Long-Term Outcomes of COVID-19 Otolaryngology Symptoms in Saudi Arabia

Objectives: The objectives of the study are to measure the prevalence of the most common symptoms and different long-term otorhinolaryngology manifestations among COVID-19-positive patients in Saudi Arabia. Methods: This is a cross-sectional study. Data were collected using a Google form questionnaire sent to the study sample. The data were entered and then analyzed using SPSS version 25.0 (IBM Corp, Armonk, NY). Results: A total of 13,530 COVID-19-positive adult patients were enrolled in the current study. The most reported initial symptom was fever (53.3%) followed by headache (49.3%), sore throat (48.9%), nasal congestion, rhinorrhea (42.1%), and loss of smell and/or loss of taste (37.8%). Regarding the continuation of the symptoms, vertigo was mentioned by 5852 (43.3%) followed by fever (16.1%) and blocked ear sensation (15.6%). Conclusion: The most commonly reported initial symptom was fever followed by headache. Interestingly, vertigo is a frequent long-term complication after a COVID-19 infection. Other otology-related symptoms include hearing loss and ear blockage, while rhinology and upper airway-related symptoms were less frequent in the long term after the acute phase of the infection.


Introduction
COVID-19 is an infectious disease that started in Wuhan, China, and the onset of the first known case dates back to 8 December 2019. On 11 March 2020, the WHO officially characterized the global COVID-19 outbreak as a pandemic [1]. Several studies showed that common symptoms are fever, fatigue, and dry cough [1][2][3][4]. However, a study by Telmesani et al. conducted through three centers in various regions of Saudi Arabia revealed that the initial symptoms of otorhinolaryngology (ORL) were sore throat, anosmia, and loss of taste [5].
We aim in this study to measure the prevalence of the most common ORL symptoms among COVID-19positive patients in Saudi Arabia. We also aim from this study to investigate and discuss different long-term ORL manifestations in those who were reported as COVID-19-positive adult patients.

Materials And Methods
This is a cross-sectional study. Data were collected from August to September 2022, and the study targeted those who were infected with COVID-19 from the beginning of the disease in Saudi Arabia. An online questionnaire designed on Google Forms was used as a tool for the study and was sent to the study sample.
The questionnaire consists of sections, and each section contains a set of questions. The first section includes the demographic characteristics of the participants. The second section includes clinical data, such as initial presentation, duration, general symptoms during the acute phase of the disease, and long-term symptoms that appeared or continued from the acute phase for a month at least. While the third, fourth, and fifth sections detailed the rhinology, upper airway/gastroesophageal reflux disease (GERD), and otology findings, respectively. They were measured by the 4-point Likert scale, where 1 indicates "never," 2 indicates "sometimes," 3 indicates "often," and 4 indicates "always." This section was added to evaluate the impact of each symptom on the participants.
All data were entered into the analytical program V.25 of the Statistical Package for the Social Sciences (SPSS; IBM Corp, Armonk, NY). Descriptive analysis was used for demographic and clinical data sections. Mann-Whitney test was used to study the differences between smokers and non-smokers in relation to symptoms of COVID-19 infections. Finally, the chi-square (χ 2 ) test was used to find out the relationship between smoking and other factors, and a P-value ≤0.05 was considered statistically significant.
We obtained approval for this work through the Ethics Committee of King Fahad Specialist Hospital -Dammam (approval number: ENT0004).

Background and demographic information
A total of 13,530 COVID-19-positive adult patients were included in this study. Official data from the Ministry of Health reported a total of 817,838 COVID-19-confirmed cases in Saudi Arabia and 9369 mortality cases. The study sample represents 2% of the study population. Most of them were females (68.5%) while 4261 (31.5%) were males. The majority of them were in the age group of 18-25 and 26-40, which represent 48.3% and 31.5%, respectively. The majority were of Saudi nationality (88.1%) while 1605 (11.9%) non-Saudi. A total of 11,347 (83.9%) were non-smokers (83.9%) and 2183 (16.1%) were smokers. Regarding other comorbidities, most of the study participants had no disease other than COVID-19 (63.1%), while 1567 had diabetes (11.6%), 1477 had asthma (10.9%), 1246 had morbid obesity (9.2%), 1153 had hypertension (8.5%), and 566 (4.2%) had other illnesses. Most of the study participants did not have a history of ORL diseases (63.1%) before the infection while 3603 (26.6%) had a history of allergic rhinosinusitis. In more than one-third of the participants, 12 months have passed since they were diagnosed as having infection with COVID-19. Concerning the source of COVID-19 infection, close contact with the known case was the most reported source (52.2%) followed by healthcare workers (27.5%). The majority of the participants were treated by home isolation (93.8%). Finally, 11,396 (84.2%) recovered without complications, 1852 (13.7%) recovered but still have complications, 169 (1.3%) have not recovered yet with symptoms improvement, and 60 (0.4%) have not recovered yet and their symptoms have worsened (
Initial symptoms resolved in less than a week in more than half of the participants (52.8%), between a week to a month in 5568 (41.2%), and in more than a month in 817 (6%). General symptoms during the acute phase of the infection are detailed in Table 2. When the participants asked about the appearance of symptoms or the continuation after COVID-19 treatment, vertigo was reported by 5852 (43.3%) of the participants followed by fever (16.1%) and blocked ear sensation (15.6%).

Questions Categories Frequency (%)
What are the initial presenting symptoms when you were diagnosed with COVID-19?

Association between smoking and symptoms associated with COVID-19 infection
Regarding the rhinology symptoms, it was found that there were significant differences between smokers and non-smokers in the prevalence of nasal congestion/rhinorrhea, anosmia/hyposmia, and epistaxis. Smokers had a significantly higher incidence of epistaxis (P-value < 0.002) while non-smokers had a significantly higher incidence of nasal congestion/rhinorrhea and anosmia/hyposmia (P-value < 0.001, < 0.001, respectively). There were no differences in postnasal drip and facial pain/pressure between smokers and non-smokers (P-value = 0.053, 0.525, respectively).
Concerning upper airway/GERD-related symptoms, there were significant differences between smokers and non-smokers regarding sore throat, loss of taste, dysphagia, and hoarseness of voice and it was in favor of non-smokers (P-value < 0.001, < 0.001, 0.008, and < 0.001, respectively), while there were no significant differences in heartburn between them (P-value = 0.682).
As for otology-related symptoms, hearing loss was higher among smokers (P-value < 0.001) while dizziness/vertigo was higher among non-smokers (P-value < 0.002). There were no differences in ear pain/pressure, tinnitus, and ear fullness between smokers and non-smokers (P-value = 0.924, 0.752, and 0.118, respectively) ( Table 4).

Rhinology symptoms
Nasal

Association between the degrees of recovery from COVID-19 and symptoms associated with infection
Rhinology symptoms, upper airway/GERD-related symptoms, and otology-related symptoms were significantly different according to the current condition of the participants (P-value < 0.001). It was observed that congestion/rhinorrhea and anosmia/hyposmia were higher among recovered participants who still have complications (P-value < 0.001), while postnasal drip, facial pain/pressure, and epistaxis were higher among the group of patients whose symptoms worsened but there was no recovery yet (P-value < 0.001).
Concerning upper airway/GERD-related symptoms, sore throat, loss of taste, and hoarseness of voice were higher among the participants who had recovered but still had complications (P-value < 0.001), while dysphagia and heartburn were higher among non-recovered participants with worsened symptoms (P-value < 0.001).
All the otology-related symptoms including ear pain/pressure, tinnitus, hearing loss, dizziness/vertigo, and ear fullness were found to be significantly higher among non-recovered participants with worsened symptoms ( Table 5).

Discussion
In this study, we have reported, of varying degrees, the long-term effects of COVID-19 on ORL symptoms. Otology symptoms were apparently most affected by long-term sequelae of COVID-19 infection. Vertigo was the most prevalent complaint with an interesting rate of 43.3%, while blocked ear sensation was reported by 15.6% of the participants. Hearing loss was only reported by 4.8%; however, it is worthy of consideration for future studies. General effects of COVID-19, such as fever, cough, and headache, were also reported with an incidence of less than 20%. Our result showed that rhinology symptoms were less frequent in the long term after the acute phase of the infection. Studying the long-term effects of COVID-19 infection on ORL is important as it could result in early prediction of these effects and hence prevention or reduction of undesirable symptoms' incidence through early suitable intervention and management.
Concerning comorbidities with COVID-19, diabetes was most reported by 11.6% of the participants followed by asthma (10.9%), and this was contradictory to Ng Wh et al.'s findings in which the most reported comorbidity among COVID-19 patients was hypertension followed by obesity [13].
As for the clinical presentation of the participating patients, the most commonly reported initial symptom when they were diagnosed with COVID-19 was fever (53.3%) followed by headache (49.3%), sore throat (48.9%), nasal congestion and rhinorrhea (42.1%), and loss of smell and/or loss of taste (37.8%). This was consistent with the findings reported by Amin et al. in which more than 50% of the participants experienced the previously mentioned symptoms as the initial presentation [14].
Regarding long-term symptoms after COVID-19 treatment, vertigo was reported by 43.3% of the participants, and similar findings were mentioned in the parallel study carried out by Saniasiaya et al., which demonstrated the link between COVID-19 infection and dizziness and vertigo [15].
Anosmia has been an alerting symptom of COVID-19 by many [16]. In our study, less than half of the participants (45.5%) complained of anosmia/hyposmia: about one-fifth (19.9%) were sometimes exposed to it, 11.8% were usually exposed to it, and 13.8% were always exposed to anosmia/hyposmia. This percentage is similar to Borah et al.'s finding in which 44% of the participants had anosmia [17].
Upper airway and GERD symptoms were more prominent during the acute phase of the infection but were unremarkable in the long term. More than half (54%) had a sore throat during infection with COVID-19 but only 5.5% complained of it in the long term. Dysphagia was reported by 38.6% of the participants as an acute-phase presentation. However, the long-term outcome was not assessed. This percentage was higher than Adkins et al.'s finding of 16.1%, and this could be attributed to genetic host factors and environmental factors [18].
Hearing loss was reported in COVID-19 infection by Masalski et al. with a prevalence of 11-28% among his study participants [19]. In our study, it was much lower with an incidence of 4.8%. Interpretation of such findings seems difficult because it might reflect a wide range of hearing loss from mild conductive hearing loss to profound sensorineural hearing loss. However, we thought to keep this for future investigations and exploration.
Smoking habits were evaluated to have a significant correlation with epistaxis, while congestion/rhinorrhea was significantly higher among non-smokers. Similar findings were reported in the study carried out by Reh et al., in which smoking was linked with rhinosinusitis [20]. Otology-related symptoms were likewise differently correlated to smoking habits. Dizziness/vertigo was significantly higher among non-smokers while hearing loss was higher among smokers. This finding was consistent with the findings of Istrate et al. in which a positive correlation between smoking and hearing loss was demonstrated [21]. As for upper airway/GERD-related symptoms, except for heartburn, all were significantly higher among non-smokers.
The status of the disease was also correlated to symptoms; patients who stated they were in recovery but still have complications showed a significant correlation for nasal congestion/rhinorrhea as well as anosmia/hyposmia. Other rhinology symptoms were significantly correlated to the group of patients who had symptoms worsened with no recovery yet. Concerning upper airway/GERD-related symptoms, it was found that sore throat, loss of taste, and hoarseness of voice were higher among participants who had but still had complications while dysphagia and heartburn were higher among non-recovered participants with worsened symptoms. All the otology-related symptoms including ear pain/pressure, tinnitus, hearing loss, dizziness /vertigo, and ear fullness were found to be significantly higher among non-recovered participants with worsened symptoms.

Conclusions
The most commonly reported initial symptom when they were diagnosed with COVID-19 was fever followed by headache. Interestingly, vertigo is a frequent long-term complication after a COVID-19 infection. Other otology-related symptoms include hearing loss and ear blockage, while rhinology-related symptoms were less frequent in the long term after the acute phase of the infection.

Additional Information Disclosures
Human subjects: Consent was obtained or waived by all participants in this study. King Fahad Specialist Hospital -Dammam issued approval ENT0004. Animal subjects: All authors have confirmed that this study did not involve animal subjects or tissue. Conflicts of interest: In compliance with the ICMJE uniform disclosure form, all authors declare the following: Payment/services info: All authors have declared that no financial support was received from any organization for the submitted work. Financial relationships: All authors have declared that they have no financial relationships at present or within the previous three years with any organizations that might have an interest in the submitted work. Other relationships: All authors have declared that there are no other relationships or activities that could appear to have influenced the submitted work.