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 Table of Contents  
CASE REPORT
Year : 2020  |  Volume : 26  |  Issue : 2  |  Page : 103-105

Bilateral otitis media and nasopharyngitis as the presentation of tuberculosis


1 Department of Otorhinolaryngology, School of Medical Sciences, Universiti Sains Malaysia, Kubang Kerian, Kelantan, Malaysia
2 Department of Otorhinolaryngology, Head and Neck Surgery, Hospital Pulau Pinang, Penang Island, Malaysia

Date of Submission02-Feb-2020
Date of Acceptance17-Feb-2020
Date of Web Publication17-Jul-2020

Correspondence Address:
Prof. Mohd Khairi Md Daud
Department of Otorhinolaryngology, School of Medical Sciences, Health Campus, Universiti Sains Malaysia, 16150 Kubang Kerian, Kelantan
Malaysia
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/indianjotol.INDIANJOTOL_17_20

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  Abstract 


Tuberculosis (TB) is a common infectious disease worldwide. It most commonly affects the lungs, though any organ can be affected. Upper respiratory tract involvement is uncommon, and involvement of the nasopharynx with bilateral TB otitis media is even rarer. These conditions can be overlooked and often mistaken for other more common and less extensive diseases, and these can lead to delay of diagnosis. We report a case of a 29-year-old man who presented with bilateral reduced hearing and tinnitus, but he was found to have TB of the nasopharynx, otitis media, and lung.

Keywords: Nasopharynx, otitis media, tuberculosis


How to cite this article:
Kanesan N, Md Daud MK, Zakaria Z. Bilateral otitis media and nasopharyngitis as the presentation of tuberculosis. Indian J Otol 2020;26:103-5

How to cite this URL:
Kanesan N, Md Daud MK, Zakaria Z. Bilateral otitis media and nasopharyngitis as the presentation of tuberculosis. Indian J Otol [serial online] 2020 [cited 2020 Aug 12];26:103-5. Available from: http://www.indianjotol.org/text.asp?2020/26/2/103/289947




  Introduction Top


Tuberculosis (TB) remains a major threat to health, leading to high rates of morbidity and mortality.[1] Although pulmonary TB is by far the most common form, there are still at least 15% of extrapulmonary TB cases.[1] This is especially true in developing countries, such as Malaysia. Therefore, a high index of suspicion is essential for early diagnosis and prompt treatment. Here, we would like to report a 29-year-old male with TB otitis media and TB nasopharynx.


  Case Report Top


A 29-year-old Malay male with no known medical illness presented with bilateral otorrhea and reduced hearing which were worse on the right side for the duration of 1 month. This was associated with bilateral tinnitus. Otherwise, he did not complain of otalgia or vertigo. He did have on and off fever for the same duration.

Otherwise, he denies any nasal symptoms or any history of chronic cough or night sweats. There was no significant weight loss. He also denied any contact with patients with TB. He previously had received a course of oral antibiotics and eardrops from a private clinic. However, there was no clinical improvement.

Otoscopic examination showed mucopurulent discharge at the external ear canal with granulation tissues arising from the middle ear in both ears.The tympanic membranes were both centrally perforated [Figure 1] and [Figure 2]. Nasal endoscopic examination revealed thick secretions at the postnasal space with granulation tissue [Figure 3]. There was no mastoid tenderness or facial nerve palsy. Biopsy of the granulation tissue from both middle ears showed areas of necrosis rimmed by abscess and scattered multinucleated giant cells. Biopsy of the postnasal space tissue showed epithelioid cells with central caseating necrosis and multinucleated giant cells. Pure-tone audiometry showed moderate-to-severe mixed hearing loss bilaterally. There was no cervical lymphadenopathy.
Figure 1: Otoscopic finding of the right ear showing mucopurulent discharge with granulation tissue

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Figure 2:Otoscopic finding of the left ear showing perforation over the left tympanic membrane with granulation tissue

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Figure 3:Nasopharynx showing irregular mass with thick purulent discharge

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Chest X-ray showed evidence of pulmonary TB. Sputum acid-fast bacillus direct smear was positive, and erythrocyte sedimentation rate was increased to 88 mm/h. High-resolution computed tomography (HRCT) temporal bone revealed soft-tissue density mass occupying both epitympanum and mesotympanum, extending posteriorly into mastoid air cells and laterally into external auditory canal [Figure 4].
Figure 4: High-resolution computed tomography temporal of the patient showing a soft-tissue mass in the middle ear extending to the external ear canal and mastoid air cells

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A diagnosis of pulmonary TB with extrapulmonary involvement of the bilateral middle ears and nasopharynx was made. He was then referred to a respiratory team where he was started on four types of anti-TB drug which consisted of isoniazid, rifampicin, ethambutol, and pyrazinamide for the duration of 6 months. During a review at 4 months of anti-TB treatment, both ears have improved markedly. However, the perforation over the right side was persisted, but the left has completely healed. Pure-tone audiometry of this patient posttreatment did not show any improvement, and he was planned for hearing aid trial.


  Discussion Top


TB is a chronic bacterial infection caused by Mycobacterium tuberculosis.[1],[2] The incidence of TB has shown to be an important cause of morbidity, as well as mortality, and this is true despite new developments in diagnosis and treatment programs. This can be due to the rise of drug resistance toward TB, lacking of TB awareness program and increasing number of comorbid such as AIDS and diabetes.[2]

M. tuberculosis infection presents most commonly as pulmonary TB in around 80% of the cases although it can occur in all tissues of the body.[3] Head-and-neck TB infection is uncommon, with TB lymphadenitis being the most common, followed by TB larynx.[3] TB otitis media as well as TB nasopharynx is rare, and it is even more rare to have bilateral TB otitis media coexisting with TB nasopharynx.[1] The rarity of the diagnosis and the wide diversity of clinical presentation of this disease may be the reason for it to be frequently missed.

Painless otorrhea, multiple perforations over the tympanic membrane, pale granulation tissues, facial nerve palsy, and severe hearing loss would be the classical presentation of TB otitis media.[2],[4] At a later stage, the multiple tympanic perforations may coalesce later into a single large perforation. However, the symptoms are becoming more variable and polymorphic over time and in accordance with the patients' immune status.[2],[5],[6] The otorrhea is described as painless, but it can be painful later due to the granulation tissue in the middle ear or bacterial superinfection.[6] TB otitis media should be considered in patients with known or suspected TB with chronic ear infection. This is because the concomitant pulmonary lesions are present in 50% of these cases.[7] This is true, especially in cases that are not responsive to standard treatment for otitis media.[7] Computed tomography scan showing soft tissue filling the tympanum and mastoid air cells and cortical bone destruction with no evidence of cholesteatoma is highly suspicious of TB otitis media.[2]

Our patient presented with painless otorrhea and progressive hearing loss bilaterally for a short period of 1 month that was not responsive to medical treatment. He had granulation tissue over the bilateral external ear canal, and HRCT temporal showed soft-tissue density mass occupying the middle ear extending to the mastoid cavity posteriorly and external ear canal laterally. TB otitis media should be suspected in this patient even though he did not present with any symptoms of pulmonary TB because TB is prevalent in this part of the world.

The pathogenesis of TB otitis media involves one of the three major mechanisms. The first is aspiration of mucus through the  Eustachian tube More Details, the second is blood-borne dissemination from other tuberculous foci, and the third is direct implantation through the external auditory canal and a perforation over the tympanic membrane.[6],[8] Whereas, TB nasopharynx is thought to be either from primary infection from Waldeyer's ring, hematogenous spread from TB focus, likely from lung or direct inoculation from pulmonary TB. As ear and nose are of close proximity, infected mucus from the nasopharynx can be aspirated through the Eustachian tube to the middle ear, which is likely the pathophysiology of this patient. Even though the patient did not present with any nasal symptoms, it is essential for full ENT examination because of the close approximation of the organs.

External ear canal cultures are reported to be positive for TB in <35% of the cases, and the smears are positive in approximately 20% of the cases.[6] The identification of TB can be difficult in TB otitis media or nasopharynx. This is because the mycobacterial counts are low in extrapulmonary TB, and there are also secondary infections in up to 79% of the patients.[6],[8] Hence, the clinician should have a high index of suspicion to repeat culture if required or by looking for TB in other organs.

Complications can occur when the diagnosis and subsequent management is delayed. The complications that may occur include retroauricular fistulae, meningitis, petrous pyramid osteomyelitis, cerebral and cerebellar abscess, and peripheral facial nerve palsy.[5] Our patient did not have these complications.

After reaching the diagnosis, the antituberculous drugs are used as the first-line treatment option, and the prognosis can be improved in most patients.[2],[8] Early diagnosis and treatment can prevent possible complications.[2] Even though his symptoms have markedly improved, his hearing did not improve 4 months postcompletion of antituberculous medications and he opted for hearing aid. The role of surgical management is limited to complications such as subperiosteal abscess and bony sequestrate.[9]


  Conclusion Top


TB otitis media and nasopharynx is rare, and the presentation can vary and differ from the disease's classical description. This can cause difficulty, as well as delay in diagnosis and unnecessary interventions. Moreover, the delay in diagnosis can lead to delay in management and that can lead to many serious complications such as meningitis, osteomyelitis, and facial nerve palsy. To avoid this, clinicians should have a high index of suspicion, especially in an endemic country.

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.
Management of Tuberculosis. Malaysia Clinical Practice Guidelines. 3rd ed. Ministry of Health, Malaysia;2012. Available from: http://www.moh.gov.my/moh/attachments/8612.pdf. [Last retrieved on 2019 July 05].  Back to cited text no. 1
    
2.
Malaysia Health Technology Assessment Section. Management of Tuberculosis. Malaysian Clinical Practice Guidelines. Putrajaya: Malaysia Health Technology Assessment Section; 2012.  Back to cited text no. 2
    
3.
Mercedes FA, Thais G, Igor TR, Vitor YR, Pedro IM, Ricardo LM, et al. Tuberculosis otitis media. J Int Adv Otol 2011;7:413-7.  Back to cited text no. 3
    
4.
Yeoh XY, Pua KC. An unusual presentation of tuberculosis of the nasopharynx. J Tuberc Res 2015;3:50-3.  Back to cited text no. 4
    
5.
Gupta N, Dass A, Goel N, Tiwari S. Tuberculous otitis media leading to sequentialib bilateral facial nerve paralysis. Iran J Otorhinolaryngol 2015;27:231-7.  Back to cited text no. 5
    
6.
Bruschini L, Ciabotti A, Berrettini S. Chronic tuberculous otomastoiditis: A case report. J Int Adv Otol 2016;12:219-21.  Back to cited text no. 6
    
7.
Aremu SK, Alabi BS. Tuberculous otitis media: A case presentation and review of the literature. BMJ Case Rep 2010;2010. pii: bcr0220102721.  Back to cited text no. 7
    
8.
Hand JM, Pankey GA. Tuberculosis otomastoiditis and nontuberculous mycobacterial infections. Microbiol Spectr Am Soc Microbiol Press 2016;7:309-12.  Back to cited text no. 8
    
9.
Bhatkar D, Utpat K, Desai U, Joshi JM. Bilateral tuberculous otitis media: An unique presentation. Indian J Tuberc 2017;64:334-6.  Back to cited text no. 9
    


    Figures

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



 

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