Xinyi, Lin1; Euan, Murugasu1
1 Department of Ear, Nose and Throat (ENT) – Head and Neck Surgery, Ng Teng Fong General Hospital, Singapore.
Tuberculous otitis media (TOM) is a rare form of extrapulmonary tuberculosis and its diagnosis is challenging due to the wide variability in symptoms and difficulty in isolation of acid-fast bacilli (AFB) in swab or tissue samples due to its paucibacillary nature.
We report a case of an immunocompetent lady with TOM and asymptomatic pulmonary tuberculosis, who underwent a left ear combined approach tympano-mastoidectomy.
A 40-year-old lady presented with left-sided hearing loss and left-sided otitis media with effusion (OME) after an upper respiratory tract infection. She subsequently underwent myringotomy and Grommet tube insertion in view of persistent left-sided OME. Post-procedure, she developed left-sided chronic suppurative otitis media (CSOM) refractory to conventional antimicrobial treatment. Examination showed a subtotal left tympanic membrane perforation, attic squames, denuded malleus and middle ear granulation tissue. She underwent a left ear combined approach tympano-mastoidectomy. Histology for the middle ear mucosa reported chronic inflammation and focal areas of epithelioma granulomas with necrosis but AFB smears and MTB PCR tests were negative. A sputum sample was positive for tuberculosis. The final diagnosis was pulmonary tuberculosis with TOM, and she was started on anti-tuberculosis medications.
TOM should be suspected in patients with refractory CSOM despite empiric or culture-directed antimicrobial therapy, especially in at-risk groups. As TOM is a paucibacillary condition, in cases with granulomatous middle ear inflammation on histology but negative tuberculosis studies, chest x-ray and sputum studies should be conducted to evaluate for pulmonary TB focus. The mainstay of treatment of TOM is anti-tuberculosis therapy, with possible surgical intervention in cases of complicated TOM.