COVID-19 and Ear Surgery: (RK Jackler, Stanford)

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To the best of our knowledge no one knows whether the respiratory mucosal lining the middle ear and
mastoid air cells system is involved by COVID19 or not – but it seems likely that they are. As the rest of
the airway is involved, and the nose and nasopharynx intensely so, it seems probable that the lining of
the eustachian tube, middle ear, and mastoid air cell system are all contaminated.
Many articles verify the presence of respiratory virus in the middle during acute illnesses. (see list
below) Two references specifically document coronavirus (not COVID-19 specific) in the middle ear
during URI. These viruses have affinity for respiratory mucosa and may populate the otic structures
either via direct mucosal spread or viremia.

Drilling through the mastoid creates droplets and aerosols in significant clouds which, if virus is present,
could risk infecting everyone in the operating room environment. As contaminated mists harbor viable
virus for several hours, especially in enclosed spaces, caution is warranted. For these reasons, I think we
should consider mastoidectomy to be a procedure of heightened risk. It may be relevant that infections
among OR staffs following transnasal endoscopic surgery which uses powered instruments (including
drills) that create plumes of droplets has been reported.

Ideally, we should test for COVID-19 preoperatively for any ear surgery and, if negative, proceed with
surgery using standard PPE (face shields and N95). Of course, we cannot entirely rule out early infections
with undetectable viral load or even false negative testing. If positive, surgery should be delayed until
the patient has cleared the disease. Hence the pre-procedure test as indicated in my view because it
would affect management.

In an ear surgical procedure, only a single surgeon need be in the room and all observers should be
excluded. This is important to reduce potential exposures, but also to limit use of PPE (eg N95 masks
and face screens). For educators, suggest making a video recording the surgery to share with trainees as
time permits.

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
Pitkäranta A, Virolainen A, Jero J, Arruda E, Hayden FG. Detection of rhinovirus, respiratory syncytial
virus, and coronavirus infections in acute otitis media by reverse transcriptase polymerase chain
reaction. Pediatrics. 1998 Aug;102(2 Pt 1):291-5.
Wiertsema SP, Chidlow GR, Kirkham LA, Corscadden KJ, Mowe EN, Vijayasekaran S, Coates HL, Harnett
GB, Richmond PC. High detection rates of nucleic acids of a wide range of respiratory viruses in the
nasopharynx and the middle ear of children with a history of recurrent acute otitis media. J Med Virol.
2011 Nov;83(11):2008-17. doi: 10.1002/jmv.22221.
Nokso-Koivisto J, Räty R, Blomqvist S, Kleemola M, Syrjänen R, Pitkäranta A, Kilpi T, Hovi T. Presence of
specific viruses in the middle ear fluids and respiratory secretions of young children with acute otitis
media. J Med Virol. 2004 Feb;72(2):241-8.
Heikkinen T, Thint M, Chonmaitree T. Prevalence of various respiratory viruses in the middle ear during
acute otitis media. N Engl J Med. 1999 Jan 28;340(4):260-4.

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