The Laryngoscope
Lippincott Williams & Wilkins, Inc.
© 2005 The American Laryngological,
Rhinological and Otological Society, Inc.
Mastoidectomy and Trans-Corneal Viral
Transmission
Ali Hilal, FRCSI(OTO); Peter Walshe, FRCSI (ORL); Samir Gendy, FRCSI (OTO);
Susan Knowles, MRCPI; Hugh Burns, FRCSI(ORL)
The incidence of chronic middle ear disease is
falling in Britain, and in adults, is currently approxi-
mately 2.6% (inactive) and 1.5% (active). The inci-
dence of HIV and hepatitis C is, however, rising. With
this in mind, the chances of operating on a patient
with undiagnosed infection is increasing. Operations
involving the drilling or cutting of bone in patients
with bloodborne communicable diseases are inher-
ently dangerous to surgeons. In the pre-antibiotic era,
many orthopaedic surgeons succumbed to infection
and septicemia after being pierced with a spicule of
bone during the execution of their duty. With the
advent of the antibiotic era, the phenomenon is no
longer life threatening where a bacterium is the of-
fending microorganism. The principle, however, may
be just as valid today with regard to viral communi-
cable diseases. The world medical literature is full of
reports of transmission of HIV from doctor to patient
or dentist to patient. Very little is written about the
reverse. This study attempted to address the appar-
ent imbalance in the debate over exactly who is most
at risk of iatrogenic transmission of potentially lethal
viruses. We took fish eyes and held them in place
around a mastoid cavity during drilling of a temporal
bone. The eyes were then stained with fluorescein
and a blue light shone over them to identify any spi-
cules and corneal tears. Also, during this study, the
maximum distance of bone dust scatter from an in
vivo mastoid operation was measured from the cavity
in all directions and documented. The HIV and hepa-
titis C virus are discussed and the importance of pro-
tection to staff highlighted. Key Words: Mastoidec-
tomy, HIV, hepatitis.
Laryngoscope, 115:1873–1876, 2005
INTRODUCTION
The complications of mastoidectomy are typically di-
vided into intracranial and intratemporal. This is a stan-
From the Departments of Otolaryngology (A.H., P.W., S.G., H.B.) and
Microbiology (S.K.), The Royal Victoria Eye and Ear Hospital Dublin, Dub-
lin, Ireland.
Editor’s Note: This Manuscript was accepted for publication June 30,
2005.
Send Correspondence to Mr. Peter Walshe FRCSI (ORL), Royal
Victoria Eye and Ear Hospital, Adelaide Road, Dublin 2, Ireland. E-Mail:
peterwalshe2002@yahoo.co.uk
DOI: 10.1097/01.mlg.0000177459.80574.2d
Laryngoscope 115: October 2005
dard example of categorizing complications in mastoid
surgery. However, nowhere have we seen the complica-
tions to medical staff included in the complication listings.
The incidence of chronic middle ear disease is falling
in Britain, and in adults, is currently about 2.6% (inactive)
and 1.5% (active).1 The incidence of HIV and hepatitis C
is, however, rising.2,3 With this in mind, the chances of
operating on a patient with undiagnosed infection is in-
creasing. Operations involving the drilling or cutting of
bone in patients with bloodborne communicable diseases
are inherently dangerous to surgeons. In the pre-
antibiotic era, many orthopedic surgeons succumbed to
infection and septicemia after being pierced with a spicule
of bone during the execution of their duty. There are many
papers scattered throughout the literature on transfer of
potentially lethal viral infections from doctors to pa-
tients.4 –7 Most people will be familiar with the case of the
Florida dentist8 and the French orthopedic surgeon7 as
well as many other doctors who have probably given their
patient HIV despite no obvious episode to suggest a trans-
mission incident, such as needle stick injury.
A full literature review on the topic of patient to
doctor transfer of HIV and hepatitis viruses from bone
spicules to the eye during bone drilling yielded nothing.
There have been several documented cases of death to
orthopedic surgeons in the mid 19th century. These
deaths were caused by bone spicule-induced septicemia
from infected patients. Spicule-induced bacterial infection
was indeed an occupational hazard to the surgeons at that
time. This continued until Sir Alexander Fleming discov-
ered penicillin in 1940 and the antibiotic age was born.
There are, however, insidious dangers of a similar nature
to surgeons who deal with cutting bone in the form of
potential inoculation of the operator and other members of
the theater staff with patient-derived hepatitis C and
HIV.
The corneal route of viral transmission was docu-
mented when corneal grafts from cadavers caused recipi-
ents of those grafts to contract rabies.9 Therefore, it is
known that trans-corneal viral transmission is possible
where the cornea is inoculated. It is probable that the
same applies to hepatitis B virus (HBV), hepatitis C virus
(HCV), and HIV.
Hilal et al.: Mastoidectomy and Trans-Corneal Viral Transmission
1873
 Interestingly, the aerosol route of rabies transmis-
sion has been well documented where the viral load is
large enough.10 Is the same principle applicable to the
large viral load potentially encountered during mastoid-
ectomy on infected patients?
If bone dust has blood on its surface and the patient
has polymerase chain reaction (PCR)-positive serum for
hepatitis C, then that bone dust is PCR positive.11 In ENT,
bone spicules are generated during mastoidectomy, man-
dibular surgery, and maxillectomy as well other opera-
tions. Other specialties such as neurosurgery, orthopae-
dics, dentistry, maxillofacial surgery, thoracic surgery,
and plastic surgery are also potentially at risk.
Objectives
An animal organ-based experiment was carried out
in the temporal bone laboratory to assess the risk of trans-
mission of viruses through the corneal route during mas-
toidectomy. In vivo measurements during standard mas-
toidectomy were considered also.
MATERIALS AND METHODS
A cadaver temporal bone and a drill were used in the tem-
poral bone laboratory. The bone was drilled at 25,000 revolutions
per minute, for 10 seconds. Using a mask used for practicing eye
operations borrowed from ophthalmology colleagues in the hospi-
tal, we were able to mount pairs of fish eyes to prepare them for
the experiment. The fish chosen was pollock because the eyes
were of a similar size to humans and they were supplied free from
a fishmonger.
All eyes were free from corneal abrasions before their use in
the experiment and any that had abrasions were discarded. This
exclusion criterion left us with six pairs of eyes, which were
bathed in normal saline before use.
The mask with the mounted eyes was placed perpendicu-
larly to the temporal bone at distances of 1 m and 50 cm. Next, the
pairs of eyes were examined under a slit lamp to clearly identify
Fig. 1.These photographs show the Pollock eyes in the mask in the
ophthalmology laboratory being stained with fluorescene and their
subsequent examination at a slit lamp.
Laryngoscope 115: October 2005
1874
the corneal surfaces before and after staining with fluorescein
(Fig. 1).
Because bone dust is not the only aerosol to consider during
mastoidectomies and blood aerosol may be even more dangerous,
we felt that this aspect of potential viral transmission should be
examined.
Some red food dye was placed onto the surface of the tem-
poral bone, and the bone was drilled at 25,000 revolutions per
minute with a 4 mm cutting burr for 10 seconds. This action
caused an easily identifiable and measurable spatter pattern
(Fig. 2).
RESULTS
When the corneas were examined without (Fig. 3A)
and with fluorescein (Fig. 3B), there were numerous small
bone particles scattered all over and penetrating the cor-
neal surface. This applied to all examined eyes.
The red food dye was found to scatter 50 cm in the
direction of the drill but also, as shown, at 30 cm in the
opposite direction of the drill (at 25,000 RPM). This meant
that there was an arc-like scatter of blood aerosol directed
upward toward the operator. In vivo, we measured bone
scatter during typical mastoidectomy and found that av-
erage scatter in all directions was 3.5 feet (Fig. 4).
DISCUSSION
Operations involving the drilling or cutting of bone in
patients with bloodborne communicable diseases are in-
herently dangerous to surgeons. Orthopedic surgeons
have in the past succumbed to infection and septicemia
after being pierced with a spicule of bone. This problem is
generally no longer a factor when a bacterium is the
offending microorganism. This is because of the advent of
the antibiotic era, but the principle may be just as valid
today with regard to viral communicable diseases.
The world medical literature is full of cases and re-
ports of transmission of HIV from doctor to patient or
dentist to patient.4 –7 Very little is written about the re-
verse.
Fig. 2. Spatter pattern after drilling with the drill revolving from right
to left.
Hilal et al.: Mastoidectomy and Trans-Corneal Viral Transmission

Fig. 3. (A) Bone spicules on the cornea (arrows); (B) same as in A
except corneas are stained with fluorescein.
From the experiment above, both bone particles and
the dye and therefore blood will scatter in an arc up
toward the operator and other members of the theater
staff. Surely, the concentrations of viruses in this region
Fig. 4. In vivo bone dust scatter.
Laryngoscope 115: October 2005
and beyond would far exceed the concentrations necessary
to contract communicable disease. But how far will these
bone spicules and particles travel with extractors in the-
ater ?
Hepatitis B is far more transmissible than HIV and
hepatitis C. There is, however, an effective and safe vac-
cine available to provide immunity to hepatitis B. There is
no vaccine for HIV and hepatitis C, and therefore the
protection of health care workers is best achieved by way
of good infection control measures.
The risk of transmission of a bloodborne virus to
health care workers is related to the prevalence of the
virus in the population, the efficiency of virus transmis-
sion, and the nature and frequency of occupational expo-
sure to blood products and penetrating events. The most
efficient means of transmission is by way of the percuta-
neous exposure to infected blood. The risk of transmission
of HIV after needlestick injury with contaminated blood
from a hepatitis C PCR-positive source is 6.1%.12 The
figure is currently unknown for bone particles and trans-
mission by way of mucous membranes.
The risk of transmission of HIV in similar circum-
stances is 0.3% with a single exposure.13 HIV has been
isolated in the cornea, conjunctiva, and tears,14 and ocular
transmission of hepatitis C is possible15. HIV transmis-
sion from infected bone has been shown to be possible.11 It
is in our interests to assume that transmission of both
viruses by way of the cornea is possible.
CONCLUSION
Bone dust and blood particles travel directly and as
aerosols during operation. Unprotected corneas are at risk
of contamination. The corneal route of disease transmis-
sion is documented.
Undiagnosed HIV, HBV, and HCV is present in the
general population, and it has been shown that inocula-
tion is possible. There is one consideration that we need to
address in the interest of the surgeons and theater attend-
ees, namely, should all patients for mastoid surgery be
screened for HIV and hepatitis C? There is one recommen-
dation that we make also, namely, that all members of
theater staff should wear goggles during mastoid surgery.
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Laryngoscope 115: October 2005 Hilal et al.: Mastoidectomy and Trans-Corneal Viral Transmission
1876