tuberculosis otitis mediabimjonline.com/pdf/bimj 2013 volume 9, issue 5... · 2013. 12. 9. · high...
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Tuberculosis otitis media Poon Seong LIM, Bee See GOH, Lokman SAIM
Department of Otorhinolaryngology-Head and Neck Surgery, Faculty of Medicine,
Universiti Kebangsaan Malaysia, Malaysia
ABSTRACT
Tuberculosis otitis media is relatively rare and often masquerade as other common otological conditions
resulting in delay of diagnosis and complications of disease. It is usually characterised by painless
chronic ear discharge with multiple tympanic membrane perforation and presence of abundant granula-
tion tissues in the middle ear on examination. We report the case of a 66-year-old man who presented
with symptoms of acute otitis media secondary to tuberculosis.
Keywords: Otitis media, ear, tuberculosis, tympanic membrane
INTRODUCTION
Tuberculosis is a rare cause of ear discharge
and diagnosis of tuberculosis otitis media is
often delayed, leading to dissemination and
complications. Despite being one of the oldest
diseases known to mankind, it is still a major
cause of morbidity, especially in the develop-
ing countries. Tuberculosis is known to affect
almost every organ in human body. Hence a
high index of suspicion for early diagnosis
and multidisciplinary approach often brings
good outcomes in managing this disease. We
report the case of a 66-year-old man who
presented with a two-month history of right
ear discharge, intermittent otalgia, tinnitus
and progressive hearing loss secondary to
tuberculous otitis media.
Case Report
Correspondence author: GOH BS,
Department of Otorhinolaryngology-Head and Neck Surgery, Faculty of Medicine, Universiti
Kebangsaan Malaysia, Malaysia. Tel: +60391455555, Fax: +60391456675,
E mail: [email protected]
Brunei Int Med J. 2013; 9 (5): 329-333
CASE REPORT
A 66-year-old man with no known medical
illness presented with a two-month history of
persistent right ear mucopus discharge. This
was associated with intermittent otalgia, tinni-
tus and worsening hearing loss. He also expe-
rienced backache of two-week duration that
had progressively worsened. He denied any
history of fever, prolonged cough, loss of ap-
petite or weight, and no previous contact with
tuberculosis patient. He had previously re-
ceived a course of oral antibiotic and antibiotic
ear drops with no improvements of symp-
toms.
Otoscopic examination of the right ear
revealed a central tympanic membrane perfo-
ration with jagged edge with presence of
granulation tissue over the superior region,
and a whitish polypoidal mass in the middle
ear (Figure 1a). There was no mastoid tender-
ness or facial nerve palsy. Pure tone audiome-
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try revealed a profound hearing loss of the
right side and moderate to severe sensori-
neural hearing loss of the left side. A high res-
olution computed tomography scan revealed
changes consistent with mastoiditis in the
presence of right middle ear soft tissue densi-
ty with no erosions of ossicles (Figure 1b).
Biopsy of the right granular tympanic
membrane revealed chronic granulomatous
inflammatory changes and was positive for
acid fast bacilli on Ziehl-Neelsen stain. Further
evaluation with chest and spine radiographs
revealed evidence of pulmonary and spine
tuberculosis (Figures 2a and b). Mantoux test
was positive with a measurement of 12mm
and erythrocyte sedimentation rate (ESR) was
high at 83 ml/hr (normal <15). A provisional
diagnosis of pulmonary tuberculosis with ex-
trapulmonary involvements (middle ear and
spine) was made. He was referred to the res-
piratory and orthopaedic team for initiation of
LIM et al. Brunei Int Med J. 2013; 9 (5): 333
Figs. 1: a) Tympanic membrane appearance on first
visit, and b) Axial computed tomography scan reveal-
ing mastoiditis changes with no bony erosion.
Figs. 2: a) Chest radiograph
showing changes in the
right mid and left apical
zones consistent with
tuberculosis, and b) Spine
radiograph showing
involvement of the spine.
a
b
a b
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his anti-tuberculosis drug and further man-
agement of spinal tuberculosis respectively.
He was commenced on anti-
tuberculosis medications (isoniazid, rifampic-
in, ethambutol and pyrazinamide) and was
treated for one year. He underwent spinal
surgery for evacuation of the paraspinal ab-
scess and instrumentation over his thoracic
vertebra. The otological symptoms improved
markedly on treatment, with total recovery of
otitis media and healing of the perforation of
tympanic membrane after six months of treat-
ment (Figures 3a and b). However, the hear-
ing did not improve post-treatment and he is
currently using hearing aid.
pulmonary tuberculosis. It accounts for 0.04-
0.90% of all cases of suppurative otitis media,
and its incidence is rising steadily in countries
where tuberculosis is endemic. 2
Tuberculosis otitis media classically
presents with unilateral painless otorrhoea
with multiple tympanic perforations and gran-
ulation tissues in middle ear which does not
respond to empirical antibiotic treatment.
Other classical features include presence of
early conductive hearing loss that is often out
of proportion to the clinical findings, which
may progress to a mixed or sensori-neural
hearing loss as the disease progresses. 3, 4
The key to better outcome in tuberculosis oti-
tis media is early diagnosis. If anti tubercu-
losis treatment is advocated early, the otolog-
ical manifestations usually heal completely
without the need of surgery. Thus we would
like to highlight the importance of high index
of suspicion in order to make early diagnosis.
There are three postulated routes of
transmission to the ear: via the Eustachian
tube, haemotogenous spread and direct inoc-
ulation through a pre-existing perforated tym-
DISCUSSION
Despite advances in medical sciences and
technology, tuberculosis remains a global bur-
den with an incidence rate of 9.4 million and
mortality of 1.78 million in 2009. Most were
found in Southeast Asia and Africa (35% and
30% of total cases respectively). 1 Tuberculo-
sis can be divided into pulmonary tuberculosis
and extra-pulmonary tuberculosis. Tuberculo-
sis otitis media is a rare form of extra-
LIM et al. Brunei Int Med J. 2013; 9 (5): 331
Figs. 3: a) Tympanic
membrane after one
month of anti-
tuberculosis treat-
ment showing heal-
ing, and b) after 6
months of treatment
showing complete
healing. a b
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tympanic membrane. 5 In our case, haemo-
togenous spread is the most likely route as
there were pulmonary and spinal tuberculosis
at the same time.
The classical clinical appearance of
multiple tympanic perforations in tuberculosis
otitis media is not always present nowadays.
In fact, the otoscopic findings is highly varia-
ble, ranging from middle ear effusion with
intact tympanic membrane to perforated tym-
panic membrane (single/multiple) with or
without middle ear granulation tissue/mass. 6
This patient presented with right otalgia with
presence of middle ear mass medial to a sin-
gle tympanic membrane perforation. Due to
variability of clinical presentations, we recom-
mend early biopsy as a mean of obtaining
early diagnosis. It had been shown in litera-
tures that histological examination is most
reliable in diagnosing tuberculosis otitis me-
dia. 7
Early diagnosis is important as early
treatment can prevent the occurrence of com-
plications which include facial nerve palsy,
necrosis of ossicles, bony destruction of mas-
toid and petrous temporal bone, periauricular
fistulas, lymphadenopathy and intracranial
tuberculomas or abscess. 8, 9 This patient did
not have any complications of disease upon
diagnosis.
It is also important to screen patient
for presence of disseminated tuberculosis
even in the absence of previous tuberculosis
contact or immunocompromised conditions as
tuberculosis is a multisystemic disease. It is
always important to routinely perform a chest
radiograph to look for presence of pulmonary
tuberculosis. Our patient complained of back-
Ache, and a thoracolumbar radiograph led to
the diagnosis of spinal tuberculosis. There was
presence of dissemination of tuberculosis in-
fection involving the ear, lung and spine. This
is rare as he has no medical illness, not im-
munocompromised and there was no history
of previous tuberculosis infection or contact.
The main stay for treatment of tuber-
culosis otitis media is still medical therapy.
The role of surgery is only preserved for cases
with complications such as the presence of
extensive bony sequetrum in middle ear/
mastoid, subperiosteal abscess and presence
of facial nerve palsy. 7 Surgery is also indicat-
ed in cases where the diagnosis is inconclu-
sive in order to attain tissue for a histological
diagnosis. It is always wise to perform a high
resolution CT scan prior to any surgical proce-
dure to assess the extent and presence of any
complications of the disease.
In conclusion, the authors would like
to highlight to clinicians the importance of
high index of suspicion and to consider early
tissue biopsy in order to diagnose tuberculosis
otitis media early as this often lead to better
treatment outcome. It is also important to
screen for other organ involvement of tuber-
culosis infection as multi-organ involvements
is common and advocate early multidiscipli-
nary care for optimum treatment.
LIM et al. Brunei Int Med J. 2013; 9 (5): 332
REFERENCES
1: WHO Report on Global Tuberculosis Control 2010
(Accessed 15th August 2012),
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losis: an overview. Am Fam Physician 2005; 72:
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3: Friedman I. Inflammatory disease of the ear. In:
Pathology of The Ear. Oxford: Blackwell Scientific
Publications, 1994: 119-26.
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