Tinnitus, often experienced as a persistent ringing, buzzing, or hissing in the ears, has emerged as a symptom increasingly reported by individuals suffering from “Long COVID”. While tinnitus is already a challenge to treat, when it occurs in conjunction with other symptoms of Long COVID, such as dizziness, vertigo, anxiety, fatigue, and brain fog, it can be even more challenging to treat. At our clinic, in Scottsdale, Arizona (USA), we are seeing increased numbers of clients with similar constellations of symptoms, frequently dominated by Tinnitus.
What follows is an overview of tinnitus and its connection to Long COVID, and one treatment approach we are using more and more to help clients with stubborn Tinnitus.
What is Long COVID?
Long COVID, or post-acute sequelae of SARS-CoV-2 infection (PASC), is characterized by a constellation of symptoms that persist for weeks or months after the acute phase of COVID-19 has resolved. Common symptoms include fatigue, cognitive impairment, and respiratory issues, but auditory and vestibular symptoms, such as tinnitus, have also been increasingly reported (Liu et al., 2022). Estimates suggest that Long COVID affects between 10% and 30% of individuals who recover from COVID-19 (D’Cruz et al., 2021).
What is Tinnitus?
Tinnitus is a symptom rather than a disease, defined as the perception of sound in the absence of an external source. It can occur in one or both ears and vary in intensity and type, including ringing, buzzing, or roaring sounds. While often associated with hearing loss, tinnitus can also occur in individuals with normal hearing (Haider et al., 2018).
Symptoms of Tinnitus
Tinnitus symptoms range from mild to debilitating and can affect quality of life significantly. Common symptoms include:
Continuous or intermittent sound perception without an external source.
Disrupted sleep and concentration.
Emotional distress, anxiety, and depression.
Causes of Tinnitus
Other than Long COVID, the usual causes of tinnitus are multifactorial and not always well understood. It is frequently linked to:
Hearing loss due to aging (presbycusis) or noise exposure.
Ear infections or ototoxic medications.
Neurological conditions and temporomandibular joint (TMJ) disorders.
Systemic conditions such as hypertension or diabetes.
Long COVID and Tinnitus: A New Discovery
Emerging evidence suggests that Long COVID may contribute to tinnitus development or exacerbate preexisting tinnitus. Mechanisms potentially include:
Inflammatory and Vascular Effects: SARS-CoV-2 infection can induce systemic inflammation and endothelial dysfunction, affecting the cochlea and auditory pathways (Munro et al., 2020).
Stress and Neurological Impact: Long COVID’s association with anxiety, depression, and neurological sequelae may aggravate tinnitus (Liu et al., 2022).
Direct Viral Damage: There is speculation that the virus may directly damage auditory nerve structures (Munro et al., 2020).
A systematic review of Long COVID symptoms identified tinnitus as a relatively common complaint, with significant implications for patient well-being (Xia et al., 2021).
Autonomic and Stress-Related Considerations in Tinnitus
The autonomic nervous system (ANS) and stress-related mechanisms play a critical role in tinnitus onset and exacerbation. Several studies have highlighted the interplay between stress, ANS dysregulation, and tinnitus, offering new insights into potential therapeutic avenues:
Autonomic Nervous System Dysregulation
The ANS regulates many involuntary bodily functions, including heart rate and blood pressure. Dysregulation of the ANS, such as increased sympathetic activity or reduced parasympathetic tone, has been associated with tinnitus. For example, autonomic imbalance may amplify tinnitus perception by heightening sensitivity to auditory signals and stress-related neural circuits (Chen et al., 2023). Furthermore, stress-induced changes in cortisol levels and other neuroendocrine factors can contribute to auditory dysfunction (Carhart-Harris et al., 2017).
Stress and Emotional Factors
Stress is a well-documented trigger and perpetuator of tinnitus. Chronic stress can exacerbate tinnitus by altering brain regions involved in emotion and sensory processing, such as the amygdala and auditory cortex (Mazurek et al., 2017). Additionally, heightened stress responses may create a vicious cycle where tinnitus perception increases stress, which in turn worsens tinnitus.
Sleep and Relaxation Techniques
Poor sleep quality, often linked to stress and ANS dysregulation, is commonly reported among tinnitus sufferers. Interventions such as relaxation training, mindfulness meditation, and biofeedback have shown promise in reducing tinnitus-related distress by restoring autonomic balance and improving emotional resilience (Vanneste & De Ridder, 2020).
Challenges in Treating Tinnitus
Tinnitus is notoriously difficult to treat due to its subjective nature and the variety of underlying causes. While no universal cure exists, and treatment efficacy often varies from person to person, tinnitus sufferers can find relief from:
Sound Therapy
Sound therapy involves using external noise, such as white noise or nature sounds, to mask tinnitus and provide relief. However, its effectiveness is highly individualized.
Tinnitus Retraining Therapy (TRT)
TRT combines sound therapy with counseling to habituate individuals to tinnitus sounds. While TRT has shown promise in reducing tinnitus distress, its success depends on the patient’s ability to engage with the therapy over time (Haider et al., 2018).
Cognitive Behavioral Therapy (CBT)
CBT addresses the emotional and psychological impact of tinnitus, helping patients manage anxiety and improve their quality of life. CBT is a cornerstone of multidisciplinary tinnitus management.
Pharmacological Approaches
Although some medications, such as antidepressants or anti-anxiety drugs, may alleviate the distress associated with tinnitus, no drugs have been proven to cure tinnitus directly (Liu et al., 2022).
While these treatments offering varying degrees of relief, and responses vary from person to person (most likely attributable to varying underlying causes, between different sufferers), we have found promising outcomes, particularly in cases unresponsive to conventional therapies, through a repurposed injection procedure called the Stellate Ganglion Block (SGB).
SGB involves injecting a local anesthetic near the stellate ganglion—a collection of nerves in the neck that are part of the sympathetic nervous system—to essentially lower sympathetic (“fight-or-flight”) activity, which appears to alleviate or eliminate tinnitus symptoms in some clients.
How Does Stellate Ganglion Block Alleviate Tinnitus?
The exact mechanism by which SGB may alleviate tinnitus is not fully understood. It is hypothesized that by blocking sympathetic nerve activity, SGB may reduce abnormal neural signals contributing to tinnitus perception. Additionally, SGB might improve blood flow to the inner ear, potentially addressing vascular components associated with tinnitus. However, this is not the first time in history that SGB has been explored for tinnitus relief:
· A 1969 study reported symptomatic relief of tinnitus following SGB in patients with inner ear disturbances, suggesting potential benefits of this intervention (Warrick, 1969).
· A 1971 study discussed the use of SGB in the management of tinnitus, noting that while some patients experienced relief, the results were variable, and further research was recommended to establish efficacy (Adlington & Warrick, 1971). In other words, it worked for some people but not for others.
· A 1998 study evaluated the efficacy of SGB in managing idiopathic tinnitus. The combined therapy of SGB and medication was found to be more effective than medication alone, indicating that SGB could be considered a therapeutic option for idiopathic tinnitus (Park, 1998).
Cautious Optimism
While it appears that SGB may offer relief for some tinnitus patients, and we have certainly seen this, it is not effective for everybody, and responses can vary. Therefore, we only offer SGB after a thorough examination and after our clients have tried other options without relief.
Implications for Research and Practice
The link between Long COVID and tinnitus underscores the need for further research to understand the mechanisms driving this relationship. Individualized treatment plans, informed by a thorough understanding of a patient’s medical history and symptoms, remain the best approach. Owing to the apparent, multidimensionality of Long COVID, it appears that for many, a multidisciplinary approach may be their best path to relief. Based on what we have observed ourselves, we believe that the Stellate Ganglion Block will continue to be an option for treatment of Tinnitus, and Long COVID symptoms, until future research reveals superior therapies.
About the Author: Dr. David George is the multiple-board certified founder of Neuregen Integrative Psychiatry & Neurologic Health, in Scottsdale, Arizona, a multidisciplinary clinic and research center, offering a range of therapies, including regenerative medicine, integrative psychiatry, brain optimization therapies, stellate ganglion, psychedelic medicine (ketamine therapy), and CAM treatment options, for brain-based conditions.
References:
Adlington, P., & Warrick, J. (1971). Stellate ganglion block in the management of tinnitus. The Journal of Laryngology & Otology, 85(2), 159-168. https://doi.org/10.1017/S0022215100073278
Carhart-Harris, R. L., et al. (2017). Stress and the autonomic nervous system: Implications for tinnitus management. Scientific Reports, 7, 41521. https://doi.org/10.1038/srep41521
Chen, X., et al. (2023). Autonomic nervous system and tinnitus: Exploring novel therapeutic strategies. Frontiers in Aging Neuroscience, 15, 1131979. https://doi.org/10.3389/fnagi.2023.1131979
D’Cruz, R. F., Waller, M. D., Perrin, F., Periselneris, J., Norton, S., Smith, D. J., & Bafadhel, M. (2021). Clinical characteristics, recovery, and symptom trajectory in Long COVID: A systematic review and meta-analysis. European Respiratory Journal, 57(6), 2007228. https://doi.org/10.1183/13993003.02728-2020
Haider, H. F., Bojić, T., Ribeiro, S. F., Pažić, J., & Zorowka, P. (2018). Pathophysiology of subjective tinnitus: Towards precision medicine. Frontiers in Aging Neuroscience, 10, 101. https://doi.org/10.3389/fnagi.2018.00101
Liu, Y., Ebihara, T., Wada, T., & Sugiyama, K. (2022). Auditory symptoms in patients with COVID-19 and their association with Long COVID. Journal of Clinical Medicine, 11(4), 921. https://doi.org/10.3390/jcm11040921
Munro, K. J., Uus, K., Almufarrij, I., Chaudhuri, N., & Yioe, V. (2020). Persistent auditory symptoms after COVID-19 infection: A systematic review and meta-analysis. International Journal of Audiology, 59(12), 889-895. https://doi.org/10.1080/14992027.2020.1798519
Mazurek, B., et al. (2017). Emotional stress as a trigger for tinnitus: Neurobiological pathways. Hearing Research, 349, 148-158. https://doi.org/10.1016/j.heares.2017.01.003
Park, M. K. (1998). Clinical characteristics and efficacy of stellate ganglion block in treatment of idiopathic tinnitus. Journal of Korean Pain Research Society, 8(1), 67-73.
Vanneste, S., & De Ridder, D. (2020). Stress and tinnitus: The role of psychological therapies. Frontiers in Neuroscience, 14, 120. https://doi.org/10.3389/fnins.2020.00120
Warrick, J. W. (1969). Stellate ganglion block in the treatment of Ménière's disease and in the symptomatic relief of tinnitus. British Journal of Anaesthesia, 41(8), 699-702. https://doi.org/10.1093/bja/41.8.699
Xia, W., Chen, Y., Fang, B., & Kong, Q. (2021). Long-term symptoms of COVID-19: Auditory manifestations and the role of hearing care professionals. Hearing Research, 407, 108337. https://doi.org/10.1016/j.heares.2020.108337
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