The severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) virus and associated coronavirus disease 2019 (COVID-19) disease pandemic have rapidly spread around the world since December 2019. The high rate of droplet spread can endanger healthcare workers during procedures of the aerodigestive tract,1 particularly affecting otolaryngologists. Although there are no human data relating to the SARS-CoV-2 virus in the middle ear, the recommendations to mitigate these risks include precautions for middle ear and mastoid surgery, because middle ear effusions have been shown to contain some non–SARS-CoV-2 coronaviruses. Frazier, et al. (2020) present confirmation of SARS-CoV-2 colonization of the middle ear and mastoid in two of three patients.

The Johns Hopkins Hospital research autopsy program4 includes institutional review board-approved autopsy of COVID-19–positive (nasal swab, Cepheid GeneXpert SARS-CoV-2 assay) decedents, subject to safety limitations including avoidance of powered instrumentation. Three decedents were selected, and each underwent bilateral cortical mastoidectomy and exposure of the aditus using osteotomes and curettes. Mastoid specimens included the bone and mucosa were obtained by curettage. The middle ear specimens were obtained using three cytobrush swabs (Cobas polymerase chain reaction [PCR] medial dual swab, Roche). Specimens were stored in RNA media (RNAlater, Invitrogen). Nucleic acid extraction and amplification was performed per protocol. Specimens were vortexed vigorously for 30 seconds with 500 uL extracted using the BioMerieux easyMAG platform, and specimens were eluted in 50 uL volume. Real-time reverse transcriptase-PCR was performed using the Centers for Disease Control panel assay.

All three patients were COVID-19 positive and met SARS criteria (Table). Each sample was assayed for the N1, N2, and internal control target genes (Figure). For case 3, all samples were positive with cycle thresholds ranging from 24 to 36. Two of the 3 patients tested positive for SARS-CoV-2 virus in the mastoid or middle ear, with viral isolation from 2 of 6 mastoids and 3 of 6 middle ears. Results for case 1 were positive for the right middle ear only. Case 2 had negative results for all samples.

Reference: Frazier KM, et al. 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