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 Table of Contents  
ORIGINAL ARTICLE
Year : 2017  |  Volume : 23  |  Issue : 4  |  Page : 260-263

Tuberculous otomastoiditis: A therapeutic and diagnostic challenge


Department of Otolaryngology, Dayanand Medical College and Hospital, Ludhiana, Punjab, India

Date of Web Publication2-May-2018

Correspondence Address:
Dr. Rohit Verma
Department of Otolaryngology, Dayanand Medical College and Hospital, Ludhiana, Punjab
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/indianjotol.INDIANJOTOL_80_17

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  Abstract 


Context and Aims: Tuberculosis (TB) has affected mankind since time immemorial. Extrapulmonary TB poses special diagnostic and therapeutic challenges. Temporal bone is an extremely rare target organ for tuberculous infection. It constitutes just 0.05%–0.9% of all chronic middle ear otitis cases. However, because of its rarity, it is often missed as a diagnosis, and thus there is a significant delay in initiating the treatment. The aim of this study was to identify the cases of tuberculous otomastoiditis (TOM) in patients undergoing middle ear surgery in a tertiary care hospital. Settings and Design: This was a retrospective chart review carried out in a tertiary care hospital. Materials and Methods: Nine hundred and fifty charts of patients undergoing middle ear surgery were studied. Three cases of TOM were identified. Results: All the patients had painless otorrhea and hearing loss as the presenting feature. Only one patient had facial nerve palsy. During the initial phase of management, TB was not suspected in any of the patients. Histopathological examination (HPE) of the tissue obtained at surgery provided the diagnosis in all the cases. The response to antitubercular treatment (ATT) was satisfactory in all three cases. Conclusions: TB should always be kept as a differential diagnosis in case of chronic middle ear infection, especially if there is a poor response to antibacterial treatment. HPE of the tissue and specific microbiological testing are the gold standard for diagnosis. The primary treatment in these cases is ATT with a limited role of surgery.

Keywords: Mastoiditis, otitis, tuberculosis


How to cite this article:
Verma R. Tuberculous otomastoiditis: A therapeutic and diagnostic challenge. Indian J Otol 2017;23:260-3

How to cite this URL:
Verma R. Tuberculous otomastoiditis: A therapeutic and diagnostic challenge. Indian J Otol [serial online] 2017 [cited 2019 Dec 16];23:260-3. Available from: http://www.indianjotol.org/text.asp?2017/23/4/260/231648




  Introduction Top


Tuberculosis (TB) is a global health-care concern, leading to almost 2 million deaths annually. Extrapulmonary TB constitutes about 15% of the total disease burden. Tuberculous otomastoiditis (TOM) is a rare entity accounting for 0.05%–0.9% of chronic middle ear infections.[1] The disease can involve any part of the temporal bone. Although improved socioeconomic status and better health-care have led to a progressive decline in the incidence of TOM in the past century, it remains important differential diagnosis of chronic suppurative otitis media (CSOM) in developing nations. The routes of entry of tubercular bacillus into the temporal bone can be many. It can be aspiration through  Eustachian tube More Details,[2] hematogenous spread from distant sites, contiguous spread from adjacent extracranial or intracranial infection, and rarely from maternal systemic/genitourinary infection to the infant.[3] The clinical presentation of TOM is nonspecific and varied. A chronic otorrhea resistant to usual antibiotics is a common presentation.[4],[5],[6] The textbook description of multiple tympanic membrane perforations, pale granulations, severe mixed hearing loss, and facial paralysis may not be seen nowadays.[4] Many of these patients end up getting operated for CSOM. They may land up with persistent otorrhea, delayed or incomplete healing. The computed tomography (CT) scan findings of TOM include soft tissue density in the middle ear and mastoid. There may not be any bone erosion.[7] As these findings are not pathognomonic of TOM, the accurate diagnosis is based on histopathological examination (HPE) or microbiological culture.


  Materials and Methods Top


The available charts of 950 patients undergoing middle ear surgery at a tertiary care center from 2011 to 2017 were studied. A total of three cases of confirmed TOM were found. Complete clinical profile of these patients was studied. This has been described in this paper.


  Results Top


A total of three cases of TOM were included in the study. All patients were males with age ranging from 24 to 52 years. None of the patients had any obvious state of immunocompromise or any other systemic illness. Family and personal history was negative for any contact with TB.

Case 1

A 24-year-old male presented to the outpatient department with 2-month history of painless right-sided ear discharge with decreased hearing. This was refractory to usual antibiotic treatment. Otoscopy revealed a granuloma in the deep part of external auditory canal over the surface of tympanic membrane with total loss of landmarks [Figure 1]. Pure tone audiometry (PTA) showed moderately severe conductive hearing loss (CHL). CT scan of the patient showed soft tissue density filling middle ear and mastoid without any bone erosion [Figure 2] and [Figure 3]. At the time of surgical exploration, granuloma was removed and tympanomeatal flap was elevated. The tympanic cavity was full of fleshy granulations which were biopsied. No further mastoid exploration was done. The tissue sent for HPE showed caseating epithelioid cell granulomas with Langhans and foreign body giant cells consistent with TB. Patient was started on antitubercular treatment (ATT) which was given for 6 months. Posttherapy otoscopy showed thickened tympanic membrane with no granulations [Figure 4]. Otorrhea had subsided within 3 weeks of starting ATT. PTA showed improvement to mild CHL. Patient remains disease free after 2-year follow-up.
Figure 1: Otoscopy showing granuloma in the deep external auditory canal

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Figure 2: Computed tomography showing soft tissue in middle ear, external ear canal

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Figure 3: Computed tomography showing no bone erosion

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Figure 4: Case 1 otoscopy posttreatment

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Case 2

A 52-year-old male presented with 5-month history of left side otorrhea and hearing loss. Patient developed ipsilateral facial palsy 3 months after the start of otorrhea. Otoscopy showed a total perforation. The middle ear mucosa visualized through the perforation was avascular and necrotic. Patient had a House–Brackmann (HB) grade four facial paresis. There was severe mixed hearing loss on PTA. CT scan showed soft tissue density filling middle ear and mastoid without any bone erosion [Figure 5]. Facial canal was normal. Aural swab culture yielded pseudomonas and staph aureus. A diagnosis of necrotizing otitis media was made, and patient underwent a canal wall up mastoidectomy with tympanic membrane grafting. The tissue from middle ear as well as mastoid showed nonspecific inflammation. The graft never healed, and in the postoperative period, patient developed postaural discharging fistula. CT scan was repeated after 3 weeks. This time, the soft tissue had filled again in the entire middle ear and mastoid cavity [Figure 6]. Patient was operated again. This time modified radical mastoidectomy was done. The whole of the previously operated cavity had filled up with granulations. No attempt was made at ossiculoplasty. HPE of the granulations confirmed TB. Patient received ATT for 9 months. Ear healed well and the facial nerve function improved to HB 2/3. The patient remains disease free after follow-up of 12 months.
Figure 5: Computed tomography of case 2 showing soft tissue in mastoid and middle ear

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Figure 6: Computed tomography of case 2 after cortical mastoidectomy showing cavity full of soft tissue

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Case 3

A 35-year-old male presented with 1-month history of blocking sensation right ear. Patient received treatment from his native place. A CT scan was done which showed soft tissue density in the tympanic cavity and mastoid with some loss of mastoid air cell septa. The ear, nose, and throat surgeon did a myringotomy after which the blocking sensation improved slightly. However, patient started having ear discharge. When patient presented to us, otoscopy showed a small perforation in the anteroinferior quadrant of the ear drum with serous discharge. There was sagging of posterior-superior canal wall. Patient had moderate mixed loss on PTA. Aural swab culture revealed no growth of organisms. A decision for surgical exploration was taken. Patient underwent cortical mastoidectomy with tympanotomy. Florid bleeding granulations were seen in the mastoid air cells as well as the middle ear. These were cleared and sent for HPE which showed features consistent with TB. Patient is currently on ATT for 3 months. The otorrhea has subsided and patient has improved symptomatically.


  Discussion Top


TOM was first described in 1953.[8] The classical clinical features described were painless otorrhea, multiple tympanic membrane perforations, granulations in middle ear and mastoid, progressive CHL, and facial nerve palsy.[8] Such textbook presentations are no longer seen consistently. Most of the time, the presentation is similar to that of any other case of CSOM. As it was seen in our series, the condition may mimic necrotizing otitis media, cholesteatoma, otitis externa, or even coalescent mastoiditis. Due to the nonspecific clinical findings, a delay in diagnosis is commonly seen. Otorrhea and hearing loss were consistent findings in all of our cases. However, it is the failure of otorrhea to respond to conventional antimicrobial treatment which should raise the possibility of the pathology being tubercular. In contrast to what has been described in the literature, only one of the patients had facial nerve involvement. None of the patients were immunocompromised, and none had any other systemic focus of TB.

A CT scan of temporal bone is the standard radiological investigation for evaluation of any case of chronic otitis media. This, however, did not show the characteristic findings of TOM as described in the literature.[7] However, CT is important to delineate the extent of pathology. It also helps in localizing the facial canal in cases with facial paralysis. The gold standard for establishing the diagnosis of TOM includes culture and HPE of material obtained from middle ear and mastoid.[9] In retrospect, the author feels that an ear swab should have been sent for TB culture and polymerase chain reaction analysis in our cases. However, this was not done as TB was never suspected in the first place.

The standard treatment for TOM is antitubercular chemotherapy. The duration of ATT should be at least 6 months. This can be extended depending on the clinical response. In our series, the patients received ATT for 6–9 months. One patient is yet to finish the treatment. All the patients recovered uneventfully. As far as the role of surgery in TOM is concerned, the literature is not uniform. There is no good evidence to demonstrate effectiveness surgery for TOM.[10],[11] On the other hand, antitubercular drugs do not have a good middle ear penetration. Surgery in the absence of any complications has been condemned by some authors.[12] Some studies have demonstrated higher rates of dry ears when surgery precedes ATT.[13] All the patients in our series underwent surgical exploration. However, it was not with an established diagnosis of TOM. It was only the findings at the time of surgery that lead the author to suspect TOM. This was the reason for not going ahead with a canal wall down mastoidectomy in two of the patients. In third patient, canal wall up mastoidectomy was performed initially. This resulted in graft failure and postaural fistula. A re-exploration showed extensive granulations. Canal wall down mastoidectomy was done and diagnosis of TOM confirmed on HPE.


  Conclusions Top


This series demonstrates the diagnostic and therapeutic challenges posed by a rare entity called tubercular otitis media. This is owing to the fact that the clinical features are nonspecific, and standard microbiological and radiological tests fail to differentiate this condition from other chronic temporal bone pathologies. A high index of suspicion is mandatory to establish the diagnosis. It is important for the treating physician to be aware of this condition as an early diagnosis and prompt initiation of treatment is a must for a favorable outcome and to prevent serious, life-threatening complications.

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.
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. 1
    
2.
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Hoshino T, Miyashita H, Asai Y. Computed tomography of the temporal bone in tuberculous otitis media. J Laryngol Otol 1994;108:702-5.  Back to cited text no. 5
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Rho MH, Kim DW, Kim SS, Sung YS, Kwon JS, Lee SW, et al. Tuberculous otomastoiditis on high-resolution temporal bone CT: Comparison with nontuberculous otomastoiditis with and without cholesteatoma. AJNR Am J Neuroradiol 2007;28:493-6.  Back to cited text no. 7
    
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Wallner LJ. Tuberculous otitis media. Laryngoscope 1953;63:1058-77.  Back to cited text no. 8
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Migliori GB, Zellweger JP, Abubakar I, Ibraim E, Caminero JA, De Vries G, et al. European union standards for tuberculosis care. Eur Respir J 2012;39:807-19.  Back to cited text no. 9
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Meher R, Singh I, Yadav SP, Gathwala G. Tubercular otitis media in children. Otolaryngol Head Neck Surg 2006;135:650-2.  Back to cited text no. 10
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Awan MS, Salahuddin I. Tuberculous otitis media: Two case reports and literature review. Ear Nose Throat J 2002;81:792-4.  Back to cited text no. 11
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Saunders NC, Albert DM. Tuberculous mastoiditis: When is surgery indicated? Int J Pediatr Otorhinolaryngol 2002;65:59-63.  Back to cited text no. 12
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Kwon M, Choi SH, Chung JW. Roles of an anti-tuberculosis medication and surgery in patients with tuberculous otitis media. Acta Otolaryngol 2010;130:679-86.  Back to cited text no. 13
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    Figures

  [Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5], [Figure 6]



 

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