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

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.

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.