key: cord-1049034-m8hrxue5 authors: Parrino, Daniela; Frosolini, Andrea; Toninato, Daniele; Matarazzo, Alessandro; Marioni, Gino; de Filippis, Cosimo title: Sudden hearing loss and vestibular disorders during and before COVID-19 pandemic: An audiology tertiary referral centre experience date: 2021-09-16 journal: Am J Otolaryngol DOI: 10.1016/j.amjoto.2021.103241 sha: 2e8575b5a58c1d0bee3a9408d0e104dabd68abad doc_id: 1049034 cord_uid: m8hrxue5 PURPOSE: During the Coronavirus disease 2019 (COVID-19) pandemic a reduction in the diagnosis of many otorhinolaryngological and audiological disorders has been widely reported. The main aim of this investigation was to evaluate the impact of COVID-19 outbreak on the incidence of acute hearing and vestibular disorders. MATERIALS AND METHODS: A retrospective analysis was performed of all patients evaluated in an audiology tertiary referral centre for acute cochleo-vestibular impairment between March 1st 2020 and February 28th 2021 (Pandemic Year Period, PYP). Results were compared to patients presenting with the same disorders during two previous periods (March 1st 2019 to February 29th 2020 and March 1st 2018 to February 28th 2019; First Precedent Year Period, FPYP and Second Precedent Year Period, SPYP, respectively). RESULTS: The annual incidence of total acute audio-vestibular disorders (number of annual diagnoses divided by total number of annual audiological evaluations) was 1.52% during the PYP, 1.31% in FPYP and 1.20% in SPYP. Comparison between the pandemic period and previous periods did not show a significant difference (p > 0.05). The overall incidence of SSNHL and combined acute cochlear-vestibular involvement was significantly higher during the PYP compared to the previous periods (p = 0.022). CONCLUSIONS: There were no differences in the absolute number of acute audio-vestibular disorders during the pandemic compared to previous periods. Although not significant, the SSNHL during the pandemic appeared worse in terms of pure-tone average with a higher incidence of associated vestibular involvement. Further studies are needed to clarify the role of SARS-CoV-2 on audio-vestibular disorders incidence and pathophysiology. Since the beginning of the Coronavirus disease 2019 (COVID-19) pandemic, the healthcare systems have been subjected to increasing pressure and forced to a sudden and never previously occurred series of organizational changes. Most hospitals reduced or suspended elective procedures and examinations in order to face the pandemic burden and avoid viral transmission. In the most critical phases of the pandemic, outpatient visits were limited to urgent and oncological cases [1] . A large decrease in the number of Ear Nose and Throat outpatient urgent consultations was observed during the first phase of the pandemic probably due to national lockdown orders associated with patients' reticence and fear of going to the hospitals [2] . Consequently, a reduction in the diagnosis of many otorhinolaryngological and audiological disorders such as epistaxis, pharyngo-tonsillitis, otitis media, equilibrium disorders, and sudden sensorineural hearing loss (SSNHL) has been reported [2] [3] [4] . On the other hand, reports of SSNHL and vestibular neuritis (VN) COVID-19related are definitely emerging. A recent meta-analysis of COVID-19-associated audiovestibular symptoms resulted in a pooled prevalence of 7.6% for hearing loss, 14.8% for tinnitus, and 7.2% for rotatory vertigo [5] . An immune-mediated mechanism has been postulated, since coronaviruses are known to be neurotrophic and may cause peripheral nerves' disorders and/or central nervous system manifestations. [6, 7] Secondly, the long-lasting COVID-19 pandemic and related psychological distress might precipitate tinnitus and peripheral vestibular disorders in susceptible patients [8] [9] [10] . These aspects may potentially have increased the number of patients seen for acute cochleo-vestibular impairment due to patients' urgency and concern of the diagnosis, in contrast to what was observed in the earliest stages of the pandemic. The main aim of this investigation was to evaluate the impact of the COVID-19 outbreak on the incidence of acute hearing and vestibular disorders in a one-year period J o u r n a l P r e -p r o o f Journal Pre-proof of the pandemic. A secondary aim was to identify in our tertiary referral audiological centre possible differences in clinical presentation and outcome of these disorders in the investigated period, eventually related to the direct effect of SARS-CoV-2 on the audiovestibular system or to behavioural aspects and contingencies of the pandemic. The study was conducted in accordance with the principles of the Helsinki Declaration. Data were examined in compliance with Italian privacy and sensitive data laws, and with the in-house rules of the Audiology Unit at Treviso Hospital, University of Padova. All participants gave their written permission for the publication of their clinical data. Year Period, SPYP, respectively). A quarterly comparative sub-analysis was also conducted. Inclusion criteria were: (i) first diagnosis of SSNHL, (ii) acute peripheral vestibular disorder or (iii) combined acute cochlear and vestibular disorders confirmed by clinical evaluation, audiometric test and videonystagmography. SSNHL was defined as a sensorineural decrease in hearing ≥30 dB affecting at least 3 consecutive frequencies and occurring within a 72-hour period [11] . Acute peripheral vestibular disorders were diagnosed according to current international evidence [12] . The simultaneous presence of criteria for SSNHL plus clinical presentation of acute peripheral vestibular disorder was considered as acute cochlear-vestibular disorder. Patients with previously known audio/vestibular disorders such as Menière's disease (MD), otosclerosis, chronic otitis media, autoimmune inner ear disorders were J o u r n a l P r e -p r o o f Journal Pre-proof excluded as well as those with hearing and/or vestibular loss due to proven traumatic or toxic origin. Demographic and clinical data were assembled for all considered patients. Clinical data included the side of the cochlear and/or vestibular disorder, auditory measurements and treatment prescribed. The patient auditory measurements were based on the pure-tone average (PTA; hearing thresholds at 500, 1000, 2000 and 4000 Hz) before and after treatment. The hearing recovery was classified according to the modified Siegel's criteria for SSNHL [13] : complete recovery (CR), partial recovery (PR), slight improvement (SI), no improvement (NI), and non-serviceable hearing (NSH). Any test results related to SARS-CoV-2 infection were also searched and recorded when available. The one-year period incidence of acute cochlear and/or vestibular impairment The restrictive measures adopted during the COVID-19 outbreak determined a large decrease in the number of otolaryngology emergency consultations in Italy. This occurred especially in the first phase of the pandemic [2] . Likewise, the total outpatient audiological visits performed at our institution during 2020 showed a notable reduction. [10]. Ueda et al. [3] investigated the impact of the COVID-19 pandemic on vertigo/dizziness outpatient cancellations. They found a 45% reduction in the total number of vertigo-associated visits between March and May 2020 in comparison to the same period of 2019. Interestingly, patients with Ménière's disease (MD) exhibited a lower percentage reduction in clinic attendance with respect to other vestibular conditions [3] . According to this, we discovered a significantly higher incidence of MDrelated acute vertigo attacks and MD first diagnosis during 2020, probably due to the pandemic-associated stress and anxiety load [10] . Our one-year period analysis showed heterogeneous results. The absolute number of acute cochlear-vestibular dysfunction was essentially unchanged during the pandemic period compared to the previous period. However, the incidence at our institution during the pandemic year period was higher in comparison to the previous two years. This was due to a reduction in the overall number of outpatient visits, as previously reported [3, 10] . This is consistent with the pandemic restrictions enforced by the Italian government that limited activity to urgent and oncological cases, so patients with acute audiological symptoms were admitted to the clinic while patients with slowly progressive hearing loss, or other mild audiological symptoms were postponed (See table 1 ). According to our retrospective analysis, demographic data were not statistically [20] . A change in treatment modality of SSNHL during the COVID-19 crisis was reported [17] . This was consistent with what was observed during the PYP at our unit, with preferential use of oral corticosteroids as first line treatment. Nevertheless, our 3 considered cohorts showed no differences in terms of post-treatment recovery according to the modified Siegel classification [13] . Some limitations of the present study have to be taken into account: the retrospective settings, the small study sample and absence of routine SARS-CoV-2 screening in the PYP group. J o u r n a l P r e -p r o o f In conclusion, no differences were found at our centre in the absolute number of cases with acute audio-vestibular disorders during the pandemic compared to previous periods. Clinical presentation of patients with SSNHL at our institution during the pandemic was more severe in terms of PTA and presented a significantly higher incidence of associated vestibular involvement. Considering our preliminary data and J o u r n a l P r e -p r o o f J o u r n a l P r e -p r o o f The burden of the pandemic on the non-SARS-CoV-2 emergencies: A multicenter study COVID-19: what happened to all of the otolaryngology emergencies? 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