Guidance for undertaking otological procedures during COVID-19 pandemic
The following provides guidance for clinicians involved in the care of patients with otological
disease in light of the current COVID-19 pandemic. The situation is rapidly evolving and
guidance may change over time.
Mastoid surgery
1) Significant aerosolisation of bone and other tissues occurs during mastoid drilling1.
Whilst the main route of transmission of the COVID-19 virus is through the
respiratory system, there is some evidence of blood-borne transmission, although
this risk is likely to be low2,3. Similarly, there is evidence that corona viruses are
present in the epithelium of the middle ear during upper respiratory tract infections,
although there is no specific evidence, to date, in COVID-19 specifically4,5. As a result,
there may be a significant risk of viral transmission when undertaking this type of
surgery in patients infected with COVID-19 virus. It is not possible to prevent drill-
induced aerosolisation and although FFP3 masks prevent inhalation of particles,
standard eye protection may not adequately prevent ocular exposure. Mastoid
surgery should therefore be avoided unless there is a life-threatening urgency to
proceed.
2) Urgent indications may include:
acute mastoiditis
otogenic intracranial sepsis
operable temporal bone malignancy.
3) Vestibular schwannoma surgery should not be regarded as urgent unless there is
life-threatening brainstem compression. A retrosigmoid, rather than
translabyrinthine approach, should be used to minimise drill time, and exposure to
middle ear mucosa.
4) The duration of the COVID-19 pandemic period is unclear but, assuming a 3-month
period before normal practice can resume, cholesteatoma surgery and auditory
implantation, including in children, should not be regarded as urgent. Further
guidance will be offered in the event that ongoing precautions will be required
beyond 3 months.
5) Testing for COVID-19 is unlikely to be helpful as sensitivity of throat/nose swabs has
been reported to be as low as 32%. In addition, long turnaround times make testing
impractical. All patients should therefore be presumed to be positive.
6) If mastoid drilling is unavoidable, drilling should be kept to a minimum and PPE
including FFP3 mask, close fitting eye protection (glasses are preferable to a visor),
waterproof gown and gloves should be used as a minimum whilst not using the
microscope (subsequently referred to as full PPE).
7) Use of the microscope may offer some degree of eye protection during drilling but
drilling should still be kept to a minimum. If possible, the surgeon should continue to
wear eye protection.
8) Some clinicians may feel more comfortable using a hazmat suit with external
filtration if undertaking mastoid surgery, particularly if the patient is confirmed as
COVID-19 positive. The decision to use this level of protection lies with the clinician.
9) A rigid otoscope with camera may be used instead of the microscope, accepting the
limitations of single-handed surgery if the PPE equipment makes use of the
microscope difficult.
10) All unnecessary staff should leave theatre and those that remain should wear PPE as
above.
11) For acute mastoiditis, curettage should be carried out rather than mastoid drilling, if
possible.
12) If drilling is required, slowing drill speed, reducing irrigation volume and using
effective suction may reduce aerosolisation.
13) Good hypotension will minimise bleeding and may also reduce aerosolisation.
14) Surgery should be carried out by the most experienced otological surgeon available.
Other otology procedures
Most otology procedures should be deferred until after the COVID-19 pandemic has passed.
Urgent cases (e.g. biopsy of suspected neoplasia) will need to be assessed on a case-by-case
basis.
Full PPE as per mastoid surgery should be used.
Additional guidance for microsuction
Significant aerosolisation of biological materials may occur during microsuction, particularly
with fenestrated suction. The risk of COVID-19 transmission with microsuction is, however,
low, particularly with wax clearance in the absence of inflammation. Nevertheless, full PPE
as outlined above is recommended. Unfenestrated suction probably reduces the risk of
aerosolisation.
Steroid use for treatment of otological conditions
Within otological practice, steroids are commonly used to treat Meniere’s Disease, Sudden
Sensorineural Hearing Loss (SSNHL) and idiopathic facial palsy (Bell’s palsy).
Current opinion is that high dose steroid use, whether to manage Covid 19 infection or to
treat an unrelated condition, may be associated with a worse outcome6,7. The use of high
dose oral steroids is therefore not recommended to treat either Meniere’s Disease or
Sudden Sensorineural Hearing Loss (SSNHL). The systemic dose of steroid following intra-
tympanic treatment is significantly lower than that of oral treatment, and it is therefore
likely that the impact on COVID-19 outcomes will be less. It is therefore preferable to use
intra-tympanic steroid to treat these conditions. There is, however, no evidence base for
this assumption, and the potential impact on outcome of COVID-19 infection following intra-
tympanic steroid use should be discussed with the patient and informed consent obtained
prior to proceeding. Whether or not to proceed should be decided on a case-by-case basis.
If undertaking intra-tympanic treatments, it has been usual practice to ask the patient to
spit and not swallow for 20 minutes after the injection. This should be avoided during the
COVID-19 pandemic as spitting generates aerosol containing viruses.
In idiopathic facial palsy, the use of oral steroids should be discussed with the patient.
Evidence from the Scottish Bell’s Palsy study suggests that the use of oral steroids improves
recovery from 85% to 96%8. The potential risks and benefits of oral steroid use during the
current pandemic need to be made clear and a balanced decision made. For patients with
known COVID-19 infection the balance may weigh towards avoiding steroids. For those not
believed to be infected the balance of risk may weight towards treatment with steroids.
Necrotising Otitis Externa
The fundamental management of necrotising otitis externa should not be affected by
COVID-19. Patient’s should, however, have their peripherally inserted central venous
catheter inserted as early as possible and they should be discharged back to the community
as soon as possible.
1. Jewett et al. Blood-containing aerosols generated by surgical technique: A possible
infectious hazard. Am Ind Hyg Assoc J (1992) 53:228-31.
2. Zhang et al. Molecular and Serological Investigation of 2019-nCov infected patients.
Emerg Microbes Infect (2020) 9:386-389.
3. Chang et al. Coronavirus Disease 2019: Coronaviruses and blood safety. Transfus
Med Rev (2020).
4. Heikkinen et al. Prevalence of various respiratory viruses in the middle ear during
acute otitis media. N Eng J Med (1999) 340:260-4.
5. Wiertsema SP et al. 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 acute otitis media. J Med Virol (2011) 83:2008-17.
6. Russell et al. Clinical evidence does not support corticosteroid treatment for 2019-
nCoV lung injury. The Lancet (2020); 20:30317-2.
7. The Faculty of Pain Management guidelines.
8. Sullivan FM et al. A randomised controlled trial of the use of aciclovir and/or
prednisolone for the early treatment of Bell's palsy: the Bell’s study. Health Technol
Assess. 2009;13(47): iii–130.
Authors
Professor Peter Rea, Consultant ENT Surgeon, Leicester
Professor Simon Lloyd, Consultant ENT Surgeon, Manchester
Dr David Jenkins, Consultant Medical Microbiologist, Leicester
BSO Council.
23/3/2020
