Audigy had the opportunity to discuss tinnitus and managing the temporary side effects of hydroxychloroquine on hearing with Christopher Spankovich, the Associate Professor and Vice Chair of Research in the Department of Otolaryngology and Communicative Sciences at the University of Mississippi Medical Center. Here are the top takeaways from our discussion.
What concerns are there for COVID-19 and hearing and balance?
There is limited evidence that COVID-19 has any direct implications for hearing and balance. There will likely be a case study or two showing sudden hearing loss with COVID-19, but this is not a common complication as of date. Perhaps of greater concern was initial evidence supporting use of quinine derived agents (chloroquine and hydroxychloroquine) in treatment and of COVID-19 and potential ototoxic side effects. Chloroquine and in particular hydroxychloroquine, the more publicized agent in the United States, have fairly low risk for ototoxicity and case reports have commonly been restricted to long-term use. That being said, higher doses of these agents in short-term use may pose risk, but as enthusiasm wanes for these drugs, so does concern for ototoxicity.
In addition to concerns for direct influence of COVID-19 on hearing/balance and potential drug toxicity related to treatment, another concern is tinnitus. Not only tinnitus as an ototoxic side effect, but probably even more so, persons with pre-existing tinnitus independent of COVID-19 status. The stressors related to the COVID-19 pandemic, as well as the measures to mitigate spread (e.g. social isolation) may results in more noticeable or bothersome pre-existing tinnitus. Further, utilization of masks may compromise communication and lead to persons further attributing their frustrations to the presence of tinnitus.
This may be a good time to reach out to tinnitus patients and check on their status. Luckily, tinnitus counseling lends itself nicely to telehealth platforms. Some topics to consider are how stress can alter tinnitus perception and applications of mitigation strategies including stress reduction exercises, sound enrichment, attention modulation, and healthy lifestyle.
If needed, how should we monitor potential risk for ototoxicity?
First, both the American Speech Language Hearing Association (ASHA) and American Academy of Audiology (AAA) have published guidelines for ototoxicity monitoring. In brief, a key to monitoring is establishing baseline measures. The measures of choice should consider the age and capability of the patient and drug related factors. Common measures include tympanometry to determine middle ear status, pure tone audiometry including extended high frequencies, and otoacoustic emissions. Recommendations are less clear for balance; oscillopsia and ataxic gate are the two common reported symptoms of bilateral vestibular dysfunction. Rotary chair testing is the gold standard for bilateral vestibular weakness, but access to diagnostic testing can be a limitation. Other considerations include basic bedside examination, dynamic visual acuity testing, video head impulse testing, caloric testing, and dynamic posturography. In the case of limited access to services, simple questions on presence of hearing loss and balance related symptoms pre and post use of drug can serve as a starting point and serve as an indicator for subsequent referral for a comprehensive evaluation.