SARS-CoV-2 Isolated From Middle Ear, Mastoid Bone

By Will Boggs MD

July 31, 2020

NEW YORK (Reuters Health) - SARS-CoV-2 has been isolated from mastoid-bones and middle-ear autopsy specimens from two patients who died with COVID-19, which has implications for otolaryngology practice, according to a new report.

"Identification of a new area of body infected by the SARS-CoV-2 virus is relevant and helpful for understanding risk for transmitting infection during procedures," said Dr. C. Matthew Stewart of Johns Hopkins School of Medicine, in Baltimore, Maryland.

"Knowledge of these proven risks can help protect healthcare providers during physical examination and common procedures of the ear and mastoid," he told Reuters Health by email.

Middle-ear effusions have been shown to contain some non-SARS-CoV-2 coronaviruses, but there are no human data relating to the SARS-CoV-2 virus in the middle ear.

Dr. Stewart and colleagues selected three COVID-19-positive decedents and performed bilateral cortical mastoidectomy and exposure of the aditus.

Two of the three patients tested positive for SARS-CoV-2 virus in the mastoid or middle ear, with viral isolation from two of six mastoids and three of six middle ears, the team reports in JAMA Otolaryngology-Head and Neck Surgery.

All samples were positive for one patient, only the sample from the right middle ear was positive for another patient, and the third patient had negative results for all samples.

These findings support the use of droplet precautions during ear surgery for patients with COVID-19 owing to the risk of infection to healthcare personnel, the authors say. The precautions apply to both outpatient procedures and elective ear surgery, which might be delayed until negative SARS-CoV-2 testing can be confirmed.

Moreover, should live SARS-CoV-2 virus be identified in middle-ear effusions, additional precautions might be necessary for surgeons and staff who handle equipment such as instruments, suction tubing, and suction canisters.

"We are very interested in understanding the long-term effects, if any, of having recovered from infection of the ear and mastoid," Dr. Stewart said. "We hypothesize that potential symptoms could be changes in the character and quality of hearing, balance, ringing, or sensations of fullness or pressure. There are also special sensory nerves that travel through this space. We now have reasons to include this type of evaluation in those patients who have recovered from COVID-19."

"We know that the intact tympanic membrane serves as barrier between the middle ear and mastoid and the external ear and outside world," he said. "We suspect that patients who lose this barrier due to perforation or changes after surgery, such as the creation of canal wall down cavities for cholesteatoma, may have an addition route of viral spread and infection. Since this area is not covered by facial masks, this would increase the risk of spread to others, particular healthcare workers that care for the ear and nearby areas."

Dr. Bradley W. Kesser of the University of Virginia, Charlottesville, who wrote an invited commentary on the report, told Reuters Health by email, "We otolaryngologists and otologists/neurotologists should not perform elective ear surgery on patients infected with SARS-CoV-2. It may mean that all patients undergoing ear surgery will be tested preoperatively, but this can vary with local hospital and health department regulations. Emergency ear surgery, while rare, will be performed under the strictest of infection control parameters."

"Physicians and staff must have policies and procedures in place both in their offices and in the operating room to eliminate, or greatly mitigate, the risk of infection in the healthcare team," he said. "Local hospital and state guidelines have been put in place to protect healthcare workers; the exposed middle-ear space and mastoid are now potential routes/sources of infection for those healthcare workers."

Dr. Huseyin Isildak of The Milton S. Hershey Medical Center, Pennsylvania State University, who recently reviewed best-practice recommendations for pediatric otolaryngology and safety precautions for otological surgery during the COVID-19 pandemic, told Reuters Health by email, "It is known from prior reports that instrumentation of the aerodigestive tract, particularly with high-speed drills, poses a risk of viral aerosolization. There are several notable cases from Wuhan where transnasal, transsphenoidal surgery led to a patient-to-provider transmission of SARS-CoV-2 to most of the OR staff despite the use of enhanced PPE including N95 masks."

"Due to the contiguous anatomy of the middle ear and mastoid with the nasopharynx, as well as the presence of other respiratory viruses in the middle ear, it was surmised that SARS-CoV-2 would also be present in the middle ear," said Dr. Isildak, who was not involved in the new report. "However, until now, there had been no studies that confirmed the presence of a viral reservoir in the middle ear/mastoid space."

"Therefore, with this knowledge in hand, physicians and patients should be aware that contact with middle-ear tissue and fluid (such as otorrhea from a tympanostomy tube or perforation) carries the same risk as contact with respiratory tissue/fluid and should be treated with the same precautions," he said. "Likewise, middle-ear surgery should use the same precautions as aerodigestive surgery (the use of N95 masks, negative pressure rooms, postponing cases in those who with COVID-19, etc.)."

SOURCE: https://bit.ly/2CVgQxz and https://bit.ly/2X0enbW JAMA Otolaryngology-Head and Neck Surgery, online July 23, 2020.

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