Tinnitus, defined as the perception of sound without an external source, affects millions of people worldwide and is commonly linked to hearing loss, noise exposure, ototoxic medications and neurological disorders [1]. The COVID-19 pandemic has brought new insights into the underlying mechanisms of tinnitus, with emerging evidence suggesting a connection between viral infections, neuroinflammation, microvascular dysfunction and heightened psychological stress [2,3]. Several studies indicate that SARS-CoV-2 may directly impact the auditory system, causing inner ear damage and contributing to the onset or worsening of tinnitus [2,4.5]. The persistence of tinnitus symptoms post-COVID-19 has raised concerns regarding long-term auditory complications, emphasizing the need for further research into its pathophysiology and treatment options [2,5,6,7].

A systematic review by Almufarrij and Munro identified tinnitus as a frequent post-COVID symptom, while Bhatt et al. reported that individuals with tinnitus experienced significantly higher levels of anxiety and depression during the pandemic, exacerbating the severity of their symptoms [8-10]. Additionally, healthcare disruptions limited access to treatment, most of the f tinnitus patients experiencing worsened symptoms due to medical delays [2,11]. A study in India by Saraf et al. and Mukherjee et al. found that a lot of post-COVID patients reported tinnitus, highlighting the growing burden of this condition in developing countries [12,13]. These findings suggest that both physiological and psychological factors played a crucial role in tinnitus onset and progression during and after the pandemic [14].

The impact of COVID-19 on tinnitus has also been influenced by increased exposure to environmental and behavioral risk factors. Prolonged screen time, virtual work environments and excessive use of headphones have been linked to auditory fatigue, which may contribute to tinnitus perception [2,14,15]. Additionally, increased stress levels associated with financial insecurity, social isolation and pandemic-related uncertainty may have exacerbated symptoms for those already experiencing tinnitus [16,17]. These factors further underscore the need for a multidisciplinary approach to tinnitus management, integrating both physiological and psychological interventions to improve patient outcomes [18,19].

Given the long-term auditory implications of COVID-19, this review aims to analyze tinnitus prevalence before, during and after the pandemic, with a particular focus on Indian studies. Additionally, it explores various treatment modalities, including Tinnitus Retraining Therapy (TRT), Hyperbaric Oxygen Therapy (HBOT), Cognitive Behavioral Therapy (CBT), sound therapy, medications and hearing aids. While TRT has shown an 80% success rate in habituation, HBOT has demonstrated benefits for acute cases but lacks efficacy for chronic tinnitus [20-23]. By evaluating global and Indian data, this review seeks to provide clinicians, researchers and policymakers with a comprehensive understanding of tinnitus trends, treatment options and future research priorities. As the global burden of tinnitus continues to rise, improved awareness, policy-level interventions and advancements in research are essential to ensuring better patient care and management strategies.

Study Design

This systematic review was designed to assess tinnitus incidence and prevalence trends across three distinct phases: pre-COVID-19, per-COVID-19 and post-COVID-19. It also evaluates the effectiveness of different treatment approaches, including Tinnitus Retraining Therapy (TRT), Hyperbaric Oxygen Therapy (HBOT) and other management options. The study design involved a structured literature search, data extraction and analysis of peer-reviewed sources and clinical reports.

Data Sources and Search Strategy

To ensure comprehensive coverage of relevant studies, data were collected from multiple peer-reviewed sources, including PubMed, Scopus, Web of Science, ScienceDirect, Google Scholar, Cochrane Library and Medline. Additional data were retrieved from institutional reports such as those from the World Health Organization (WHO), Centers for Disease Control and Prevention (CDC), National Institute on Deafness and Other Communication Disorders (NIDCD) and the Indian Council of Medical Research (ICMR). Medical journals, including JAMA Otolaryngology, The Lancet, Journal of Audiology, International Tinnitus Journal and Indian Journal of Otolaryngology, were reviewed for relevant studies. Clinical trials and meta-analyses from Cochrane Reviews and Randomized Controlled Trials (RCTs) were also considered.

The search strategy was based on predefined keywords, including "Tinnitus prevalence before COVID-19," "Tinnitus incidence during COVID-19 pandemic," "Tinnitus after COVID-19 recovery," "Effectiveness of Tinnitus Retraining Therapy (TRT)," "Hyperbaric Oxygen Therapy (HBOT) for tinnitus," and "Tinnitus treatment in India." Boolean operators (AND/OR) were applied to refine search results and maximize data relevance.

Inclusion and Exclusion Criteria

Studies included in this review met specific criteria to ensure relevance and reliability. Inclusion criteria comprised studies published between 2010 and 2024, allowing for a broad analysis of tinnitus trends before and after the pandemic. Only peer-reviewed articles, systematic reviews, meta-analyses and clinical trial reports were considered. Studies that focused on tinnitus incidence and management during different pandemic phases were prioritized, particularly those including data on both global and Indian populations. Only articles published in English were included.

Exclusion criteria involved the elimination of case reports, opinion pieces and letters to the editor due to their anecdotal nature. Studies with small sample sizes (n<50) that lacked statistical robustness were excluded. Non-peer-reviewed publications, studies published in languages other than English and research exclusively focused on pediatric populations were also omitted, as the primary objective was to assess tinnitus prevalence and treatment in adults.

Data Extraction and Synthesis

The data extraction process was structured to ensure uniformity and minimize bias. Extracted data were categorized into thematic areas, including tinnitus incidence and prevalence segmented into pre-COVID, per-COVID and post-COVID periods. Factors influencing tinnitus trends, such as viral infection, stress, lifestyle changes and healthcare disruptions, were analyzed. Treatment efficacy was examined through an evaluation of TRT, HBOT and alternative therapies. Additionally, regional variations in tinnitus prevalence and treatment availability were compared between global and Indian data.

A structured data extraction form was utilized to document key findings from each study, including sample size, study design, geographic focus and outcome measures. Descriptive statistics, prevalence rates and treatment outcomes were compiled and synthesized into a comparative framework to highlight significant trends and associations.

Data Analysis and Quality Assessment

The quality of included studies was assessed using established frameworks to ensure methodological rigor. The Newcastle-Ottawa Scale (NOS) was applied to evaluate observational studies for bias, particularly in patient selection, comparability and exposure assessment. The Cochrane Risk of Bias (RoB) tool was used to assess randomized clinical trials, considering factors such as randomization process, blinding and outcome assessment. Heterogeneity among studies was analyzed using the I² statistic to determine variability in reported findings. Statistical analyses included pooled prevalence estimates and confidence intervals where applicable, ensuring a robust comparative analysis.

This Table 1 presents a detailed evaluation of the quality and robustness of key studies included in this review. The Newcastle-Ottawa Scale (NOS) was applied to assess the quality of observational studies, while the Cochrane Risk of Bias (RoB) tool was utilized for Randomized Controlled Trials (RCTs) and systematic reviews. Most observational studies scored ≥7 on the NOS, indicating high methodological quality with minimal risk of bias. Studies such as those conducted by Bhatt et al. [10] and Almufarrij et al. [9] achieved scores of 8/9, reflecting strong methodological rigor and comprehensive data collection. Similarly, RCTs by Jastreboff et al. [29] and Mao et al. [14] were rated as “Low Risk” under the RoB tool, demonstrating well-controlled randomization processes and blinding techniques. Notably, studies such as Bennett et al. [31] and Baldo et al. [34] showed moderate-quality scores or "Some Concerns" due to sample size limitations or potential publication bias. Heterogeneity values (I²) varied across studies, with values ranging from 28% (low heterogeneity) in TRT studies to 53% in medication reviews, indicating variability in sample populations and treatment outcomes.

This Table 2 highlights the dynamic shifts in tinnitus prevalence across different time periods. Before the COVID-19 pandemic, tinnitus prevalence was estimated to range between 10-15% globally and 6.7-29.3% in India, commonly linked to hearing loss, aging and underlying health conditions such as hypertension and diabetes, as demonstrated in studies by Bhatt et al. [15] and Makar et al. [24]. During the pandemic, tinnitus incidence increased notably, with reports suggesting that 14.8% of COVID-19 patients experienced tinnitus as a post-infection symptom. In India, many studies reported that 14.1-27.9% of post-COVID patients reported tinnitus symptoms, highlighting the substantial impact of COVID-19 on auditory health [25-28]. Post-COVID-19 data further suggested an elevated tinnitus prevalence in some populations, with reports indicating persistent symptoms in 30.1-42.8% of severe COVID-19 survivors. These findings underscore the complex interplay between viral infection, stress and healthcare disruptions in driving tinnitus prevalence [29-31].

This Table 3 comprehensively compares the effectiveness of various tinnitus treatments. Tinnitus Retraining Therapy (TRT) demonstrated a remarkable ~80% success rate, positioning it as the most effective long-term intervention for tinnitus management. TRT combines sound therapy with structured counseling to facilitate habituation, making it particularly beneficial for chronic tinnitus sufferers. However, its accessibility is often restricted to specialized audiology centers. Hyperbaric Oxygen Therapy (HBOT) showed promising outcomes in acute tinnitus cases, with studies reporting a 40-50% success rate when administered within three months of symptom onset. Despite this, HBOT’s efficacy for chronic tinnitus remains limited, with reported success rates dropping to 15-20% in long-term cases. Cognitive Behavioral Therapy (CBT) achieved success rates of 60-70%, making it a valuable intervention for managing tinnitus-related anxiety and distress. Meanwhile, sound therapy, particularly through masking devices and smartphone apps, offered a cost-effective and accessible method for symptom relief, though it does not directly address underlying tinnitus causes. Lastly, medications such as antidepressants and anti-anxiety drugs provided limited direct tinnitus relief but proved effective in managing associated psychological distress. Hearing aids, which amplify external sounds to reduce tinnitus perception, demonstrated significant efficacy, particularly for patients with hearing loss-associated tinnitus.

Table 1: Comprehensive Study Quality Assessment Results

Table 2: Tinnitus Incidence and Prevalence Across Pre-COVID-19, During COVID-19 and post-COVID-19 Periods

Table 3: Tinnitus Management and Treatment Outcomes

Table 4: Comparative Success Rates of Tinnitus Treatments

This Table 4 provides a side-by-side comparison of the success rates and key considerations of various tinnitus treatment modalities. TRT showed the highest success rate of ~80%, reinforcing its position as the gold-standard intervention for tinnitus management. While HBOT showed moderate success in acute cases (40-50%) with early intervention, its effectiveness diminished significantly for chronic tinnitus patients, rendering it a less viable long-term solution. Conversely, CBT achieved 60-70% success rates, demonstrating its effectiveness in addressing the psychological distress often associated with tinnitus. CBT’s focus on changing negative thought patterns offers meaningful improvements in coping mechanisms for tinnitus sufferers, particularly those whose symptoms are aggravated by anxiety and depression.

This Table 5 illustrates disparities in access to specialized tinnitus care across different regions. High-income countries generally have better access to comprehensive management options such as TRT, CBT and multidisciplinary care. However, in low- and middle-income countries, tinnitus management remains limited due to resource constraints, poor healthcare infrastructure and limited access to trained specialists. For example, in India, tinnitus treatment is predominantly available in major metropolitan areas, while rural populations have minimal access to specialized care. Additionally, HBOT remains largely inaccessible in low-resource settings due to its high cost and limited availability. Kilroy et al. [37] reported that rural populations rely heavily on primary care providers with limited tinnitus management expertise, emphasizing the need for telemedicine and digital healthcare solutions to bridge these gaps.

This Table 6 illustrates disparities in access to specialized tinnitus care across different regions. High-income countries generally have better access to comprehensive management options such as TRT, CBT and multidisciplinary care. However, in low- and middle-income countries, tinnitus management remains limited due to resource constraints, poor healthcare infrastructure and limited access to trained specialists. For example, in India, tinnitus treatment is predominantly available in major metropolitan areas, while rural populations have minimal access to specialized care. Additionally, HBOT remains largely inaccessible in low-resource settings due to its high cost and limited availability. Kilroy et al. [37] reported that rural populations rely heavily on primary care providers with limited tinnitus management expertise, emphasizing the need for telemedicine and digital healthcare solutions to bridge these gaps.

This Table 7 underscores the significant impact of psychological factors on tinnitus severity. Stress was shown to exacerbate tinnitus symptoms by increasing cortisol levels, which heighten the brain’s sensitivity to perceived sounds. Anxiety emerged as a strong contributor to tinnitus distress, amplifying symptom awareness and reducing coping mechanisms. Depression was also linked to worsened tinnitus outcomes, with individuals experiencing low mood and emotional instability reporting greater tinnitus intensity. Research by Bhatt et al. [10] and Beukes et al. [16] revealed that individuals who experienced heightened anxiety and stress during the pandemic reported more severe tinnitus symptoms, highlighting the need for integrated mental health interventions as part of comprehensive tinnitus care.

Table 5: Effectiveness of Sound Therapy, Medications, and Hearing Aids in Tinnitus Treatment

Table 6: Regional Disparities in Tinnitus Management and Treatment Access

Table 7: Impact of Stress, Anxiety, and Depression on Tinnitus Severity

Table 8: Key Factors Contributing to Tinnitus Worsening During COVID-19

This Table 8 identifies the primary factors contributing to tinnitus exacerbation during the COVID-19 pandemic. Increased psychological stress emerged as a major factor, with heightened anxiety and emotional distress amplifying tinnitus symptoms. Disruption in healthcare services was another significant factor; lockdown restrictions delayed medical appointments and treatment access, resulting in prolonged suffering for tinnitus patients. Increased screen time and headphone use during remote work and virtual communication also contributed to auditory fatigue, potentially worsening tinnitus perception. Additionally, studies by Munro et al. [8] and Beukes et al. [16] suggested that COVID-19-induced neuroinflammation and microvascular damage may have directly impacted the auditory system, further explaining the increase in tinnitus cases during and after the pandemic. Lastly, social isolation emerged as a significant contributor, with reduced social interaction, loneliness and lack of support further amplifying tinnitus distress.

These results collectively highlight the multifactorial nature of tinnitus, the diverse treatment approaches available and the impact of COVID-19 on tinnitus prevalence and management. The combination of physiological, psychological and healthcare-related factors requires a comprehensive, multidisciplinary approach to ensure effective tinnitus care. Future research should prioritize identifying innovative treatment strategies, improving access to care and addressing the long-term auditory effects of COVID-19 to better support affected individuals.

The findings of this review demonstrate that the COVID-19 pandemic significantly influenced tinnitus prevalence and severity through both direct and indirect mechanisms. Before the pandemic, tinnitus was predominantly linked to well-established risk factors such as age-related hearing loss, prolonged exposure to loud noise, ototoxic medications and systemic conditions such as diabetes and hypertension. However, during the pandemic, a complex interplay of viral effects, psychological stress and healthcare disruptions contributed to a notable increase in tinnitus cases and symptom severity.

Emerging evidence suggests that SARS-CoV-2 may have direct ototoxic effects, potentially contributing to auditory dysfunction. A study by Munro et al. [8] reported that 13.2% of COVID-19 patients experienced new or worsening hearing issues post-infection, suggesting inner ear involvement linked to viral-induced neuroinflammation and cochlear damage. Similarly, studies highlighted that SARS-CoV-2 may compromise cochlear hair cells through microvascular damage, which may trigger auditory symptoms such as tinnitus [16]. Further supporting this, Almufarrij and Munro⁹ conducted a systematic review of 56 studies and identified tinnitus as a frequent post-COVID symptom, reinforcing the hypothesis that viral-induced injury to the auditory system may be a key mechanism behind increased tinnitus prevalence. These findings underscore the need for more extensive research into the potential long-term impact of COVID-19 on auditory function and tinnitus progression.

In addition to its physiological effects, the psychological burden induced by the pandemic played a significant role in worsening tinnitus symptoms. Research by Beukes et al. [16] found that lockdown-induced stress, social isolation and financial insecurity exacerbated tinnitus symptoms in 46% of patients surveyed in the UK. Anxiety, sleep disturbances and heightened emotional distress increased tinnitus awareness, amplifying its perceived intensity. This aligns with findings by Bhatt et al. [10], who reported that individuals with tinnitus during the pandemic experienced significantly higher levels of anxiety and depression, further reinforcing the established link between mental well-being and tinnitus perception. These findings emphasize the critical need for psychological support interventions, particularly for patients with chronic tinnitus whose symptoms were exacerbated during the pandemic.

The COVID-19 pandemic severely disrupted healthcare systems, limiting access to routine audiological care and treatment for individuals with tinnitus. Studies highlighted that many tinnitus patients faced delays in receiving care due to lockdown restrictions and healthcare resource limitations. This resulted in worsened symptoms, heightened distress and delayed intervention. Supporting these findings, a global survey by Tinnitus Hub revealed that 77% of tinnitus sufferers reported worsened symptoms due to postponed medical consultations, reduced access to treatment and limited audiological support [11]. These disruptions highlight the vulnerability of tinnitus patients in times of healthcare crises, reinforcing the need for improved telemedicine solutions to ensure uninterrupted care.

The management of tinnitus remains complex, largely due to its subjective nature and the absence of a definitive cure. Several treatment modalities were evaluated in this review, including Tinnitus Retraining Therapy (TRT), Hyperbaric Oxygen Therapy (HBOT), Cognitive Behavioral Therapy (CBT), sound therapy, medications and hearing aids.

Among these approaches, TRT emerged as the most effective long-term intervention. Studies demonstrated an 80% success rate in patients undergoing TRT, with significant reductions in tinnitus distress following 12 months of therapy [38,39]. As TRT combines sound therapy with structured counseling, it effectively facilitates habituation and improves patients' ability to manage their symptoms. However, despite its efficacy, TRT’s availability remains limited to specialized centers, posing accessibility challenges in low-resource settings, particularly in rural regions of developing countries such as India.

HBOT, though effective in some acute tinnitus cases, has shown limited efficacy for chronic tinnitus. While studies reported that 50% of acute tinnitus patients experienced symptom relief following HBOT within three months, a Cochrane review (2021) concluded that HBOT provided no significant long-term benefit for individuals with chronic tinnitus [31,40]. Due to its high cost and limited availability, HBOT remains an impractical option for large-scale tinnitus management.

CBT has emerged as a powerful intervention for managing tinnitus-related distress. A systematic review by Hesser et al. [33] found that CBT reduced tinnitus-related anxiety and depression by over 60%, making it one of the most effective psychological interventions for tinnitus management. However, despite its success, CBT services are often concentrated in urban regions, posing accessibility challenges for patients in rural or underserved areas.

Sound therapy has gained widespread use as a cost-effective and accessible tinnitus management strategy. Research demonstrated that sound therapy effectively reduces hyperactivity in the auditory cortex, alleviating tinnitus symptoms [41,42]. During the pandemic, smartphone-based sound therapy apps gained popularity, providing patients with a convenient and affordable solution. As reported by Bhatt et al. [15], patients using sound therapy apps experienced a 40% improvement in their tinnitus perception, underscoring the value of digital solutions for symptom relief.

Medications, including antidepressants and anti-anxiety drugs, have shown limited success in directly treating tinnitus but remain useful for managing tinnitus-related distress. A meta-analysis by Baldo et al. [43] found that while Selective Serotonin Reuptake Inhibitors (SSRIs) and benzodiazepines can alleviate anxiety and improve quality of life, they do not directly reduce tinnitus perception.

Hearing aids have consistently shown strong efficacy for patients with hearing loss-associated tinnitus. A study by Lee et al. [44] found that 60% of tinnitus sufferers experienced a reduction in symptoms following hearing aid use. By amplifying ambient sounds, hearing aids help mask tinnitus perception, reinforcing the importance of comprehensive audiological assessments for individuals presenting with tinnitus.

Significant disparities exist in access to tinnitus treatment, particularly between high-income and low-income countries. In developed nations, specialized tinnitus clinics provide comprehensive care that integrates TRT, CBT and multidisciplinary interventions. In contrast, tinnitus management in countries like India is largely confined to major metropolitan centers, leaving rural areas underserved. HBOT remains particularly inaccessible in India due to its high cost and limited number of hyperbaric centers. TRT, though effective, is only available in select audiology clinics, creating financial and logistical barriers for many patients.

The COVID-19 pandemic further exacerbated these disparities. Limited healthcare resources, financial instability and pandemic-induced restrictions created additional obstacles for tinnitus sufferers seeking care. While telemedicine services and digital therapy solutions provided some relief, these options were often less accessible to patients in remote or economically disadvantaged communities.

Future Directions and Research Priorities

The persistence of tinnitus symptoms among post-COVID patients highlights the urgent need for further research into the long-term auditory effects of COVID-19. Future studies should explore the role of neuroinflammation in tinnitus persistence and investigate novel treatment modalities such as neuromodulation, pharmacological interventions targeting central auditory processing and gene therapy. Identifying effective interventions for COVID-19-related tinnitus will be crucial in addressing the growing burden of tinnitus worldwide.

Healthcare policymakers must prioritize improving tinnitus care accessibility. Expanding telemedicine services, integrating digital sound therapy platforms and promoting awareness of tinnitus prevention strategies can help mitigate the condition's impact. Public health campaigns focused on hearing conservation, workplace noise reduction and ototoxic medication risks are essential to reducing tinnitus incidence rates.

Hence, tinnitus management requires a multidisciplinary strategy that combines effective treatment options with improved healthcare accessibility. As the global burden of tinnitus continues to grow, advancing research, enhancing treatment availability and strengthening public health initiatives will be vital in improving the quality of life for tinnitus sufferers.

The COVID-19 pandemic has significantly influenced tinnitus incidence, with increased cases attributed to viral effects, psychological stress and healthcare disruptions. While Tinnitus Retraining Therapy (TRT) remains the most effective long-term management approach, other interventions such as Cognitive Behavioral Therapy (CBT), sound therapy and hearing aids play crucial roles in symptom relief. Hyperbaric Oxygen Therapy (HBOT) has shown benefits for acute cases but lacks substantial evidence for chronic tinnitus. Disparities in treatment accessibility, particularly in low-resource settings, highlight the need for improved healthcare policies and telehealth solutions. Future research should focus on the long-term auditory impact of COVID-19 and the development of novel, accessible treatment strategies to enhance the quality of life for tinnitus sufferers globally.

Ethical Approval

Since this study is a systematic review based on previously published literature, no direct involvement of human or animal subjects was required. Ethical approval was not necessary; however, all referenced studies were verified to comply with ethical research standards and had obtained necessary institutional approvals. Proper citations and references were maintained to uphold academic integrity and transparency in reporting.

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