When the Noise Never Stops: Coping With the Challenges of Tinnitus.

Researchers are just beginning to untangle how Covid-19 might be linked to a ringing in the ears. Here’s what we know.

“There’s never not a time when I don’t have noise running through my head,” Ms. Ceresa said. “It makes it hard to concentrate, it makes it hard to hold conversations with others, it makes it almost impossible to lie down and go to sleep. It’s maddening, and you can’t fully understand it unless you experience it yourself.”

Following the recent death of Kent Taylor, the founder and chief executive of the Texas Roadhouse restaurant chain who took his own life at age 65 after suffering from post-Covid-19 symptoms, including severe tinnitus, many are wondering how Covid-19 and tinnitus may be linked. Also, how might tinnitus — a vexing condition that afflicts as many as 60 million people in the United States — influence mental health?

While some early research and anecdotal evidence suggest an association between tinnitus and Covid-19, experts caution that it’s still too early to make a definitive link. “Am I seeing patients who come in saying they noticed tinnitus after developing Covid-19? Yes,” said Dr. Douglas Hildrew, an ear, nose and throat specialist and surgeon at Yale Medicine. But, he noted, it may also be exacerbated by other factors, like stress.

Here’s what we know.

What causes tinnitus?

According to Dr. Maura Cosetti, an ear, nose and throat specialist at Mount Sinai Hospital in New York City, the most common cause of chronic tinnitus is age. As the hair cells inside your inner ear become damaged over time, she said, they may no longer send sound waves to your brain, so your brain tries to recreate them on their own, which is what might cause the ringing.

But experts have long known that some viruses can temporarily cause hearing loss or ringing in the ears, too. When the body fights an infection, the overall inflammation from the virus can damage the nerves or hair cells in the ear, Dr. Cosetti said.

“Sometimes, a patient has already had mild tinnitus that they never really noticed before,” said Dr. David Friedmann, an ear, nose and throat specialist at NYU Langone Medical Center. “But once it’s temporarily exacerbated by a virus, they continue be bothered by it even after the initial infection has resolved.”

Can Covid-19 cause tinnitus?

There’s not enough research to say for sure. “There haven’t been any studies yet that I’m aware of that compare rates of tinnitus among survivors of Covid-19 with those in the general population,” Dr. Hildrew said.

In one review, published Monday in the International Journal of Audiology, researchers pooled data from nearly 60 case reports and studies and found that nearly 15 percent of adults diagnosed with Covid-19 reported tinnitus. Another study, published in the same journal in July, followed 138 patients for eight weeks after they had been discharged from a hospital in the United Kingdom after suffering severe symptoms of Covid-19. Among them, 16 (13 percent) reported either a change in hearing or tinnitus.

Natalie Lambert, an associate research professor of biostatistics and health data science at the Indiana University School of Medicine, surveyed nearly 5,200 “long-hauler” Covid-19 patients and found that nearly 17 percent reported new tinnitus, with more than three-quarters of those people saying it was ongoing. She cautioned that more research is needed to confirm the results, which have not yet been peer-reviewed or published in a medical journal.

There’s also evidence that Covid-19 symptoms can exacerbate existing tinnitus. In one online survey of about 3,100 people from 48 countries who suffer from tinnitus, researchers found that among the 237 people who experienced Covid-19 symptoms, 40 percent said that their tinnitus symptoms had been significantly worsened. Nearly a third of all the respondents also reported the stress of the pandemic itself exacerbated their tinnitus, even if they hadn’t contracted Covid-19. “We know that anxiety can worsen tinnitus, and it becomes a vicious cycle: The worse your tinnitus, the more anxious you are,” Dr. Hildrew said. “It becomes a very aggressive loop that can be difficult to break.”

How does tinnitus affect mental health?

When Marlene Suarez contracted Covid-19 during the second week of January, her symptoms of fever, cough and difficulty breathing weren’t so severe that she needed to be hospitalized, but they were bad enough to warrant treatment with monoclonal antibodies to reduce her risk of serious complications. About a week after her diagnosis, while watching TV, she noticed a ringing in her left ear, and that she couldn’t hear anything in her right.

“I went to the emergency room, where the E.N.T. on call said it was probably from Covid-19,” said Ms. Suarez, 62, an attorney in Collinsville, Ill. The ringing continued for weeks. “I was so depressed and scared I’d never get better,” Ms. Suarez said. “I speak and talk for a living — how was I going to be able to have a conversation with a client or present in court if it constantly sounded like bells were exploding on my left side?”

Ms. Suarez was given oral corticosteroids for several weeks, and now, more than two months later, her tinnitus and hearing loss have mostly resolved. But for many with more chronic ringing in the ears, the result can be devastating.

Tinnitus has been linked to several mental health conditions, including anxiety and depression, and mostly in women. “It can be particularly challenging for many people initially because it’s something they have absolutely no control over,” said Richard Tyler, an audiologist at the University of Iowa Carver College of Medicine. “No one can tell them if it will get worse, or if it will eventually go away. Suddenly, they have trouble sleeping, they can’t carry on a conversation, and they can’t concentrate. It can seem an overwhelming challenge.”
The condition has also been linked to an increased risk of suicide. In a research letter published in JAMA Otolaryngology–Head & Neck Surgery in 2019, researchers found that among more than 16,000 adults in Sweden who had ever experienced tinnitus, women — and in particular, those with severe tinnitus — had a small increased risk of suicide. However, those who had been diagnosed, and possibly treated for, the condition were not at increased risk.

“For most people with tinnitus, the worst time is the first six to nine months after it begins,” Dr. Tyler said. “After that, most people adjust and learn to live with it, especially if they’re given the right treatments.”

How is tinnitus treated?

If you are diagnosed with Covid-19 and you experience tinnitus that lasts for more than two days, tell your doctor right away. “The same treatment that can help you recover from tinnitus and sudden hearing loss is a steroid, which can also help treat Covid-19,” Dr. Hildrew said. Nonsteroidal anti-inflammatories, like ibuprofen, can also temporarily cause tinnitus, Dr. Cosetti added. This usually resolves within a few days once you stop taking them.

If your tinnitus persists after you’ve recovered from the virus, make an appointment with an ear, nose and throat doctor, who can check for blockages in your ears (like from fluid or ear wax), which can cause symptoms. If no blockage exists, you might be sent to an audiologist to check your hearing.

If your tinnitus does persist and is related to hearing loss, your E.N.T. may refer you back to an audiologist to get fitted for a hearing aid, Dr. Friedmann said. Your audiologist may be able to add a device to it that produces low-level sounds to help mask tinnitus noise.

There’s also good evidence that cognitive behavioral therapy, a type of talk therapy that can help you strategize ways of ignoring your tinnitus or dealing with the stress of it, can help. One study found that incorporating C.B.T. with mindfulness techniques, like meditation, significantly reduced tinnitus-related distress.

After many months of dealing with the tinnitus that began last spring, Ms. Ceresa is now being treated for her constellation of lingering symptoms at the Center for Post-Covid care at Mount Sinai Hospital in New York City. Tinnitus is still near the top of her list of complaints. “It’s always there and with me all the time — I can never escape it,” she said, adding that she has to take sedatives now to fall asleep. “I have days when I don’t know if I can handle this anymore. But I have to go on being hopeful.”

How can CBT help?

With this therapeutic technique, people learn to adjust their reaction and response to tinnitus.

“We can change how we tolerate physical sensations, particularly if they are aversive and causing any anxiety,” says psychologist Johanna Kaplan, PhD, the director of Washington Anxiety Center of Capitol Hill.

That is, if you embark on cognitive-behavior therapy, the goal isn’t to end your tinnitus—but to change how you respond to the symptom.

“Someone suffering may think, I cannot do this anymore or will this be my life from now on? We combat this catastrophic-type thinking with cognitive restructuring techniques meant to reduce anxiety caused by these thoughts,” Kaplan explains.

As the American Tinnitus Association (ATA) puts it, the difference between seeing tinnitus as “no big deal” or “deeply upsetting” rests in the emotional response to the sounds, not the sounds themselves.

There are other key ways CBT can be helpful, Kaplan says:

• Building familiarity: CBT therapy often involves gradual exposure to uncomfortable situations. That’s true when it’s used for tinnitus as well. “We work on behavioral exposure exercises that bring on similar sensations to the tinnitus,” Kaplan says.
• Helping with redirect strategies: “Attentional bias” means you’re frequently distracted by a stressor in your life. In this case, tinnitus. Learning redirect techniques can help. “We address attentional bias to the symptoms and how to redirect your attention to reduce symptoms without actually avoiding them,” Kaplan says.

People often get relaxation training and discover imagery techniques through CBT, according to an article in the Korean Journal of Audiology. This type of therapy is short-term, not ongoing. Some people experience relief within two months, Kaplan says. It’s common to have up to six months of weekly sessions, she says.

Should you try cognitive behavioral therapy for your tinnitus?

Research points to CBT as being an effective strategy when it comes to tinnitus. In a 2010 review examining randomized controlled trials, for instance, researchers found participants had improved quality of life if they had CBT, compared to participants with no treatment or other interventions, such as yoga.

And, a 2014 review of studies published in the Journal of the American Academy of Audiology found that “CBT treatment for tinnitus management is the most evidence-based treatment option so far.”