Middle Ear Viral Load Considerations in the COVID-19 Era: A Systematic Review

Detection of SARS-CoV-2 virus in middle ear effusions and its association with otitis media with effusion

A large-scale outbreak of Severe Acute Respiratory Syndrome Coronavirus 2 (SARS-CoV-2) occurred in Shanghai, China, in early December 2022. To study the incidence and characteristics of otitis media with effusion (OME) complicating SARS-CoV-2, we collected 267 middle ear effusion (MEE) samples and 172 nasopharyngeal (NP) swabs from patients. The SARS-CoV-2 virus was detected by RT-PCR targeting. The SARS-CoV-2 virus, angiotensin-converting enzyme 2 (ACE2), and transmembrane serine protease 2 (TMPRSS2) expression in human samples was examined via immunofluorescence. During the COVID-19 epidemic in 2022, the incidence of OME (3%) significantly increased compared to the same period from 2020 to 2022. Ear symptoms in patients with SARS-CoV-2 complicated by OME generally appeared late, even after a negative NP swab, an average of 9.33 ± 6.272 days after COVID-19 infection. The SARS-CoV-2 virus was detected in MEE, which had a higher viral load than NP swabs. The insertion rate of tympanostomy tubes was not significantly higher than in OME patients in 2019-2022. Virus migration led to high viral loads in MEE despite negative NP swabs, indicating that OME lagged behind respiratory infections but had a favorable prognosis. Furthermore, middle ear tissue from adult humans coexpressed the ACE2 receptor for the SARS-CoV-2 virus and the TMPRSS2 cofactors required for virus entry.

SARS-CoV-2 in the Middle Ear-CovEar: A Prospective Pilot Study

In post-mortem analyses, SARS-CoV-2 was found in the middle ear of some, but not all, patients with COVID-19. It is not clear whether SARS-CoV-2 penetrated the ear passively post mortem, or existed in the middle ear of living patients during, and perhaps also after, infection. This study investigated whether SARS-CoV-2 can be found in the middle ear of living patients during ear surgery. Swabs from the nasopharynx, the filter connected to the tracheal tube and secretions from the middle ear were collected during middle ear surgery. All samples were tested for the presence of SARS-CoV-2 using PCR. History of vaccination, COVID-19 history and contact with SARS-CoV-2-positive individuals were recorded preoperatively. Postoperative SARS-CoV-2 infection was noted at the follow-up visit. Overall, 63 participants (62%) were children and 39 (38%) were adults. SARS-CoV-2 was found in the middle ear and in the nasopharynx of two and four CovEar study participants, respectively. The filter connected to the tracheal tube was sterile in all cases. Cycle threshold (ct) values of the PCR test were between 25.94 and 37.06. SARS-CoV-2 penetrated the middle ear of living patients and was found in asymptomatic patients. The presence of SARS-CoV-2 in the middle ear may have implications for ear surgery and can pose a risk of infection for operating room staff. It may also directly affect the audio-vestibular system.

Sinus, middle-ear and mastoid radiological findings of severe acute respiratory syndrome coronavirus-2

OBJECTIVE

To assess the incidence of radiological inflammation within the paranasal sinuses, middle ear and mastoid in patients with confirmed severe acute respiratory syndrome coronavirus-2.

METHODS

A retrospective cohort study was conducted to examine consecutive adults (aged over 18 years) with coronavirus disease 2019 (confirmed on polymerase chain reaction within 7 days of imaging) who underwent computed tomography of the head between 1 March 2020 and 24 June 2020. Lund-Mackay and mastoid and middle-ear opacification scores were used to categorise the extent of sinus and mastoid opacification on axial and coronal computed tomography images.

RESULTS

Of 147 patients originally identified, only 83 met the inclusion criteria. Sinus opacification was present in 51.8 per cent of patients (n = 43), and middle-ear or mastoid opacification was observed in 24.1 per cent (n = 20). There was no statistically significant difference in sinus or middle-ear and mastoid opacification between patients after stratification based on 30-day all-cause mortality.

CONCLUSION

Radiological computed tomography findings suggest mild mucosal disease within the sinuses, middle ear and mastoid. There was no statistical correlation between such opacification and 30-day mortality.

Aerosol Generation During Otologic Surgery

OBJECTIVE

To assess whether aerosol generation occurs during otologic surgery, to define which instruments are aerosol generating, and to identify factors that enhance safety in protection against airborne pathogens, such as severe acute respiratory syndrome coronavirus 2.

STUDY DESIGN

An observational prospective study on aerosol measurements during otologic operations recorded between August and December 2020.

SETTING

Aerosol generation was measured with an Optical Particle Sizer as part of otologic operations with anesthesia. Particles with a size range of 0.3 to 10 μm were quantified. Aerosol generation was measured during otologic operations to analyze aerosols during drilling in transcanal and transmastoid operations and when using the following instruments: bipolar electrocautery, laser, suction, and cold instruments. Coughing is known to produce significant concentration of aerosols and is commonly used as a reference for high-risk aerosol generation. Thus, the operating room background concentration and coughing were chosen as reference values.

PATIENTS

Thirteen otologic operations were included. The average drilling time per surgery was 27.00 minutes (range, 2.00-71.80 min).

INTERVENTION

Different rotation speeds during drilling and other instruments were used.

MAIN OUTCOME MEASURES

Aerosol concentrations during operations were recorded and compared with background and cough aerosol concentrations.

RESULTS

Total aerosol concentrations during drilling were significantly higher than background ( p < 0.0001, d = 2.02) or coughing ( p < 0.0001, d = 0.50). A higher drilling rotation speed was associated with higher particle concentration ( p = 0.037, η2 = 0.01). Aerosol generation during bipolar electrocautery, drilling, and laser was significantly higher than with cold instruments or suction ( p < 0.0001, η2 = 0.04).

CONCLUSION

High aerosol generation is observed during otologic surgery when drill, laser, or bipolar electrocautery is used. Aerosol generation can be reduced by using cold instruments instead of electric and keeping the suction on during aerosol-generating procedures. If drilling is required, lower rotation speeds are recommended. These measures may help reduce the spread of airborne pathogens during otologic surgery.

Mapping the global literature output on nocturia: A bibliometric and visualized analysis

PURPOSE

This study aims to facilitate researchers' and clinicians' understanding of research frontiers and trends in nocturia. It explores the scientific research outcomes and key bibliometric indices and plots global research on nocturia.

METHODS

A bibliometric retrospective study was designed, and an online search was conducted in the Web of Science Core Collection database using the potential search keywords related to nocturia in the title field with some specific filtration. HistCite™ and VOSviewer software for windows were used to analyze the data obtained for authors, journals, countries, institutions, keywords, and visualization mapping.

RESULTS

The initial search retrieved 1479 hits. A total of 1445 publications were included in the final analysis. Of these, 43.53% were published as articles. The most studied area in nocturia is urology nephrology. The most productive year was 2019 (n = 121, citations = 335), and the most prolific author, both in terms of publications (n = 97) and citations (1658) was Weiss JP. The most cited journal in nocturia research was the Journal of Urology (n = 293, citations = 3050). The most widely used keyword in nocturia publications was nocturia (n = 1249). Visualization mapping shows that the USA was the most influential and highly cited country in nocturia research.

CONCLUSION

This study showed that there has been an increasing research trend in nocturia over the past few years. The current findings provide important empirical evidence for researchers, clinicians, and physicians to understand research frontiers and trends, achievements, collaborative networks, and hotspot research topics in the research field of nocturia.

Estimating population-based incidence of community-acquired pneumonia and acute otitis media in children and adults in Ontario and British Columbia using health administrative data, 2005-2018: a Canadian Immunisation Research Network (CIRN) study

Background

There is a paucity of data on the burden of the full spectrum of community-acquired pneumonia (CAP) and acute otitis media (AOM) from outpatient and inpatient settings across the age spectrum.

Methods

We conducted a population-based retrospective study in Ontario and British Columbia (BC), Canada, to estimate the incidence rate of CAP and AOM in children and adults over a 14-year period using health administrative databases. CAP and AOM cases were identified from outpatient physician consultation and hospitalisation data in both provinces, and from emergency department visit data in Ontario.

Results

During 2005–2018, Ontario had 3 607 124 CAP, 172 290 bacterial CAP, 7814 pneumococcal pneumonia, and 8 026 971 AOM cases. The incidence rate of CAP declined from 3077/100 000 in 2005 to 2604/100 000 in 2010 before increasing to 2843/100 000 in 2018; bacterial CAP incidence rate also declined from 178/100 000 in 2005 to 112/100 000 in 2010 before increasing to 149/100 000 in 2018. The incidence rate of AOM decreased from 4192/100 000 in 2005 to 3178/100 000 in 2018. BC had 970 455 CAP, 317 913 bacterial CAP, 35 287 pneumococcal pneumonia and 2 022 871 AOM cases. The incidence rate of CAP in BC decreased from 2214/100 000 in 2005 to 1964/100 000 in 2010 before increasing to 2176/100 000 in 2018; bacterial CAP incidence rate increased from 442/100 000 in 2005 to 981/100 000 in 2018. The incidence rate of AOM decreased from 3684/100 000 in 2005 to 2398/100 000 in 2018. The incidence rate of bacterial CAP increased with age in older adults (≥65 years) with the highest burden in the oldest cohort aged ≥85 years both before and after 13-valent pneumococcal conjugate vaccine (PCV13) programme in both provinces. Hospitalised pneumococcal pneumonia decreased slightly but non-hospitalised pneumococcal pneumonia increased in BC during PCV13 period. No consistent direct benefit of PCV13 on CAP was observed in the paediatric population.

Conclusions

There is a substantial burden of CAP and AOM in Ontario and BC. Indirect benefits from childhood PCV vaccination and polysaccharide vaccination of older adults have not substantially decreased the burden of pneumococcal pneumonia in older adults.

Impact of the COVID-19 pandemic on acute otolaryngology inpatient activity at a tertiary referral centre: a retrospective analysis

Objective

To determine the impact of the COVID‐19 pandemic on acute admissions and inpatient activity at a tertiary referral centre.

Design

Retrospective review of coding‐based inpatient electronic records.

Setting

An otolaryngology and head and neck surgery department at a major UK trauma and tertiary referral centre.

Participants

Otolaryngology patients admitted as an emergency over a period of 10 months pre‐COVID19 (01/04/2019‐23/01/2020) and 10 months post‐COVID19 (01/04/2020‐23/01/2021).

Main outcome measures

Baseline characteristics, admission rates, length of stay (LoS), overall mortality and 30‐day mortality.

Results

A total of 1620 records were reviewed; (1066 pre‐COVID19, 554 post‐COVID19). Admissions across all age groups were reduced, with an increase in mean age from 39.88 to 47.4 years (p = .018). LoS remained unchanged (3.85 vs 3.82 days, p = .160). Infection remained the most common presentation, followed secondly by epistaxis which entailed an increased LoS compared to the pre‐COVID19 cohort. GP referrals reduced from 18.3% to 4.2% (n = 195 vs n = 23, p < .001) and ED referrals proportionally increased from 71.9% to 85.9% (n = 766 vs n = 476, p < .001). Critical care admissions were higher in the post‐COVID19 cohort (OR 1.78 (1.07–2.98) [95% CI], p = .027).

There was no significant difference in overall mortality between groups (n = 60, 5.6% vs. n = 33, 6.0%; p = .844). Thirty‐day mortality increased from 0.9% (n = 12) pre‐COVID19 to 2.3% (n = 13) post‐COVID19 (p = .039).

Conclusions

This study demonstrates significant changes and a reduction in acute otolaryngology presentations. Our findings may suggest that sicker, frailer patients were admitted during the pandemic. This study reports the observational effect that the pandemic has had on acute otolaryngology admissions, which may be relevant in addressing unmet care needs in the post‐pandemic period.

Otitis Media Practice During the COVID-19 Pandemic

The global coronavirus disease-2019 (COVID-19) pandemic has changed the prevalence and management of many pediatric infectious diseases, including acute otitis media (AOM). Coronaviruses are a group of RNA viruses that cause respiratory tract infections in humans. Before the COVID-19 pandemic, coronavirus serotypes OC43, 229E, HKU1, and NL63 were infrequently detected in middle ear fluid (MEF) specimens and nasopharyngeal aspirates in children with AOM during the 1990s and 2000s and were associated with a mild course of the disease. At times when CoV was detected in OM cases, the overall viral load was relatively low. The new severe acute respiratory syndrome coronavirus-2 (SARS-CoV-2) is the causative pathogen responsible for the eruption of the COVID-19 global pandemic. Following the pandemic declaration in many countries and by the World Health Organization in March 2020, preventive proactive measures were imposed to limit COVID-19. These included social distancing; lockdowns; closure of workplaces; kindergartens and schools; increased hygiene; use of antiseptics and alcohol-based gels; frequent temperature measurements and wearing masks. These measures were not the only ones taken, as hospitals and clinics tried to minimize treating non-urgent medical referrals such as OM, and elective surgical procedures were canceled, such as ventilating tube insertion (VTI). These changes and regulations altered the way OM is practiced during the COVID-19 pandemic. Advents in technology allowed a vast use of telemedicine technologies for OM, however, the accuracy of AOM diagnosis in those encounters was in doubt, and antibiotic prescription rates were still reported to be high. There was an overall decrease in AOM episodes and admissions rates and with high spontaneous resolution rates of MEF in children, and a reduction in VTI surgeries. Despite an initial fear regarding viral shedding during myringotomy, the procedure was shown to be safe. Special draping techniques for otologic surgery were suggested. Other aspects of OM practice included the presentation of adult patients with AOM who tested positive for SARS-2-CoV and its detection in MEF samples in living patients and in the mucosa of the middle ear and mastoid in post-mortem specimens.

Evidence of SARS-CoV-2 Virus in the Middle Ear of Deceased COVID-19 Patients

The presence of SARS-CoV-2 in the middle ear reveals the etiopathogenesis of otitis media in COVID-19, as well as an epidemiological risk during otologic examination and surgical procedures in COVID-19 patients. The study included 8 deceased patients with COVID-19. Tissue samples from the middle ear were subjected to virology, histopathology, scanning (SEM) and transmission (TEM) electron microscopy investigation. Ethmoidal mucosa samples were processed for virology analyses. qPCR resulted positive for 75% of nasal mucosa samples and 50% of middle ear samples. Ct values showed lower viral loads in middle ear samples. A proportion of 66.6% patients with positive results in the nasal mucosa showed positive results in the middle ear, and the subtype analysis of the complete genome sequences indicated B.1.1.7 lineage for all samples. In histopathological and SEM samples, no pathological aspects were identified. TEM revealed on the background of death critical alteration of cellular morphology, suggestive structures resembling SARS-CoV-2, goblet cells and immune cells. SARS-CoV-2 can be present in the middle ear of COVID-19 patients even if there is not clinical evidence of acute otitis media. Otolaryngologists could be particularly exposed to COVID-19 infection.

Respiratory viruses in the healthy middle ear and middle ear with otitis media with effusion

To investigate the presence of respiratory viruses in the middle ear cavity of the individuals with a healthy middle ear and the children with otitis media with effusion (OME). A total of 72 middle ear samples were collected from 25 children with OME (Group 1) and 47 individuals with no middle ear disease (Group 2). Multiplex real-time polymerase chain reaction was used to investigate the presence of 20 different respiratory viruses. Virus results were compared with bacteriomes of the same populations. At least one respiratory virus was detected in 56% of the patients in Group 1 and 12.8% of the individuals in Group 2. The viral co-infection rate for Group 1 and 2 was 8% and 2.1%, respectively. In Group 1, adenovirus was the most frequently detected virus with a rate of 24%, either alone (16%) or concurrent with other viruses (8%), followed by influenza B (12%), rhinovirus, and bocavirus (8%) each. Parainfluenza 4, coronavirus OC43, and RSV A/B were detected in 4% of the sample each. In Group 2, rhinovirus was detected in two samples (4.3%) followed by adenovirus, coronavirus OC43, coronavirus E299, and coronavirus NL63 with a rate of 2.1% each. The detection rate of respiratory viruses was significantly higher in children aged 6 to 11 years. There was no positive association between virus and bacteria found in the middle ear cavity. The current study has provided comprehensive data indicating the presence of diverse respiratory viruses in the healthy middle ear cavity. Our results also suggest that respiratory viruses might have a contribution to OME pathogenesis.