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 Table of Contents  
CASE REPORT
Year : 2022  |  Volume : 28  |  Issue : 1  |  Page : 77-79

Bilateral otomastoid tuberculosis with pulmonary tuberculosis in immunocompetent young patient


1 Department of Otorhinolaryngology, Head and Neck Surgery, School of Medical Sciences, Universiti Sains Malaysia, Kelantan; Department of Otorhinolaryngology, Head and Neck Surgery, Hospital Kulim, Kedah, Malaysia
2 Department of Otorhinolaryngology, Head and Neck Surgery, School of Medical Sciences, Universiti Sains Malaysia, Kelantan, Malaysia
3 Department of Otorhinolaryngology, Head and Neck Surgery, Hospital Kulim, Kedah, Malaysia

Date of Submission10-Oct-2021
Date of Decision25-Nov-2021
Date of Acceptance03-Dec-2021
Date of Web Publication25-Apr-2022

Correspondence Address:
Dr. Nik Adilah Nik Othman
Department of Otorhinolaryngology, Head and Neck Surgery, School of Medical Sciences, Universiti Sains Malaysia, Health Campus, Kubang Kerian, Kelantan 16150
Malaysia
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/indianjotol.indianjotol_147_21

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  Abstract 


Tuberculous (TB) otitis media is rare and usually seen secondary to pulmonary tuberculosis or associated with it. TB is one of the major infectious diseases with predominant involvement of lung and lymph nodes which is common in Malaysia. Regarding the tubercular otitis media or tubercular mastoiditis, Mycobacterium tuberculosis is the principal causative agent, however, other atypical agents such as Mycobacterium bovis, Mycobacterium avium and Mycobacterium fortiutum are also responsible. TB otitis media may present with other middle ear problems whereby clinicians also unfamiliar with its typical presentation. Diagnosis is difficult because it needs specific culture and pathologic studies. Early diagnosis and effective treatment may prevent ear damage as well as central nervous system complication. The objective of this study was to report a rare case of bilateral TB otitis media to alert physicians to the rare presentation of the disease as well as to discuss the diagnosis and management plan based on the literature review.

Keywords: Middle ear, otitis media, pulmonary tuberculosis, tuberculosis


How to cite this article:
Zamaili AM, Nik Othman NA, Zainor S. Bilateral otomastoid tuberculosis with pulmonary tuberculosis in immunocompetent young patient. Indian J Otol 2022;28:77-9

How to cite this URL:
Zamaili AM, Nik Othman NA, Zainor S. Bilateral otomastoid tuberculosis with pulmonary tuberculosis in immunocompetent young patient. Indian J Otol [serial online] 2022 [cited 2022 Aug 9];28:77-9. Available from: https://www.indianjotol.org/text.asp?2022/28/1/77/343751




  Introduction Top


Tuberculous (TB) otitis media is a comparatively rare variety of TB usually seen secondary to pulmonary tuberculosis (PTB) or associated with it.[1],[2] Tuberculosis is one of the major infectious diseases with predominant involvement of lung and lymph nodes but tuberculosis of the middle ear is relatively rare with an incidence of 1.9–42.8 per million.[3] We reported a case of an adolescent with progressive bilateral hearing impairment without any respiratory symptoms.


  Case Report Top


A 22-years-old Malay gentleman presented to our Otorhinolaryngology clinic, Hospital Kulim with a history of persistent bilateral ear discharge for the past 3 months with no improvement through the use of ofloxacin ear drop and tablet augmentin for the past 2 weeks. It was associated with bilateral progressive hearing loss but not associated with ear pain, vertigo, or tinnitus. The patient denied any PTB symptoms such as prolonged cough, night sweat, or loss of weight. His father was diagnosed with PTB 5 years ago and had completed the TB treatment. In general, he was comfortable and afebrile, examination of the ear revealed granulation tissue occupying both external auditory canals (EAC) with yellow-colored discharge. Both tympanic membranes were not visualized. No facial weakness was observed. Other otorhinolaryngological examinations were unremarkable. Audiometry revealed bilateral severe to profound hearing loss [Figure 1]. High resolution computed tomography (HRCT) scan of the temporal bones showed an extensive hypodense non-enhancing lesion in both right and left mastoid air cells with the destruction of the walls of mastoid air cells. It extends into the middle ear and distal part of EAC with the erosion of incus, malleus, and scutum bilaterally [Figure 2]. Facial canals were intact with intact tegmen tympani and the lateral semicircular canal. Based on the clinical history and HRCT findings diagnosis of bilateral cholesteatoma was established.
Figure 1: Pure tone audiometry revealed bilateral severe to profound hearing loss

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Figure 2: Computed tomography showed soft-tissue mass filling both the middle ears and mastoids with the erosion of incus, malleus, and scutum (a: Axial view and b: Coronal view)

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The patient was counselled for bilateral mastoid exploration but is only keen for the right side at the moment. The intra-operative finding revealed EAC was full of granulation tissue from posterior and middle ear with subtotal tympanic membrane perforation with keratin seen. Mastoid cavity was full of keratin extending to the antrum and attic of the middle ear. Facial canal erosion was seen at the mastoid and tympanic segment. Erosion of incus and malleus was seen.

However, 1 week postoperatively, incision site was partially healed with cheesy like yellowish colored discharge seen from the inferior part of wound. Histopathological examination revealed fragments of granulation tissue with areas of caseous necrosis, presence of epithelioid granulomas, and Langhans multinucleated giant cells. Areas of bony erosion were also noted. However, Ziehl–Neelsen stained reveals no acid-fast bacilli (AFB). Nonetheless, these findings were still suggestive of TB. The patient was referred to the medical team for anti-TB treatment. Further investigations confirmed the presence of AFB in the sputum and the presence of cavitation at the right upper lobe on chest X-ray. After 1 week from starting TB treatment, the patient showed marked improvement of healing of post-operative wound with no discharge. The mastoid cavity was also cleared of the disease. However, hearing did not improve.


  Discussion Top


Middle ear tuberculosis as a primary site of infection is a rare issue.[4] The majority of reported cases are unilateral. Bilateral presentation like in our case is extremely rare. The clinical picture varies according to the immunological status of patients. Clinically, our patient does not have ear pain, headache, or vertigo and no facial nerve paralysis despite the disease being extensive and causing marked bone erosions. Infection frequently reaches the tympanic cavity via the EAC, or through rhinopharyngeal inspiration via the  Eustachian tube More Details, or hematogenous spread (79%).[5] It is usually presented as the triad of pain-free otorrhea, multiple tympanic membrane perforation, and peripheral facial palsy. Besides that, there are specific findings, and the most common of which are significant otalgia, probably due to pressure caused by granulation tissue within the mastoid, and serous otorrhea, which may become purulent due to secondary bacterial contamination. Severe early sensorineural, mixed or conductive hearing loss is present in 90% of cases, which may persist after the infection has been completely treated, especially if therapy was initiated late. Our patient presented with recurrent bilateral otorrhea for 3 months with progressive hearing loss which persisted after treatment. Patients with a history of PTB contact must be included in the differential diagnosis of recurrent or persistent ear discharge. Thorough pre-operative investigation for tuberculosis is performed (including a Mantoux test, chest X-ray, and staining or culture of otic discharge), even though TB otitis media might be detected in only 26% of the patients. Early therapy is paramount to avoid complications. Once it is started, there is the rapid resolution of the infection. Surgery has a minor role but may be useful to provide polyp or granulation tissue for histological examination, and for treating complications. In our case, we were able to get confirmatory diagnosis from the histopathological specimens taken during the operation.


  Conclusion Top


Bilateral tuberculosis of the mastoid is a rare extrapulmonary tuberculosis manifestation. The possibility of tuberculosis should be kept in mind in every case of chronic otitis media which does not respond to medical treatment so the clinical symptoms and signs should be reviewed carefully. Any presentation as bilateral ear involvement should alert for the possibility of a systemic cause, such as tuberculosis of mastoid.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form, the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Cho YS, Lee HS, Kim SW, Chung KH, Lee DK, Koh WJ, et al. Tuberculous otitis media: A clinical and radiologic analysis of 52 patients. Laryngoscope 2006;116:921-7.  Back to cited text no. 1
    
2.
Vaamonde P, Castro C, García-Soto N, Labella T, Lozano A. Tuberculous otitis media: A significant diagnostic challenge. Otolaryngol Head Neck Surg 2004;130:759-66.  Back to cited text no. 2
    
3.
Mahajan M, Agrawal DS, Singh NP, Gadre DJ. Tuberculosis of middle ear – A case report. Indian J Tuberc 1995;42:55.  Back to cited text no. 3
    
4.
Midholm A, Pedersen B. Primary tuberculosis otitis media. J Laryngol Otol 1971;85:1195-2000.  Back to cited text no. 4
    
5.
Sens PM, Almeida CI, Valle LO, Costa LH, Angeli ML. Tuberculosis of the ear, a professional disease? Braz J Otorhinolaryngol 2008;74:621-7  Back to cited text no. 5
    


    Figures

  [Figure 1], [Figure 2]



 

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