SUDDEN SENSORINEURAL HEARING LOSS AND COVID-19: AN EVOLVING DISCUSSION.

Abstract

In Reply: We reported on an 18-year-old healthy young woman with anosmia, dysgeusia, and COVID-19 IgG antibodies who presented with a 7-week history of sudden sensorineural hearing loss (SSNHL) and MRI evidence of intralabyrinthine hemorrhage (1). A lung X-ray examination and nuclear acid amplification test for acute COVID-19 infection were not performed at the onset of SSNHL because the patient was otherwise asymptomatic. Exact methods of COVID-19 tests were unavailable because they were conducted in an outside institution. Serology testing performed at 10 weeks post-onset of SSNHL was positive for COVID-19 IgG antibodies, matching the timeline of her SSNHL; IgG antibodies are usually detectable several weeks after symptom onset (2). In the absence of other risk factors, we concluded that the patient's SSNHL is likely due to COVID-19 infection and associated bilateral intralabyrinthine hemorrhage (1). COVID-19 is known to cause coagulopathy—cytokine overproduction can induce deregulation of coagulation and fibrinolysis pathways as an immune response to infection, causing predisposition for microthrombi and microhemorrhage formation (3,4). Furthermore, COVID-19 related microhemorrhages have been shown to be responsible for organ failure; pulmonary (5) and cerebral (6) microhemorrhages have been reported in patients with COVID-19. Thus, it is most likely that our patient's intralabyrinthine hemorrhages were secondary to COVID-19 infection; coagulation laboratory values were normal as they were tested 10 weeks after her SSNHL, not during onset of symptoms. Furthermore, as reported in coagulopathic patients, intralabyrinthine hemorrhage was likely responsible for SSNHL (7–9). At the time of submission, we provided the only well-known description of SSNHL in a patient with COVID-19. Four manuscripts cited in the letter were published ahead-of-print after submission of our manuscript (10–13). One manuscript was published ahead-of-print one day after our submission. Although this manuscript described a case of SSNHL in a COVID-19 patient, he underwent treatment with ototoxic drugs—a notable confounding factor (14). The patient's therapeutic course with oral and intratympanic steroids is clearly delineated in our manuscript. Although hyperbaric oxygen is a potential treatment, the AAO-HNS Clinical Practice Guidelines list it as an option (not recommendation), and only when combined with steroid therapy (15). Contrary to the letter to the editor, the patient did not receive a second steroid injection; she underwent a second course of oral corticosteroids as salvage therapy at the family's request—they believed the first course helped the patient's hearing. In summary, our well-documented case report supports the hypothesis that COVID-19 may have otologic manifestations including SSNHL, aural fullness, vertigo, and intralabyrinthine hemorrhage (1).