Introduction
This study was considered exempt upon review by Vanderbilt IRB.
Since December of 2019, the ongoing global pandemic caused by the novel coronavirus (SARS-CoV-2) and associated coronavirus disease-2019 (COVID-19) has had wide-reaching effects on the American healthcare system and our ability to deliver routine surgical care. There is ample evidence that the virus is present in high quantities within the nasopharynx and oropharynx and that exposure to high viral loads, especially in the form of aerosol-generating procedures, can risk viral transmission to healthcare workers [ ]. As the middle ear is in continuity with the nasopharynx, it is presumed that the middle ear may contain viral particles which can be aerosolized during otologic procedures. This is particularly true with regards to procedures that require the use of a drill, which has been shown to cause significant aerosolization of bone, tissues, and middle ear fluid [ ]. Therefore, routine otologic surgeries including cochlear implantation that result in aerosolization via drilling have been limited or postponed in COVID-19-positive patients and patients with unknown viral status. The American Neurotology Society, American Otological Society, and American Academy of Otolaryngology – Head and Neck Surgery have recommended caution with aerosol generating procedures of the middle ear that have the potential to expose health care workers to dangerous levels of the virus [ ].
Despite these concerns, there is very little evidence demonstrating the presence and natural progression of SARS-CoV-2 within the middle ear to guide recommendations. We present a case of a 12-month-old female who persistently tested positive for COVID-19 who ultimately underwent bilateral cochlear implantation. Bilateral mastoid cavities were sampled intraoperatively and found to be negative for the presence of SARS-CoV-2 despite positive viral load sampled within the nasopharynx.
Case report
A 12-month-old female with progressive bilateral profound sensorineural hearing loss was scheduled for bilateral cochlear implantation, but tested positive for COVID-19 on routine pre-operative asymptomatic screening. Her surgery was delayed for 6 weeks according to institutional policy at that time. She remained asymptomatic during this period. However, a repeat nasopharyngeal swab was again positive at 6 weeks. After thorough discussion between the operative team and patient family, the decision was made to proceed with surgery with appropriate precautions for aerosol-generating procedures in a COVID-19-positive patient.
Intraoperatively, the bilateral mastoid cavities and nasopharynx were swabbed. Quantitative reverse transcription polymerase chain reaction (RT-qPCR) was performed on the samples according to US Centers for Disease Control and Vanderbilt University Medical Center protocols (primers and controls obtained from Integrated DNA Technologies, USA). Nasopharyngeal swab was mildly positive for the presence of viral load on RT-qPCR. The virus was not detected in either mastoid. Quantitative data is provided in Fig. 1 and Table 1 .
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