|Year : 2016 | Volume
| Issue : 4 | Page : 294-298
Dual presentation of tuberculosis: Otitis media with retropharyngeal abscess - The first case report
Priyanka Gairola1, Saurabh Varshney1, Manu Malhotra1, Poonam Joshi1, Pratima Gupta2
1 Department of ENT and Head Neck Surgery, All India Institute of Medical Sciences, Rishikesh, Uttarakhand, India
2 Department of Microbiology, All India Institute of Medical Sciences, Rishikesh, Uttarakhand, India
|Date of Web Publication||13-Oct-2016|
Department of ENT and Head Neck Surgery, All India Institute of Medical Sciences, Rishikesh - 249 201, Uttarakhand
Source of Support: None, Conflict of Interest: None
Tubercular otitis media is a rare disease and its association with retropharyngeal abscess is rarer. We have not come across any such case in the English literature of the dual presentation of tuberculosis to the best of our knowledge so far. Early diagnosis and prompt management are the key to reduce the disease burden and also to avoid life-threatening complications.
Keywords: Otitis media, retropharyngeal abscess, tubercular otitis media
|How to cite this article:|
Gairola P, Varshney S, Malhotra M, Joshi P, Gupta P. Dual presentation of tuberculosis: Otitis media with retropharyngeal abscess - The first case report. Indian J Otol 2016;22:294-8
|How to cite this URL:|
Gairola P, Varshney S, Malhotra M, Joshi P, Gupta P. Dual presentation of tuberculosis: Otitis media with retropharyngeal abscess - The first case report. Indian J Otol [serial online] 2016 [cited 2023 Feb 6];22:294-8. Available from: https://www.indianjotol.org/text.asp?2016/22/4/294/192187
| Introduction|| |
Tuberculosis (TB), despite being known as one of the oldest diseases, is still a major cause of morbidity, especially in the developing countries.  Tubercular otitis media (TOM) is one of the rarer forms of extrapulmonary TB, and it is underdiagnosed most of the times. ,, However, it has decreased in incidence since the introduction of antitubercular drugs. TOM is a rare cause of chronic suppurative infection of the middle ear, ranging from 0.05% to 0.9% of the chronic otitis media.  The classic symptoms include multiple tympanic membrane perforations, abundant granulation tissue, bone necrosis, and preauricular lymphadenopathy. Most patients also experience an associated acute-onset hearing loss that is disproportionate to the extent of their disease. ,
The retropharyngeal space is a potential space between the middle and deep layers of deep cervical fascia.  The retropharyngeal abscess (RPA) is either acute or chronic. Acute abscesses occur frequently in children because of the abundance of retropharyngeal lymph nodes.  It results from the suppuration of persistent retropharyngeal lymph nodes due to pyogenic infection, as a result of trauma by a foreign body or instrumentation (laryngoscopy, endotracheal intubation, feeding tube placement, etc.). It can also occur in the presence of associated diseases.  RPA in adults is also mostly pyogenic and usually secondary to pharyngeal or esophageal perforation or sepsis in the throat or sinuses. However, chronic RPAs are rare in immunocompetent adults; they occur mostly in immunocompromised patients, and tubercular RPAs are very rare.  Tubercular RPA is usually due to spinal TB, and it is also seen mostly in children.  Hereby, we report a case with dual tubercular presentation - TOM and tubercular chronic RPA - which is probably the first case report of such dual tubercular presentation.
| Case Report|| |
A 19-year-old Muslim male presented to the ENT outpatient department with a 6-month history of left ear discharge, decreased hearing, and tinnitus. The character of discharge was mucopurulent, scanty, and foul smelling. There was no history of vertigo, fever, headache, vomiting, facial palsy, diplopia, and blurring of vision. There was no significant past or family history. On otoscopic examination of the left ear, granulations were seen in posterosuperior and posteroinferior quadrants, rest of the pars tensa was retracted, attic was eroded [Figure 1], and the right ear was normal. There was no postaural tenderness. There was no nystagmus, fistula test was negative, and there was no sign suggestive of intracranial complications. On routine examination of the oral cavity and oropharynx, a bulge was seen on the posterior pharyngeal wall which was an incidental finding [Figure 2]; however, there was no complaint of dysphagia, odynophagia, hoarseness of voice, or fever. Examination of the neck was normal. All the hematological investigations were normal. Serological investigations were normal. On audiological examination, there was severe mixed hearing loss on the affected side [Figure 3]. High-resolution computed tomography of the temporal bone was done on the right side which was normal, the left side showed irregular soft tissue lesion in the middle ear, mastoid engulfing the ossicles, sinus plate, and dural plate was intact, and no bony erosion was seen [Figure 4]. Contrast-enhanced computed tomography (CT) of the neck (axial/coronal/sagittal views) showed hypodense lesion in the left retropharyngeal space from skull base to C4 without erosion of the cervical spine [Figure 5],[Figure 6] and [Figure 7]. X-ray of the chest was normal.
|Figure 1: Left ear otoscopy - granulations seen in posterosuperior and posteroinferior quadrants, rest of the pars tensa was retracted, and attic was eroded|
Click here to view
|Figure 3: Pure tone audiometry showing the left ear - severe mixed hearing loss|
Click here to view
|Figure 4: High-resolution computed tomography of the temporal bone - left side showing irregular soft tissue lesion in the middle ear and mastoid engulfing the ossicles, sinus plate, and dural plate was intact, no bony erosion was seen|
Click here to view
|Figure 5: Contrast-enhanced computed tomography of the neck - coronal view showing hypodense lesion in the left retropharyngeal space from skull base to C4 vertebrae|
Click here to view
|Figure 6: Contrast-enhanced computed tomography of the neck axial view showing hypodense lesion in the left retropharyngeal space|
Click here to view
|Figure 7: Contrast-enhanced computed tomography of the neck sagittal view showing hypodense lesion in the left retropharyngeal space from skull base to C4 vertebrae, without erosion of cervical spine|
Click here to view
Intraoral aspiration of pus was performed with 10 cc syringe and sent for culture and sensitivity, which showed Gram-positive cocci arranged in clusters, and Ziehl-Neelsen stain was negative. Incision and drainage of RPA and modified radical mastoidectomy were carried out under general anesthesia in the same sitting. On intraoral incision, 20-25 cc of pus was drained from the retropharyngeal area. Modified radical mastoidectomy along with total ossicular replacement prosthesis with cartilage placement was done for TOM.
Perioperative findings of the left ear were granulation tissue (with minimal bleeding) in the middle ear and antrum, only the head of malleus and footplate were present, and Fallopian canal More Details was intact. Pus which was collected perioperatively from the retropharyngeal area was sent for culture and showed Gram-positive cocci arranged in clusters. Acid-fast Bacillus culture on Lowenstein-Jensen media was positive [Figure 8]. Histopathology report of biopsy taken from granulation tissue perioperative from the middle ear showed multinucleated giant cells, epithelioid cells, and histiocytes granulomatous inflammation, suggestive of TB [Figure 9]. Tubercular culture was also positive. Postoperatively, antitubercular therapy (ATT) under Category I, under directly observed treatment, short-course program was started. The patient was followed up after 6 weeks and showed marked improvement. The retropharyngeal bulge disappeared, and postoperative cavity was also well epithelialized with a good uptake of graft [Figure 10]. However, the postoperative hearing recovery was not significant.
|Figure 8: Acid-fast Bacillus seen on Lowenstein-Jensen media - magnification ×100|
Click here to view
|Figure 9: Histopathological examination (H and E, ×100) showing multinucleated giant cells, epithelioid cells, and histiocytes granulomatous inflammation, suggestive of tuberculosis|
Click here to view
|Figure 10: Left ear otoscopy postoperative (6 weeks) - dry cavity well epithelialized with a good uptake of graft|
Click here to view
| Discussion|| |
TB mostly affects the lungs and lymph nodes. Otitis media is a rare form of extrapulmonary TB. Here, in our case, TB had a dual presentation that is otitis media with retropharyngeal abscess which is very rare; there is no such reported case in literature. Hence, this is the first case report of dual presentation of TB: Otitis media with RPA. The spread of TB to the middle ear mainly involves three routes. The first is aspiration of mucus through the Eustachian tube More Details, the second is hematogenous dissemination from other tubercular foci, and the third permits dissemination of bacteria through the external canal and a tympanic membrane perforation. 
The presentation in this patient was granulation tissue, severe mixed hearing loss, and otorrhea. The classical presentation of multiple tympanic perforations was absent, but the suspicion arose when the patient was not responding to any antibiotic, and perioperative granulations were not bleeding. TB of the middle ear should be investigated in cases, in which the usual treatment for chronic otitis media is not producing the desired outcomes, when the patient's history and clinical examinations give reason to suspect that the infection has been caused by Koch's Bacillus.  If not treated on time, the patient can develop complications such as facial palsy, petrositis, and lateral sinus thrombophlebitis. In a study by Djeric et al., the temporal bone CT revealed soft tissue attenuations that filled the mastoid and external auditory canal which was consistent with our case.  Histopathological examination of the granulation tissue and demonstration of acid-fast bacilli in it remain the cornerstone of definitive diagnosis.  Even false-negative rates up to 10% on the first testing are reported, emphasizing the need of repeating the biopsy for more accurate results. 
Here, in our case, simultaneous presentation of chronic RPA was more in favor of some tuberculi foci in the body. Chronic RPA in adolescent age group results from direct extension from adjacent structures, penetrating trauma, granulomatous disease, or cervical spine osteomyelitis. Tubercular spondylitis of the cervical spine which accounts for 7% of all cases of skeletal TB is an important causative factor of chronic RPA.  However, there was no evidence of spinal TB in our case, in contrast to the previous reports, except for three from India itself, which had concomitant spinal involvement. The probable route of spread of TB could be due to the retropharyngeal space, through the lymphatics, to a persistent retropharyngeal lymph node. A hematogenous spread from pulmonary TB or TB in other locations may sometimes be the cause.  In our patient, there was no evidence of pulmonary TB. The treatment of RPA is drainage of abscess under antibiotic cover.
TOM was treated with modified radical mastoidectomy. After the confirmation of diagnosis, ATT was started. Surgical intervention is added to drug therapy, and the type of surgery depends on the clinical presentation. More number of radical surgical procedures may be required in cases of complications such as facial paralysis, subperiosteal abscess, labyrinthitis, mastoid tenderness, and headache. 
| Conclusion|| |
TOM should be suspected in chronic otitis media cases which have pale granulation tissue in the middle ear, a disproportionately severe hearing loss, facial paralysis, the presence of normal mastoid cellular development, and a past or family history of TB. One site of tubercular lesion can affect other areas, thus manifesting as dual presentation.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
| References|| |
Seong P, See P. Tubercular otitis media. Brunei Int Med J 2013;9:329-33.
Vaamonde P, Castro C, Garcia Soto N, Labella T, Lozano A. Tuberculosis otitis media: A significant diagnostic challenge. Head Neck Surg 2004;130:759-66.
Farrugia EJ, Raza SA, Phillipps JJ. Tuberculous otitis media - A case report. J Laryngol Otol 1997;111:58-9.
Pinho MM, Kós AO. Otite Média Tuberculosa. Ver Bras Otorrinolaringol 2003;69:829-37.
Awan MS, Salahuddin I. Tuberculous otitis media: Two case reports and literature review. Ear Nose Throat J 2002;81:792-4.
Emmett JR, Fischer ND, Biggers WP. Tuberculous mastoiditis. Laryngoscope 1977;87:1157-63.
Singh B. Role of surgery in tuberculous mastoiditis. J Laryngol Otol 1991;105:907-15.
Lyle NJ, Rutherford EE, Batty VB. A pain in the neck - Imaging in neck sepsis. Clin Radiol 2011;66:876-85.
Marques PM, Spratley JE, Leal LM, Cardoso E, Santos M. Parapharyngeal abscess in children: Five year retrospective study. Braz J Otorhinolaryngol 2009;75:826-30.
Wong KK, Fang CX, Tam PK. Selective upper endoscopy for foreign body ingestion in children: An evaluation of management protocol after 282 cases. J Pediatr Surg 2006;41:2016-8.
Harkani A, Hassani R, Ziad T, Aderdour L, Nouri H, Rochdi Y, et al.
Retropharyngeal abscess in adults: Five case reports and review of the literature. ScientificWorldJournal 2011;11:1623-9.
Singh J, Velankar H, Shinde D, Chordia N, Budhwani S. Retropharyngeal cold abscess without Pott′s spine. S Afr J Surg 2012;50:137-9.
Mongkolrattanothai K, Oram R, Redleaf M, Bova J, Englund JA. Tuberculous otitis media with mastoiditis and central nervous system involvement. Pediatr Infect Dis J 2003;22:453-6.
Sens PM, Alemida CI, Valle LO, Costa LH, Angelis ML. Tuberculose de Orelha, Doença Profissional? Rev Bras Otorrinolaringol 2008;74:621-7.
Djeric D, Tomanovic N, Boric I. Tuberculous otitis media-diagnosis and treatment of four cases. Int Adv Otol 2013;9:255-9.
Sethi A, Sabherwal A, Gulati A, Sareen D. Primary tuberculous petrositis. Acta Otolaryngol 2005;125:1236-9.
Dhar MC, Chaudhari S, Pain S, Halder U, Chakraborty A, Basu K. Retropharyngeal tuberculosis abscess along with alcoholic hepatitis and pulmonary tuberculosis. Indian J Tuberc 2002;49:159-60.
Colmenero JD, Jiménez-Mejías ME, Reguera JM, Palomino-Nicás J, Ruiz-Mesa JD, Márquez-Rivas J, et al.
Tuberculous vertebral osteomyelitis in the new millennium: Still a diagnostic and therapeutic challenge. Eur J Clin Microbiol Infect Dis 2004;23:477-83.
Windle-Taylor PC, Bailey CM. Tuberculous otitis media: A series of 22 patients. Laryngoscope 1980;90 (6 Pt 1):1039-44.
[Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5], [Figure 6], [Figure 7], [Figure 8], [Figure 9], [Figure 10]