Covid-19 can remain in the middle ear effusion (MEE) long after infection


In this blog post, we will review a recent case series published in the European Archives of Oto-Rhino-Laryngology by Zhang et al. (2023) on COVID-19-related secretory otitis media in the omicron era.

Middle ear effusion (MEE) is a common condition that affects many children and adults. It occurs when fluid accumulates in the middle ear cavity, behind the eardrum. MEE can cause hearing loss, discomfort, and sometimes complications such as ear infections or chronic otitis media.

Causes of MEE

MEE is usually caused by a blockage or dysfunction of the eustachian tube, which is a narrow canal that connects the middle ear to the back of the nose. The eustachian tube helps to equalize the pressure and drain the fluid from the middle ear. When the eustachian tube is blocked by inflammation, infection, allergy, or tumor, the fluid cannot escape and builds up in the middle ear.

Some factors that increase the risk of MEE are:

  • Upper respiratory tract infections, such as colds or flu
  • Allergic rhinitis or sinusitis
  • Smoking or exposure to secondhand smoke
  • Adenoid hypertrophy or infection
  • Craniofacial anomalies, such as cleft palate or Down syndrome
  • Immune deficiency or chronic diseases

Symptoms and diagnosis of MEE

MEE may not cause any symptoms in some cases, especially if it is mild or transient. However, some common signs and symptoms of MEE are:

  • Hearing loss or muffled hearing
  • Ear fullness or pressure
  • Ear pain or discomfort
  • Tinnitus or ringing in the ear
  • Balance problems or dizziness
  • Fever or malaise (if infection is present)

To diagnose MEE, a doctor will examine the ear with an otoscope, which is a device that allows to see inside the ear canal and the eardrum. The doctor will look for signs of fluid behind the eardrum, such as:

  • A dull, gray, or yellowish eardrum
  • A bulging or retracted eardrum
  • Reduced mobility of the eardrum
  • Air bubbles or fluid level behind the eardrum

The doctor may also perform other tests to assess the function of the middle ear and the hearing ability, such as:

  • Tympanometry: a test that measures how well the eardrum moves when air pressure is applied to the ear canal
  • Acoustic reflectometry: a test that measures how much sound is reflected back from the eardrum when a tone is emitted into the ear canal
  • Audiometry: a test that measures how well a person can hear different frequencies and intensities of sound

Treatment and outcomes of MEE

The treatment of MEE depends on the severity, duration, and cause of the condition. Some possible treatment options are:

  • Watchful waiting: if MEE is mild and does not cause significant hearing loss or discomfort, it may resolve spontaneously within a few weeks or months. The doctor may recommend regular follow-up visits to monitor the condition and advise on home remedies such as nasal saline sprays, decongestants, antihistamines, or pain relievers.
  • Antibiotics: if MEE is caused by a bacterial infection, antibiotics may help to clear up the infection and reduce the inflammation. However, antibiotics are not effective for viral infections or non-infectious causes of MEE.
  • Steroids: if MEE is caused by allergy or inflammation, steroids may help to reduce the swelling and improve the function of the eustachian tube. Steroids can be given orally, intranasally, or by injection into the middle ear.
  • Myringotomy: if MEE persists for more than three months or causes severe hearing loss or complications, a surgical procedure called myringotomy may be performed. Myringotomy involves making a small incision in the eardrum and draining out the fluid from the middle ear. Sometimes, a small tube called a tympanostomy tube is inserted into the eardrum to keep it open and allow continuous drainage and ventilation of the middle ear. The tube usually falls out on its own after six to twelve months.
  • Adenoidectomy: if MEE is associated with enlarged or infected adenoids, removing them surgically may help to improve the function of the eustachian tube and prevent recurrent episodes of MEE.

The outcomes of MEE vary depending on the cause, duration, and treatment of the condition. Most cases of MEE resolve without any long-term consequences, but some possible complications are:

  • Permanent hearing loss or damage to the middle ear structures
  • Chronic otitis media with effusion (COME), which is a condition where MEE recurs or persists for more than three months
  • Chronic suppurative otitis media (CSOM), which is a condition where MEE becomes infected and causes pus discharge from the ear
  • Cholesteatoma, which is a growth of skin cells in the middle ear that can erode the bones and cause hearing loss, facial paralysis, or brain infection
  • Mastoiditis, which is an infection of the mastoid bone behind the ear that can cause swelling, pain, fever, or brain abscess

Prevention of MEE

Some strategies to prevent MEE or reduce its recurrence are:

  • Avoiding or treating upper respiratory tract infections, allergies, or sinusitis
  • Avoiding smoking or exposure to secondhand smoke
  • Breastfeeding infants for at least six months
  • Vaccinating children against pneumococcal and influenza infections
  • Using nasal saline sprays or humidifiers to moisten the nasal passages
  • Blowing the nose gently and avoiding forceful nose blowing
  • Performing the Valsalva maneuver (pinching the nose and blowing gently) or chewing gum to equalize the pressure in the ears during air travel or altitude changes

Secretory otitis media, also known as otitis media with effusion, is a condition where fluid accumulates in the middle ear behind the eardrum, causing hearing loss, ear pain, and sometimes infection. It is usually associated with viral upper respiratory tract infections, such as the common cold or influenza.

However, since the emergence of the SARS-CoV-2 omicron variant, which is more transmissible and causes more severe symptoms than previous variants, there has been an increase in the number of patients with secretory otitis media in some regions. Zhang et al. (2023) investigated whether SARS-CoV-2 can infect the middle ear and cause secretory otitis media by performing tympanocentesis (a procedure where a small needle is inserted into the eardrum to drain the fluid) and testing the middle ear effusion (MEE) and nasopharyngeal secretions for SARS-CoV-2 RNA using RT-PCR.

They enrolled 30 patients with secretory otitis media who had a history of SARS-CoV-2 infection confirmed by antigen testing or contact tracing.

They found that 5 out of 30 patients (16.7%) had positive RT-PCR results for SARS-CoV-2 in their MEE, including one patient who also had positive results in their nasopharyngeal secretion. They reported and discussed the clinical features, treatment, and outcomes of these 5 MEE-positive patients and one MEE-negative patient as case studies.

The main findings of their study were:

  • SARS-CoV-2 can infect the middle ear and cause secretory otitis media even when the nasopharyngeal secretion tests negative for SARS-CoV-2.
  • The virus can persist in the MEE for a long time after SARS-CoV-2 infection, up to 40 days in one case.
  • The symptoms of secretory otitis media may be mild or nonspecific, such as hearing loss, tinnitus, or ear fullness, and may be overlooked by patients or clinicians.
  • The treatment of secretory otitis media caused by SARS-CoV-2 may include antibiotics, antivirals, steroids, decongestants, and tympanocentesis. However, the optimal treatment regimen and duration are unclear and need further research.
  • The prognosis of secretory otitis media caused by SARS-CoV-2 is generally good, with most patients recovering within 2 weeks after tympanocentesis. However, some patients may have residual hearing loss or recurrent episodes.

This study provides valuable insights into the pathogenesis, diagnosis, management, and prognosis of COVID-19-related secretory otitis media in the omicron era. It also raises awareness of this potential complication of SARS-CoV-2 infection among otolaryngologists and other health care professionals.

However, there are some limitations of this study, such as the small sample size, the lack of a control group, and the use of a single RT-PCR kit for testing. Therefore, more studies are needed to confirm and expand these findings and to explore the mechanisms and risk factors of SARS-CoV-2 infection in the middle ear.

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