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\begin{document}

\title{Otitis Media in COVID-19: A Case Series}



\author[1]{Mahboobeh Karimi-Galougahi}%
\author[1]{Nasim Raad}%
\author[1]{Jahangir Ghorbani}%
\author[1]{Narges Mikaniki}%
\author[1]{Sara Haseli}%
\affil[1]{National Research Institute of Tuberculosis and Lung Disease}%


\vspace{-1em}



  
  \date{May 16, 2024}


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\selectlanguage{english}
\begin{abstract}
Key points 1- We report otitis media in eight patients with coronavirus
disease-2019 (COVID-19) and no background history of otologic problems.
2- Otitis media was the first manifestation of COVID-19 in the majority
of patients in this case series. 3- Effusion in the middle ear was
present in six patients, three patients had typical signs of acute
otitis media, with one patient having tympanic membrane perforation. 4-
Hearing loss was present in majority of patients, with conductive and
mild sensory-neural loss at high frequency as the underlying mechanisms.
5- Our findings suggest that otitis media should be considered a
possible manifestation of COVID-19 during the current pandemic.%
\end{abstract}%



\sloppy


\textbf{Otitis Media in COVID-19: A Case Series}

\textbf{Word count:} 1,322

\textbf{Conflict of interest:} the authors report no competing interests

\textbf{Key points}

\begin{enumerate}
\tightlist
\item
  We report otitis media in eight patients with coronavirus disease-2019
  (COVID-19) and no background history of otologic problems.
\item
  Otitis media was the first manifestation of COVID-19 in the majority
  of patients in this case series.
\item
  Effusion in the middle ear was present in six patients, three patients
  had typical signs of acute otitis media, with one patient having
  tympanic membrane perforation.
\item
  Hearing loss was present in majority of patients, with conductive and
  mild sensory-neural loss at high frequency as the underlying
  mechanisms.
\item
  Our findings suggest that otitis media should be considered a possible
  manifestation of COVID-19 during the current pandemic.
\end{enumerate}

\textbf{Introduction:}

Coronavirus disease-2019 (COVID-19) often manifests with a spectrum of
symptoms, most commonly fever, cough, myalgia, fatigue, and shortness of
breathe(1). Ear, nose, and throat symptoms, including sore throat,
rhinorrhea, anosmia and dysgeusia, vertigo, and hearing loss have also
been reported(1,2). In the current study, we present a series of
patients with no background history of otologic problems who presented
with otitis media and conductive hearing loss in the context of
confirmed COVID-19.

\textbf{Case Studies}

\textbf{Patient 1.} A 38-year-old man with ``the worst cold of his life
for the past 2 weeks'' presented with chronic nonproductive cough and
mild dyspnea on exertion. Additionally, he complained of hearing loss
and a sense of pressure in his ears. The physical exam revealed
bilateral coarse crackle and wheezing on lung auscultation, and tympanic
membrane bulging and purulent effusion on otoscopy. Bilateral
consolidations with bronchiolectasis in peripheral locations were
identified in organizing pneumonia pattern on spiral non-contrast
computed tomography (CT) of both lungs. Polymerase chain reaction (PCR)
assay on sample from oropharyngeal swab was positive for COVID-19. He
received outpatient treatment and all the symptoms resolved except for
anosmia.

\textbf{Patient 2.} A 35-year-old woman presented with sudden-onset
anosmia for the past 7 days. The head and neck exam revealed no sign of
nasal congestion or discharge, however bilateral middle ear effusion was
noted. There were coarse crackles on the upper left lung lobe, in the
absence of any dyspnea. CT of the lungs revealed consolidation in the
lingula. COVID-19 was confirmed on the PCR assay of nasopharyngeal swab.

\textbf{Patient 3.} A 35-year-old woman working in the laboratory of a
COVID-19-designated hospital presented with chronic cough, moderate to
severe respiratory distress and bilateral pulmonary changes
characteristic of COVID-19 on CT, with COVID-19 confirmed with positive
PCR assay. She complained of unilateral earache and hearing loss, and
otoscopic exam showed a distinctly red tympanic membrane (Figure 1).

\textbf{Patient 4.} A 20-year-old woman presented with left-sided ear
pain and hearing loss. Ear examination showed effusion in the left
middle ear and air-fluid level. The tympanic membrane was severely
bulged and predisposed to perforation (Figure 2)\textbf{.} On coronal
views of high-resolution CT (HRCT) of temporal bones, opacification of
the left middle air cavity was noted (Figure 2). She had a recent close
contact with a family member with COVID19 but reported no other
symptoms, and physical exam was otherwise normal. CT chest was normal.
She underwent myringotomy. PCR on samples from oropharyngeal swab was
negative, nonetheless the PCR performed on the middle ear fluid was
positive for COVID-19.

\textbf{Patient 5.} A 22-year-old woman presented with nonproductive
cough, left-sided ear pain, aural fullness, hearing loss and sensation
of ear popping. Otoscopic exam showed decreased mobility of the left
tympanic membrane with bulging contour and hypervascularity and purulent
middle ear effusion. Audiogram revealed conductive hearing loss (15 dB)
on the left side, with mild sensory-neural hearing loss at high
frequency (Figure 3). Axial images on HRCT of the temporal bones
revealed opacification of the left middle air cavity, suggestive of
otitis media (Figure 3). PCR on oropharyngeal swab was negative but was
positive for COVID-19 PCR on nasopharyngeal swab.

\textbf{Patient 6.} A 25-year-old woman with nonproductive cough for the
past 3 weeks presented with right-sided hearing loss and otalgia.
Otoscopic exam showed serous otitis media with decreased tympanic
membrane movement. There were mixed coarse and fine crackles on
auscultation of the right lung. HRCT of the lungs confirmed right-sided
foci of ground-glass opacity consistent with viral pneumonia. PCR assay
performed on the oropharyngeal and nasopharyngeal swabs was positive for
COVID-19.

\textbf{Patient 7.} A 22-year-old woman presented with sudden loss of
smell and taste and left-sided otalgia and hearing loss for the past
week. Otoscopic exam shows typical signs of otitis media with effusion
and air-fluid level. She had a unilateral C type tympanogram. Axial
non-contrast CT of lungs showed patchy foci of ground-glass opacities in
the right upper lobe. PCR assay performed on the oropharyngeal swab was
positive for COVID-19.

\textbf{Patient 8.} A 45-year-old woman presented with severe acute
otalgia, ear fullness and hearing loss. Ear examination revealed a new
central perforation with purulent otorrhea (Figure 4). She had a mild
cough but no dyspnea, with bilateral coarse crackles on auscultation of
the lungs. Axial non-contrast CT chest revealed bilateral patchy
ground-glass opacities in the peripheries of the lower lobes.

\textbf{Discussion}

In this case series, we report otitis media as a new manifestation of
COVID-19. Otitis media or inflammation of the middle ear is a general
term that is further categorized to acute otitis media (AOM), otitis
media with effusion (OME), and chronic suppurative otitis media
(CSOM)(3).

Our case series includes 8 patients presenting over a two-months period
during the COVID-19 pandemic. Six out of the eight patients had otalgia,
with seven patients having hearing loss. Effusion in the middle ear was
evident on otoscopic examination in six patients. Three patients had
typical signs of AOM, with one patient having AOM with tympanic membrane
perforation. Two patients had smell dysfunction. COVID-19 was confirmed
by typical changes on CT chest and positive PCR assay on naso- or
oropharyngeal swabs. Interestingly, in one patient, PCR assay was
positive on middle ear effusion and negative on oropharyngeal swab.

We suggest that concomitant occurrence of otitis media in these patients
could be a manifestation or complication of COVID-19. AOM and OME follow
a seasonal pattern, with the incidence being the highest during the fall
and winter and lowest during spring and summer in parallel to the
incidence of upper respiratory infections(3). Our patients presented
with otitis media in the second and third months of spring when of a low
incidence of otitis media is expected. In addition, AOM and OME are most
common in the young children(3), while all patients in this case series
were adults without any pathology in the nasopharynx.

Viruses, including respiratory syncytial virus, rhinovirus, adenovirus,
coronavirus, bocavirus, influenza virus, parainfluenza virus,
enterovirus and human metapneumovirus, are known causes of upper
respiratory infections and can induce AOM(3). Viruses can be the sole
infective cause of AOM or play a role as co-infection with bacteria and,
rarely, with other viruses(4). Viral infections can disrupt immune
function and reduce the normal mucociliary clearance of mucosal cells by
changing the properties of the nasopharyngeal mucus and the Eustachian
tube leading to negative middle ear pressure(3). Negative middle ear
pressure in turn predisposes the middle ear to effusion formation or
secondary bacterial or viral infection(4).

Angiotensin-converting enzyme-2 (ACE2) receptor is the cellular entry
route for SARS-CoV-2. High levels of ACE2 receptors are expressed in the
nasal respiratory epithelium goblet, basal and ciliated cells(5).
Because of the enriched populations of the ciliated cells, glands and
goblet cells in the inferior part of the Eustachian tube(6), we suggest
that this portion of the tube can be a route for SARSCoV-2 infection of
the middle ear.

\textbf{Conclusions}

To the best of our knowledge, only a single case of otitis media in the
setting of COVID-19 has thus-far been reported(7). The current study
presents the largest series of patients with otitis media in COVID-19.
Interestingly, with the exception of one patient, otitis media was the
first manifestation of COVID-19 in this case series. Thus, we recommend
that during the current pandemic, presence of otitis media should alert
the clinicians to the possibility of COVID-19.

\textbf{References}

\begin{enumerate}
\tightlist
\item
  Chen N, Zhou M, Dong X, Qu J, Gong F, Han Y, Qiu Y, Wang J, Liu Y, Wei
  Y, Yu T. Epidemiological and clinical characteristics of 99 cases of
  2019 novel coronavirus pneumonia in Wuhan, China: a descriptive study.
  The Lancet. 2020 Feb 15;395(10223):507-13.
\item
  Karimi-Galougahi M, Naini AS, Raad N, Mikaniki N, Ghorbani J. Vertigo
  and hearing loss during the COVID-19 pandemic-is there an
  association?. ACTA Otorhinolaryngologica Italica. 2020 Jun 10.
\item
  Schilder AG, Chonmaitree T, Cripps AW, Rosenfeld RM, Casselbrant ML,
  Haggard MP, Venekamp RP. Otitis media. Nature Reviews Disease Primers.
  2016 Sep 8;2(1):1-8.
\item
  Buchman CA, Brinson GM. Viral otitis media. Current allergy and asthma
  reports. 2003 Aug 1;3(4):335-40.
\item
  Sungnak W, Huang N, B\selectlanguage{ngerman}écavin C, Berg M, Network HC. SARS-CoV-2 entry
  genes are most highly expressed in nasal goblet and ciliated cells
  within human airways. arXiv preprint arXiv:2003.06122. 2020 Mar 13.
\item
  Sando I, Aoki H, Takahashi H, Matsune S. Mucosal folds in human
  eustachian tube: a hypothesis regarding functional localization in the
  tube. Annals of Otology, Rhinology \& Laryngology. 1993
  Jan;102(1):47-51.
\item
  Fidan V. New type of corona virus induced acute otitis media in adult.
  American Journal of Otolaryngology. 2020 Apr 16:102487.
\end{enumerate}

\textbf{Figures}\selectlanguage{english}
\begin{figure}[H]
\begin{center}
\includegraphics[width=0.70\columnwidth]{figures/image1/image1}

\end{center}
\end{figure}

\textbf{Figure 1. Erythema of the tympanic membrane in a 35-year-old
woman with COVID-19.}\selectlanguage{english}
\begin{figure}[H]
\begin{center}
\includegraphics[width=0.70\columnwidth]{figures/image2/image2}

\end{center}
\end{figure}

\textbf{Figure 2. A. Effusion in middle ear on otoscopy. B.
Opacification of the left middle air cavity (arrow) coronal images on
HRCT of the temporal bones.} PCR assay of the middle ear fluid was
positive for COVID-19.\selectlanguage{english}
\begin{figure}[H]
\begin{center}
\includegraphics[width=0.70\columnwidth]{figures/image3/image3}

\end{center}
\end{figure}

\textbf{Figure 3. A. Audiogram revealing left-sided conductive hearing
loss, with mild sensory-neural loss at high frequency. B- Axial HRCT of
temporal bones revealed opacification of the left middle air cavity
(arrow), indicating otitis media.} PCR assay of nasopharyngeal swab was
positive for COVID-19.\selectlanguage{english}
\begin{figure}[H]
\begin{center}
\includegraphics[width=0.70\columnwidth]{figures/image4/image4}

\end{center}
\end{figure}

\textbf{Figure 4. Acute otitis media with central tympanic membrane
perforation in a 45-year-old woman with COVID-19.}

\textbf{Hosted file}

\verb`Figures.docx`  available at \url{https://authorea.com/users/340083/articles/467204-otitis-media-in-covid-19-a-case-series}

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