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Invited Commentary
July 23, 2020

News Flash!—SARS-CoV-2 Isolated From the Middle Ear and Mastoid

Author Affiliations
  • 1University of Virginia Department of Otolaryngology–Head and Neck Surgery, Charlottesville
JAMA Otolaryngol Head Neck Surg. 2020;146(10):966-967. doi:10.1001/jamaoto.2020.2067

Otolaryngologists (especially otologists and/or neurotologists) around the globe have been waiting 6 months for this study.1 Given the anatomic connection from the nasopharynx, site of initial infection and virus isolation of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) to the tympanic cavity through the eustachian tube, could the virus responsible for the coronavirus disease 2019 (COVID-19) and the current global pandemic gain access to the middle ear space and mastoid cavity, and thus put health care workers at additional risk of contracting the virus?

The jury is now in. Frazier and colleagues1 from the Johns Hopkins Department of Otolaryngology–Head and Neck Surgery have shown, in 2 of 3 postmortem dissections described in the article, that SARS-CoV-2 can indeed access the middle ear and mastoid. Of those 2 patients with COVID-19, SARS-CoV-2 was identified in 5 of 8 middle ear spaces and mastoid cavities. The postmortem examination in the 1 patient in whom the virus was not isolated was performed 44 hours after death, and the delay may have contributed to the negative result (or the virus may access some but not all middle ears in infected patients).

We have known for many years that viruses, including other coronaviruses, have been isolated from the middle ear space in children with acute otitis media2 and in children undergoing tympanostomy tube placement for chronic otitis media with effusion3; but until now, it was unclear if SARS-CoV-2 reached the middle ear space and whether it could be isolated from the middle ear. Frazier et al1 used reverse transcriptase–polymerase chain reaction (per Centers for Disease Control [CDC] guidelines4) on bone and mucosal samples dissected from the middle ear and mastoid (using osteotomes and curettes and cytobrush swabs to obtain middle ear samples) in 3 patients (1 woman in her 80s and 1 man and 1 woman in their 60s), who succumbed to COVID-19, 48, 16, and 44 hours after death.

Although no report has documented SARS-CoV-2 infection as a result of a middle ear or mastoid procedure in a health care worker, mastoidectomy clearly generates aerosols and exposes health care workers.5 With sound methodology in the current report, the study implications are clear: otolaryngologists and otologists/neurotologists are at risk for contracting SARS-CoV-2 with middle ear and mastoid procedures and should don and doff personal protective equipment (PPE) per recommended guidelines, both in the ambulatory setting and in the operating room.6-8

Mitigation strategies in the operating room must adhere to local and institutional policies and should include appropriate PPE for all health care workers in the room, at least to include N95 masks and, in some institutions, powered air-purifying respirators for the surgeon operating on patients with known SARS-CoV-2 infection, as well as drapes or protective coverings/barriers to isolate the surgical field and prevent aerosols from reaching the greater room air.9 For patients with unknown viral status, universal preoperative testing has been instituted in many medical centers, but use of N95 masks, in accordance with local policy, should still be used intraoperatively during procedures that expose mastoid air cells or middle ear mucosa.

As ambulatory clinics reopen and patient care visits ramp up, practitioners in the office setting must also acknowledge the results of this study. Patient prescreening a day or 2 before the office visit, in-office screening the day of the visit, reducing the waiting room population to ensure proper social distancing, and patient isolation all can mitigate viral spread. Although further work is necessary to understand the risk of aerosolization of virus during otologic office procedures, nevertheless, suctioning the middle ear through a tympanic membrane perforation, intratympanic injections, and mastoid cavity debridement (especially if the cavity is exposed to the eustachian tube) may carry the risk of aerosolization and transmission of SARS-CoV-2; appropriate PPE, including eye protection, is indicated for these in-office procedures. Updated guidelines for otologic and neurotologic procedures, both in the operating room and in the ambulatory setting, proposed and agreed on by the American Neurotology Society, the American Otological Society, and the American Academy of Otolaryngology–Head and Neck Surgery will soon be published.

The COVID-19 pandemic has brought the world to its knees; according to the CDC in its weekly surveillance summary for the week ending June 6, 2020, across the United States “levels of influenza-like illness (ILI) and COVID-19-like illness (CLI) continue to decline or remain stable at low levels. The percentage of specimens testing positive for SARS-CoV-2 increased slightly from the prior week. Mortality attributed to COVID-19 also decreased compared to last week but remains elevated above baseline and may increase as additional death certificates are processed.”10[p1] Clearly hot spots of infection remain. Despite the overall decline or stability in infections, hospitalizations, and death rates across the country, the public, patients, and health care workers must continue to be vigilant in protecting each other and mitigating risk of viral transmission. By isolating SARS-CoV-2 from the middle ear and mastoid in postmortem ears and mastoid cavities in patients succumbing to COVID-19, the study by Frazier et al1 offers proof of principle of the virus’ ability to access the middle ear and/or mastoid, documents another potential route of SARS-CoV-2 transmission, and addresses the implications for protection of health care workers caring for patients with ear disease.

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Article Information

Corresponding author: Bradley W. Kesser, MD, University of Virginia Department of Otolaryngology–Head and Neck Surgery, Charlottesville, VA 22903 (bwk2n@hscmail.mcc.virginia.edu).

Published Online: July 23, 2020. doi:10.1001/jamaoto.2020.2067

Conflict of Interest Disclosures: None reported.

Frazier  KM, Hooper  JE, Mostafa  HH, Stewart  CM.  SARS-CoV-2 virus isolated from the mastoid and middle ear: implications for COVID-19 precautions during ear surgery.   JAMA Otolaryngol Head Neck Surg. Published online July 23, 2020. doi:10.1001/jamaoto.2020.1922Google Scholar
Bulut  Y, Güven  M, Otlu  B,  et al.  Acute otitis media and respiratory viruses.   Eur J Pediatr. 2007;166(3):223-228. doi:10.1007/s00431-006-0233-xPubMedGoogle ScholarCrossref
Pitkäranta  A, Jero  J, Arruda  E, Virolainen  A, Hayden  FG.  Polymerase chain reaction-based detection of rhinovirus, respiratory syncytial virus, and coronavirus in otitis media with effusion.   J Pediatr. 1998;133(3):390-394. doi:10.1016/S0022-3476(98)70276-8PubMedGoogle ScholarCrossref
CDC. Real-Time RT-PCR Panel for Detection 2019-Novel Coronavirus Centers for Disease Control. Centers for Disease Control. https://www.who.int/docs/default-source/coronaviruse/uscdcrt-pcr-panel-for-detection-instructions.pdf?sfvrsn=3aa07934_2. Accessed June 14, 2020.
Workman  AD, Welling  DB, Carter  BS,  et al.  Endonasal instrumentation and aerosolization risk in the era of COVID-19: simulation, literature review, and proposed mitigation strategies.   Int Forum Allergy Rhinol. Published online April 3, 2020. doi:10.1002/alr.22577PubMedGoogle Scholar
CDC. Interim U.S. Guidance for Risk Assessment and Work Restrictions for Healthcare Personnel with Potential Exposure to COVID-19. https://www.cdc.gov/coronavirus/2019-ncov/hcp/guidance-risk-assesment-hcp.html. Accessed June 14, 2020.
Lammers  MJW, Lea  J, Westerberg  BD.  Guidance for otolaryngology health care workers performing aerosol generating medical procedures during the COVID-19 pandemic.   J Otolaryngol Head Neck Surg. 2020;49(1):36. doi:10.1186/s40463-020-00429-2PubMedGoogle ScholarCrossref
Saadi  RA, Bann  DV, Patel  VA, Goldenberg  D, May  J, Isildak  H.  A commentary on safety precautions for otologic surgery during the COVID-19 pandemic.   Otolaryngol Head Neck Surg. 2020;162(6):797-799. doi:10.1177/0194599820919741PubMedGoogle ScholarCrossref
Chen  JX, Workman  AD, Chari  DA,  et al.  Demonstration and mitigation of aerosol and particle dispersion during mastoidectomy relevant to the COVID-19 era.   Otol Neurotol. 2020. doi:10.1097/MAO.0000000000002765PubMedGoogle Scholar
CDC. COVIDView: A Weekly Surveillance Summary of U.S. COVID-19 Activity. https://www.cdc.gov/coronavirus/2019-ncov/covid-data/covidview/index.html. Accessed June 14, 2020.
2 Comments for this article
A long-term virus reservoir for SARS-CoV-19?
Manfd Stapff, MD PhD | LG Chem Life Science Innovation Center, Cambridge, MA, USA
The observation published by Frazier (1) and colleagues from the Johns Hopkins Department of Otolaryngology–Head and Neck Surgery does not only have relevance for Otolaryngologists because of the risk of aerosolization and transmission of SARS-CoV-2 during procedures.
It also raises the question whether sinus, mastoid cavities, and the middle ear provide a long term virus reservoir relatively protected from T-cells and immunoglobulin activity, analogue to salmonella spreading from the gallbladder or HI virus "hibernating" in lymphatic tissue. If such characteristics were applicable to SARS-CoV-19, it may change our approach to reconvalescent patients dramatically. Currently we consider patients healthy two
weeks after the symptoms subsided. This premature assumption of a one-time-disease leading to immunity is one reason why we question incidental reports of "re-infections" in patients who had recovered from COVID-19. A few countries even discuss the idea of an "immunity passport" to allow post COVID-19 patients some waivers from certain restrictions.
This all may change significantly if SARS-CoV-19 can remain dormant in, or become re-activated from, certain bodily cavities or tissues. Longterm studies on larger sample sizes, similar to the one by Frazier and colleagues, are urgently necessary!
On a totally different note: Peer reviewed contributions in times of a rapidly changing pandemic can be problematic as shown by the difference in numbers of reported COVID-19 cases, quoted in the manuscript at the times of submission (June 6th) versus the actual number at publication (July 23rd).

1. Frazier KM, Hooper JE, Mostafa HB, Stewart CM. SARS-CoV-2 virus isolated from the mastoid and middle ear: implications for COVID-19 precautions during ear surgery.  JAMA Otolaryngol Head Neck Surg. Published online July 23, 2020. doi:10.1001/jamaoto.2020.1922
Why you might find covid in ear Canal
Kelly Jennings Rr |
Were patients treated with a cpap or tubed at all . Because I use a cpap and I find that my nasal mask with chinstrap to keep mouth closed I have Air coming from ears from the cpap it’s all connected . So I would gander maybe transfer from nasal to ear or even mouth depend what’s type cpap . When I get ear infections I have to stop using cpap or I won’t get rid ear infection!