National Center for Health Statistics (NCHS) Data Brief, No. 480 Aedo-Sánchez C, Gutiérrez G, Aguilar-Vidal E. (2023). COVID-19 and vestibular symptoms and assessment: a review. Audiol Neurotol 1–7 Alexander, AL, DiSogra RM, Abbas F, Braund S. Spoles C. (2023). Case study: COVID-19 brain fog or auditory processing disorder. Hear J, 76(4), April American Academy of Audiology. (2025). COVID-19. (www.audiology.org). Accessed online 1/23/2025 American Academy of Audiology (2024). Scope of practice (www.audiology .org). Search Scope of Practice and clink on Access PDF or https://www.audiology.org/wp-content/uploads/2023/04/Scope-of-Practice_2023.pdf American Academy of Physical Medicine and Rehabilitation. (2024). Long COVID. Accessed online 1/23/2025 American Tinnitus Association (2020). Tinnitus. Winter edition Beck, D (2024). Cognition, audition, & repeated cognitive screenings, Hearing Review, May. https://hearingreview.com/hearing-loss/patient-care/evaluation/cognition-audition-repeated-cognitive-screenings. Accessed online 1/25/2025 Cancel VE, et al. (2023). A data-driven approach to identify a rapid screener for auditory processing disorder testing referrals in adults. Sci Rep. 2023 Aug 21;13(1):13636 Cancel VE, McHaney JR, Milne V, Palmer C, Parthasarathy A. (2023). A data-driven approach to identify a rapid screener for auditory processing disorder testing referrals in adults. Sci Rep. Aug 21;13(1):13636 Celik S, Kalcioglu MT, Esen F, Hanege FM, Cag Y, Kocoglu E. (2021). SARS-CoV-2 presence in cerumen. Ear Nose Throat J. Apr;100(2_suppl):158S-159S Centers for Disease Control and Prevention (CDC). (2024). Long COVID. (www.cdc.gov) Dias JW, McClaskey CM, Harris KC. (2019) Time-compressed speech identification is predicted by auditory neural processing, perceptuomotor speed, and executive functioning in younger and older listeners. J Assoc Res Otolaryngol. Feb;20(1):73-88 DiSogra RM. (2021). COVID-19 and its impact on the auditory and vestibular systems Audiol Today;July. OnLine Feature Article (www.audiology.org) DiSogra RM. (2021) COVID-19 survey: disposing of cerumen from patients with a positive history of COVID-19. Audiol Today. Available online www.audiology.org/practice-resources/covid-19-resources DiSogra RM. (2022). Are COVID-19 “brain fog” symptoms and an auditory processing disorder related? Hear Rev, 29(3) March DiSogra RM. (2024). COVID-19’s impact on hearing, balance, auditory processing and cognition. Paper presented at the Alabama Acad Audiol annual meeting, September Douaud G, Lee S, Alfaro-Almagro F, Arthofer C, Wang C, McCarthy P, Lange F, Andersson JLR, Griffanti L, Duff E, Jbabdi S, Taschler B, Keating P, Winkler AM, Collins R, Matthews PM, Allen N, Miller KL, Nichols TE, Smith SM. (2022). SARS-CoV-2 is associated with changes in brain structure in UK Biobank. Nature 604, pp. 697–707 (https://doi.org/10.1038/s41586-022-04569-5) Food and Drug Administration (2025). Emergency Use Authorization. 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