Characterizing the most Popular Tinnitus Inquiries: Is Tinnitus Incidence on the Rise Since COVID-19?

Objective

Approximately 50 million US adults experience chronic tinnitus, yet search behaviors and topics of concern to these patients have not been investigated on a national level.

Study Design

Observational

Setting

Online database and tertiary otology clinic

Patients

Nationwide and institutional samples

Interventions

None

Main Outcome Measure

A search engine optimization tool was utilized to extract metadata on “People Also Ask” (PAA) questions pertaining to tinnitus. Website quality was assessed using JAMA benchmark criteria. Search volume trends were investigated along with institutional-level data on tinnitus incidence.

Results

Of the 500 PAA questions assessed, the majority (54.0%) contained value-type content. The most popular question categories pertained to tinnitus treatment (29.3%), alternative treatment approaches (21.5%), technical details (16.9%), and timeline of symptoms (13.4%). Patients were most interested in treatment with wearable masking devices and most commonly searched for tinnitus as being attributable to a neurologic etiology. Online searches pertaining to unilateral tinnitus symptoms have increased >3-fold since the onset of the COVID-19 pandemic. Likewise, review of patient encounters at our tertiary otology clinic revealed a nearly 2-fold increase in tinnitus consultations since 2020.

Conclusions

Topics of interest and concern identified herein may inform the development of patient education materials and help guide clinical practice. Online search data suggest an increase in tinnitus searches since the onset of COVID-19, which did correlate clinically with an increase in tinnitus consultations at our institution.

INTRODUCTION

In the United States, tinnitus prevalence is estimated at 15%, with approximately half of these patients reporting bothersome symptoms (1–5). Recent reports suggest that up to 75% of adults have experienced at least one episode of acute or chronic tinnitus (6). Complaints of tinnitus are commonly described as “ringing in the ears,” without an identifiable source for the sound. Symptoms may also present as an auditory perception of roaring, buzzing, whooshing, clicking, hissing, pulsatile thumping, among other manifestations that may affect one or both ears. There is a multiplicity of potential causes for nonrhythmic tinnitus, the most common of which include hearing loss and noise exposure (7,8). In contrast, rhythmic tinnitus is usually attributable to disorders affecting vascular or muscular systems in close proximity to the cochlea (9).

Although tinnitus is one of the most common health conditions in the country, no previous report has investigated specific topics of patient interest searched online. Previous reports have been limited to assessments of the quality and readability of online information and characterization of content contained within Internet videos (10–12). Recent advancements in machine learning technologies embedded within the Google web search software now recognize patterns among individual search queries (13). After a web search is entered, Google can then predict future related searches and offer suggestions based on previous search behavior. This process generates “People Also Ask” (PAA) questions that are presented to the Internet user. Recent reports have used PAAs to study the most popular areas of patient interest on several topics (14,15). Importantly, knowledge gained through these investigations enables health education materials to be tailored to meet the informational needs of patients.

The aim of this report is to investigate topics of patient interest pertaining to tinnitus, evaluate the quality of online patient education materials most commonly encountered, and document search trends related to tinnitus. We hypothesize that patients will be most interested in treatment modalities and that the volume of searches will be increasing in recent years.

MATERIALS AND METHODS

PAA questions were assessed using the search engine optimization tool, SearchResponse.io (https://searchresponse.io/people-also-ask). This database contains metadata on >100 million PAA questions extracted from Google servers across the globe. The popularity of a PAA question is measured by the number of search engine results pages (SERPs) in which the PAA appears. SERP refers to the page of relevant websites presented to the Internet user after a search query is entered. SERPs are composed of 3 types of information: organic search results, pay-per-click (PPC) links that appear with the word “Ad” in bolded font, and PAA questions clustered in a drop-down menu. As such, PAA questions are suggested by machine learning algorithms and not searched by the user. This study was deemed exempt from review by the senior author's institutional review board, as it features publicly available data and no patient charts were accessed.

Question Classification

The most popular PAA questions associated with the keyword “tinnitus” were extracted and characterized. A comprehensive list of top PAAs was generated (Supplemental Table 1, http://links.lww.com/MAO/B631). A low popularity score resulting in the question being outside of the top 500 questions was used as the cut off for inclusion. This methodology was adapted from recent reports using online search analytics to investigate patient interest in surgical procedures (14,15). Question types were categorized based on Rothwell’s system for classification (Fact, Value, and Policy) (16,17). Consistent with Shen et al. (14), questions were further subclassified into relevant topics of interest (Table 1). A comprehensive assessment of concerns unique to patients with tinnitus were also investigated (alternative treatments/causes/disability benefits).

TABLE 1.

Classification of question types (modified Rothwell's criteria*)

Rothwell Category		Description
Fact		Asks whether something is true and to what extent. This question is answered with objective evidence.
Policy		Asks whether a specific course of action should be undertaken to solve a problem.
Value		Asks for an evaluation of desirability, likelihood, or quality. This question is answered with subjective evidence.
Topic category
Fact	Activities or restrictions	Specific activities or actions that provoke or alleviate symptoms
	Timeline of symptoms	Expected duration of symptoms
	Technical details	Causes, description of pathophysiology, how treatment achieves results
	Financial	Cost of treatment, testing, consultation, or disability benefits
	Risks or complications	Health risks associated with the condition or treatment
Policy	Indications for treatment	Purpose of treatment, candidacy criteria, when consultation is indicated
	Management	Recommendations on how to manage the condition
Value	Appraisal	Assessment of symptom severity, disability, quality of life disturbance
	Treatment	Expectations surrounding treatment experience
	Alternative treatments	Nonmedical approaches, at-home solutions, alternative techniques
Website category
Academic		Institutions directly affiliated with universities, academic centers, academic publishers, or academic societies
Industry		Organizations serving as source of health information, including corporate groups and media companies
Government		Websites with “.gov” domain or otherwise maintained by a governmental agency
Private		Websites maintained by physicians, audiologists, dentists, or lawyers without an academic affiliation.

*Rothwell JD. In Mixed Company: Communicating in Small Groups. Boston, MA: Wadsworth; 2010.

Website Categorization and JAMA Quality Assessment

All 500 PAAs were categorized by the affiliation of the website referenced to answer each question (academic, industry, government, private) similar to previous reports (18–21). A quality assessment of websites associated with the top 25 most popular PAAs was undertaken using the Journal of the American Medical Association (JAMA) benchmark criteria, in accordance with the existing literature (19,22,23). Measures of quality included authorship, attribution, currency, and disclosure. Websites meeting all JAMA criteria included: authors and contributors with their affiliations and credentials (authorship); references or sources of copyright protected information (attribution); dates of publication or revision (currency); and ownership, sponsorship, advertising, and/or funding support for the website (disclosure). Possible JAMA scores range from 0 to 4. The score of 0 indicates that no JAMA criteria were met. A score of 4 indicates that all JAMA criteria were met.

Epidemiologic Analysis

Search volume analysis in the United States was performed using Google Trends™ and the search engine optimization tool “Ahrefs.” Only searches conducted in English were included. Google Trends data were presented as a relative interest over time, with the point of highest search volume being assigned a value of 100 and all other timepoints being scaled to this value. Ahrefs enabled a higher resolution of search volume assessment. Rather than the automatically scaled “interest over time” metric available through Google, Ahrefs provides the actual number of monthly searches for a given set of keywords. Ahrefs data was available between September 2015 and March 2022. Institutional-level data on monthly incidence of patient encounters related to tinnitus were assessed. This was accomplished via extraction of billing data using the following ICD codes: H93.11 (tinnitus, right ear), H93.12 (tinnitus, left ear), and H93.13 (tinnitus, bilateral). All patients presenting to the Michigan Ear Institute with any documented complaint of tinnitus between October 2015 and May 2022 were included. No patients were excluded. Billing data were also analyzed by the ordered arrangement of diagnoses, with primary diagnoses of tinnitus being operationalized as a chief complaint, whereas secondary, tertiary, or latter diagnoses were defined as simply a complaint of tinnitus.

Independent Reviewer and Statistical Assessment

Two independent reviewers (C.F. and J.C.) classified PAAs according to Rothwell criteria, topic categories, and website affiliation type, as defined in Table 1. Discordance between reviewers was resolved through consultation of a third party (G.C.). Differences in sample means were assessed with an Independent samples t-test. A two-tailed p value ≤0.05 was considered statistically significant. Statistical analyses were performed using SPSS (version 24, IBM).

RESULTS

Of the 500 PAA questions assessed, the majority (54.0%) contained value-type content, according to Rothwell classification. Further analysis of popularity for each topic category was undertaken by assessing SERP volume of all questions in a given category relative to the popularity of all categories. The most popular question categories pertained to tinnitus treatment (29.3%), alternative treatment approaches (21.5%), technical details (16.9%), and timeline of symptoms (13.4%). Websites used to answer PAA questions had affiliations with academic (47.9%), industry (32.0%), governmental (8.9%), and private (7.9%) groups (Fig. 1).

FIG. 1.

Question categorization: Percentage of PAA questions by Rothwell category (A), popularity of PAA questions by topic category (B), popularity of PAA questions by website type (C).

PAA questions referenced a variety of alternative treatment modalities. These inquiries were stratified into 34 unique categories. The popularity of each category was calculated by summation of the SERP popularity for each PAA question within that category. Alternative treatment modality categories are presented in decreasing order of popularity in Figure 2A. As quantified by combined SERP popularity, patients appear to be most interested in treatments involving wearable masking devices (1359), dietary supplements (1193), Ginkgo biloba (Silencil) (941), and environmental noise generators (822).

FIG. 2.

Combined search popularity of alternative treatment modalities (A) and patient-searched tinnitus causes (B).

Within the technical details category, tinnitus causes were a commonly searched topic. Patient-presumed causes were stratified into 18 unique categories. Patients most commonly attributed the pathogenesis of tinnitus to neurologic (1261), cervical musculature (928), and vitamin deficiency (637), using the combined SERP count as a measure of popularity (Fig. 2B). Although questions concerning tinnitus etiology were variable, there was consistent interest in disability benefits pertaining to the United States Department of Veterans Affairs (VA) program (63.6% of disability-related questions) (Supplemental Table 2, http://links.lww.com/MAO/B632).

Websites used to answer the 25 most popular PAA questions were subjected to a JAMA quality analysis (Table 2). Duplicate websites referenced to answer multiple PAA questions were removed (n = 8). Of those 17 remaining websites, the majority were authored by entities with industry interests (11, 64.7%). Despite academic websites being most common sources used to answer the top 500 PAA questions related to tinnitus, only 3 academic websites (17.6%) were utilized to answer the most popular PAA questions. Average JAMA scores were below 3 out of 4 for all website categories, including industry (2.8 ± 1.2), academic (2.7 ± 1.5), governmental (2.5 ± 2.1), and private (1 ± n/a).

TABLE 2.

Quality assessment of top search results ordered according to JAMA benchmark criteria score

Search Rank	Website Affiliation	JAMA Score	Popularity (SERP Count)	Affiliation of Website	URL
1	MedicineNet	4	6,523	Industry	https://www.medicinenet.com/most_effective_treatment_for_tinnitus/article.htm
3	Healthline	4	997	Industry	https://www.healthline.com/health/can-lipoflavonoid-stop-ringing-in-ears
5	Healthline	4	828	Industry	https://www.healthline.com/health/tinnitus-remedies
7	National Institute of Health	4	711	Government	https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2686891/
10	Dizziness and Balance	4	660	Academic	https://dizziness-and-balance.com/disorders/hearing/tinnitus/pulsatile.html
16	Forbes	4	469	Industry	https://www.forbes.com/health/healthy-aging/tinnitus-causes-and-treatments/
2	Scientific American	3	1,165	Industry	https://www.scientificamerican.com/article/new-tinnitus-treatment-alleviates-annoying-ringing-in-the-ears1/
8	Mayo Clinic	3	703	Academic	https://www.mayoclinic.org/diseases-conditions/tinnitus/symptoms-causes/syc-20350156
15	American Tinnitus Association	3	497	Industry	https://www.ata.org/sites/default/files/Drugs%20and%20Tinnitus%20-%20Neil%20Bauman%20PhD%20-%20April%20%2709.pdf
25	Zeel	3	351	Industry	https://www.zeel.com/blog/massage/benefits-of-massage/ears-ringing-massage-can-be-an-effective-treatment-for-tinnitus/
4	TruDenta	2	878	Industry	https://trudenta.com/this-simple-trick-may-help-with-tinnitus/
21	Healthy Hearing	2	398	Industry	https://www.healthyhearing.com/report/52964-Quality-of-life-hacks-for-tinnitus-sufferers
6	Harvard Health	1	819	Academic	https://www.health.harvard.edu/diseases-and-conditions/is-it-worrisome-to-hear-a-pulse-in-my-ear
12	Hearing Services of Nashville	1	549	Industry	https://www.hearingservicesofnashville.com/hearing-loss-articles/does-tinnitus-go-away-on-its-own/
13	ENT Institute	1	538	Private	https://entinstitute.com/tinnitus-relief/
14	American Tinnitus Association	1	520	Industry	https://www.ata.org/managing-your-tinnitus/tinnitus-patient-navigator
18	National Institute of Health	1	425	Government	https://www.nih.gov/news-events/nih-research-matters/tinnitus-cure-may-lie-brain

Duplicate websites removed: 4 by Healthline, 1 by Mayo Clinic, Forbes, TruDenta, and Hearing Services of Nashville.

A monthly volumetric search analysis was undertaken. To capture patients seeking information on bilateral tinnitus, the following search terms were investigated: “ears ringing”, “ringing in ears”, “tinnitus”, and “tinnitus COVID” (Fig. 3A). This revealed a seasonal variation in search patterns, with more patients searching for tinnitus symptoms during winter months. Moreover, to capture patients seeking information on unilateral tinnitus, the following search terms were investigated: “left ear ringing,” “right ear ringing,” “ringing in left ear,” “ringing in right ear,” “ringing in left ear meaning,” and “ringing in right ear meaning.” Altogether, these unilateral tinnitus searches began to rise in March 2020 (Fig. 3B). This was followed by a more pronounced rise in searches for unilateral tinnitus in March 2021. Unlike inquiries into bilateral tinnitus that rose and subsequently fell, searches for unilateral tinnitus remain elevated above baseline to date.

FIG. 3.

Volumetric search analysis with Google trends (A–B) and Ahrefs search engine optimization tool (C–E). Vertical dashed line at march 2021 corresponds to the onset of the COVID-19 Delta variant.

To perform a more rigorous interrogation of these search trends, we employed the subscription-based Ahrefs search engine optimization software suite. For bilateral symptoms, Ahrefs again revealed a sinusoidal, seasonal oscillation in bilateral tinnitus search volumes and a spike in March 2021, consistent with Google Trends™ data (Fig. 3C). In addition to the recent rise in unilateral tinnitus-related searches, the higher resolution volume assessment afforded by Ahrefs revealed a disparity in searches based on tinnitus laterality. Left-sided symptoms were more commonly searched, as evidenced by the significant difference in average monthly search volumes for “left ear ringing” (10383.3 ± 5268.5) and “right ear ringing” (5984.8 ± 2961.6) (p < 0.001) (Fig. 3D). A recent widening of this laterality gap between left- and right-sided tinnitus searches was noted, with the average pre-pandemic volume difference of 3134.6 ± 975.3 searches/month (2015–2019), as compared with a difference of 6832.6 ± 3019.8 searches/month between 2020 and 2022 (p < 0.001). Among patients seeking to understand the meaning of their tinnitus symptoms, there were more searches for “ringing in left ear meaning” (4397.2 ± 6273.9) than “ringing in right ear meaning” (3423.7 ± 4873.5), although this was not statistically significant (p = 0.278) (Fig. 3E).

To further investigate the recent rise in tinnitus-related searches online, tinnitus symptoms at our tertiary otology clinic were assessed via retrospective analysis of ICD codes. This revealed an increase in both unilateral and bilateral tinnitus complaints since the onset of the COVID-19 pandemic, with bilateral tinnitus rates nearly doubling in the last 2 years (Fig. 4A-C). Tinnitus was found to be an associated symptom and not a chief complaint (primary diagnosis) among these excess cases. Within this cohort of patients with tinnitus, there was minimum change in the frequency of other disorders that might otherwise account for the increase in tinnitus complaints (Supplemental Table 3, http://links.lww.com/MAO/B633). There were more Ménière's patients presenting with tinnitus in recent months (up from 192 in the first half of 2018 to 429 in the first half of 2022, which is 237 additional patients). During this same period tinnitus diagnoses more than doubled (from 1,407 to 3,209, which is 1802 additional patients). Increased tinnitus complaints in Ménière's patients may account for 13.2% (237/1,802) of the total increase in tinnitus diagnoses during this period.

FIG. 4.

Epidemiologic analysis of tinnitus symptoms at a single tertiary otology clinic. Solid lines represent the 3-month moving average for each variable. Vertical dashed lines represent start of COVID-19 pandemic.

DISCUSSION

In this report, national search volume trends prompted a quantitative analysis of institutional tinnitus consultations. A temporal correspondence between the COVID-19 pandemic and recent increases in tinnitus symptoms documented at our tertiary otology clinic was observed. To the best of our knowledge, this is the first epidemiologic study in the literature to suggest an increase in the incidence of tinnitus consultations since the onset of COVID-19. This was an unexpected finding, as we had initially sought to use Google metadata to understand patient interest in a variety of topics related to tinnitus.

Machine learning algorithms were leveraged to study patient interest in tinnitus treatments and specific alternative treatment modalities, as shown in Figure 1. Upon categorization of treatment modalities and quantification of relative patient interest, wearable tinnitus masking devices garnered the most patient interest based on our nationwide search popularity analysis. Although many otolaryngologists may first recommend Ginkgo biloba to patients with persistent and disabling tinnitus symptoms, patients may also be receptive to sound masking devices. Offering in-office trials of such devices would be one method of addressing the high level of patient interest in this treatment modality (24–28). Moreover, the most commonly searched causes of tinnitus included neurologic, cervical musculature, and vitamin deficiency. Given that cervicogenic tinnitus is a relatively rare clinical entity that might otherwise be overlooked, the authors recommend that patient education materials address this topic in response to the high level of patient interest. Quality of websites used to answer PAA questions were of limited quality, with average JAMA scores below 3 of 4 (<75%) for all website categories. This highlights that there is room for improvement in online patient education materials addressing the topic of tinnitus.

With regard to the volumetric search analysis, previous reports have utilized search volume data for epidemiologic monitoring for disease outbreaks (29–31). Likewise, we leveraged Google Trends™ and Ahrefs to assess online search popularity over time. Bilateral tinnitus-related searches in the United States consistently reached a zenith in winter months followed by a nadir in the summer. This sinusoidal, seasonal variation in search query volumes related to tinnitus has been documented in both hemispheres (32). Seasonal variation in search patterns could reflect the seasonality of communicable upper respiratory viruses, which may include tinnitus among the constellation of symptoms. This is consistent with a recent report of colder temperatures being correlated with higher levels of tinnitus (33). A peak in searches for “tinnitus COVID” temporarily augmented the oscillating search pattern in Figure 3A, which could have been related to the rise in COVID-19 Delta variant cases in March 2021 or news stories of public interest. Interestingly, searches for unilateral tinnitus did not demonstrate seasonal variation in search patterns. This suggests that the underlying pathophysiologic mechanism of unilateral tinnitus could be distinct from that of bilateral tinnitus. Further investigation into the rates of unilateral tinnitus complaints within individual institutions is necessary to correlate these findings clinically.

Of note, institutional-level patient encounters did corroborate the epidemiologic search volume analysis in revealing a recent increase in tinnitus complaints. The finding that bilateral tinnitus complaints documented in our clinic were increasing at a similar, if not higher, rate than unilateral tinnitus complaints was an unexpected finding. Given that the search volume analysis in Figure 3C and 3E revealed minimal change in bilateral tinnitus searches since early 2020, it was surprising to find a relatively large population of patients presenting to our clinic with bilateral tinnitus complaints. This could be due to tinnitus severity demonstrating a unilateral predominance in the setting of bilateral complaints. Providers may designate such unilateral predominant tinnitus as bilateral for billing purposes. Such ICD coding practices may explain the discordance in symptom laterality observed between nation-wide search data and institutional-level patient encounters.

With regard to the institutional level data presented in Figure 4, there was a consistent proportionality of ~1:2 between a chief complaint of tinnitus and all tinnitus complaints. This was shown by the black line representing chief complaints that tracked in tandem with the colored line representing all tinnitus complaints. After the first quarter of 2020, this relationship was disrupted as chief complaints of tinnitus remained relatively stable, whereas all complaints of tinnitus increased. As such, the relative prevalence of tinnitus as a chief complaint has not changed. This suggests that the recent increase in tinnitus is attributable to tinnitus as an associated symptom manifesting secondary to some related disease process. Although post-COVID tinnitus is a potential culprit, the present study is underpowered to substantiate this claim. Online post-COVID tinnitus support groups and the recent post-COVID tinnitus-related suicide of American businessman and Texas Roadhouse CEO, Kent Taylor, provide anecdotal reports that highlight the need for further investigations into this topic. The authors postulate that the spike in tinnitus search volumes in March 2021 (Fig. 3A & C) could have been driven by interest from the general public following a popular New York Times article that detailed the circumstances surrounding Mr. Taylor's death. One year later, in March 2022, Dr. Gregory Poland MD, a respected Mayo Clinic virologist, forwarded an anecdotal report of tinnitus occurring immediately after his COVID-19 booster vaccination. This story was featured by multiple major news networks. Whether the otologic effects of vaccination account for some portion of tinnitus searches in this report cannot be ruled out. A recent systematic review of audio-vestibular symptoms manifesting during COVID-19 infection found that 7.6% of patients recall symptoms of hearing loss, 14.8% report tinnitus, and 7.2% report rotary vertigo (34). Although initial reports suggest that these otologic symptoms may persist after recovery (35,36), this remains an important topic for future study.

Furthermore, it is possible that increased tinnitus incidence could be attributable to broader social and economic forces. Among our patient population, there was a larger demographic working from home. Some patients report that their quiet home office setting contributes to more bothersome tinnitus symptoms, consistent with previous reports (37,38). Likewise, by some estimates, 1 in 4 workers quit their jobs in 2021 and an additional 1 in 5 will likely follow suit in 2022 (39). For these reasons, some may argue that there is an appreciable segment of the population remaining idle in the wake of the pandemic. It is possible that the unconscious process of habitation that enables sensory perceptions to be ignored could be impacted when encountering less external stimuli outside of the workforce. This raises the question of whether tinnitus incidence could be influenced by behavioral rather than medical factors. The authors acknowledge that this likely plays a role to some limited extent.

Interestingly, we found left-sided tinnitus to be more common than right-sided tinnitus. This was observed in both the search volume analysis and the institutional patient encounters. The asymmetric distribution of tinnitus favoring the left has been noted previously (40,41). Previous reports suggest that this could be linked to handedness or other lateral signs related to hemispheric dominance (42). There is also a body of literature related to asymmetric hearing loss being more common on the left (43–48). Although the neurobiologic explanation for tinnitus is complex and multifactorial, in many cases tinnitus could be consequence of the brain's response to sensory deprivation because of reduced peripheral auditory input (9,49). In a clinical setting, an explanation presented to patients may reference phantom limb perception as an analogy to the pathophysiology of tinnitus. Whether recent increases in the incidence of left-sided tinnitus are related to left-sided hearing loss warrants further investigation.

Areas of controversy should be acknowledged. It is challenging to pinpoint the underlying cause of tinnitus searches and case presentations assessed in this report. To avoid propagating false information on the otologic consequences of COVID-19 infection and vaccination efforts, it is important to emphasize that our data reveals only a temporal relationship without causation expressed or implied by the authors. How infection or vaccination-related variables affect tinnitus prevalence remains a matter of speculation. Moreover, we do not know the extent to which pent-up demand after a lull in clinical visits in early 2020 might contribute to the currently elevated level of tinnitus-related encounters. Whether these excess tinnitus complaints are transitory or permanent remains incompletely understood. The present analysis cannot comment on the severity of tinnitus or impact on quality of life. Our institutional analysis included all visits associated with a diagnosis of tinnitus, which may introduce bias because of multiple follow-up visits from the same patient. Clinical data reported was derived from a single institution in a large, culturally diverse metropolitan area, which supports generalizability only to other similar patient populations. We do not know whether social and emotional challenges attributable to the pandemic may contribute to tinnitus symptoms reported herein. Because of# the retrospective nature of this review, there was limited information on the type of tinnitus experienced by each patient.

There are multiple additional limitations of the methodology employed. This report is unable to demonstrate a clear relationship between searching for tinnitus and having tinnitus. It is possible for someone to be curious about tinnitus and conduct an online search without necessarily having symptoms. Although the authors would not expect someone without tinnitus to deliberately specify the laterality of tinnitus in their search, this is hypothetically possible. The searches for left ear versus right ear tinnitus shown in Figure 3 may be less influenced by searches from persons without tinnitus. It is more likely that the peak in “tinnitus COVID” searches in Figure 3A is attributable to searches conducted by the general public rather than patients with tinnitus. Furthermore, patients with tinnitus may not perform an online search, either because symptoms are not bothersome, technological barriers, or transient symptoms. For these reasons, our analysis may be impacted by several confounding variables and does not necessarily capture all patients with tinnitus. This study does not empirically establish the true incidence of tinnitus. Moreover, during the study window there may have been evolution in treatment strategies and diagnostic tools employed for tinnitus. To the best of the authors’ knowledge, there is no resource that enables retrospective evaluation of PAA rankings or frequencies in previous years. For this reason, commenting on changes in online search queries before versus after the onset of the COVID-19 pandemic is not currently possible.

CONCLUSIONS

Topics of interest and concern identified in this report may inform the development of patient education materials and help guide clinical practice. Increases in tinnitus searches and clinic visits since the first quarter of 2020 were revealed through a nation-wide search analysis and assessment of diagnoses made within a tertiary otologic clinic. This study is limited in its ability to determine the cause of these tinnitus complaints. There is currently no known definitive correlation between tinnitus and COVID-19 vaccination or the entity known post-COVID syndrome. Tinnitus-focused epidemiologic monitoring should be continued into the future to ensure that symptom prevalence in the community returns to pre-pandemic levels. Patients should be encouraged seek prompt evaluation by an otolaryngologist for documentation of tinnitus severity, assessment of associated symptoms, and evidenced-based management.