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Original Article

Tuberculous Otomastoiditis: A Therapeutic and Diagnostic

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

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

Introduction multiple tympanic membrane perforations, pale granulations,

severe mixed hearing loss, and facial paralysis may not be seen
Tuberculosis  (TB) is a global health‑care concern, leading
nowadays.[4] Many of these patients end up getting operated for
to almost 2 million deaths annually. Extrapulmonary TB
CSOM. They may land up with persistent otorrhea, delayed
constitutes about 15% of the total disease burden. Tuberculous
or incomplete healing. The computed tomography (CT) scan
otomastoiditis  (TOM) is a rare entity accounting for
findings of TOM include soft tissue density in the middle
0.05%–0.9% of chronic middle ear infections.[1] The disease
ear and mastoid. There may not be any bone erosion.[7] As
can involve any part of the temporal bone. Although improved
these findings are not pathognomonic of TOM, the accurate
socioeconomic status and better health‑care have led to a
diagnosis is based on histopathological examination (HPE) or
progressive decline in the incidence of TOM in the past
microbiological culture.
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 Materials and Methods
bone can be many. It can be aspiration through Eustachian The available charts of 950 patients undergoing middle ear
tube,[2] hematogenous spread from distant sites, contiguous surgery at a tertiary care center from 2011 to 2017 were
spread from adjacent extracranial or intracranial infection,
and rarely from maternal systemic/genitourinary infection to
Address for correspondence: Dr. Rohit Verma,
the infant.[3] The clinical presentation of TOM is nonspecific Department of Otolaryngology, Dayanand Medical
and varied. A chronic otorrhea resistant to usual antibiotics College and Hospital, Ludhiana, Punjab, India.
is a common presentation.[4‑6] The textbook description of Email: rohitaiims@yahoo.co.in

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DOI:
10.4103/indianjotol.INDIANJOTOL_80_17 How to cite this article: Verma R. Tuberculous otomastoiditis: A therapeutic
and diagnostic challenge. Indian J Otol 2017;23:260-3.

260 © 2018 Indian Journal of Otology | Published by Wolters Kluwer - Medknow

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Verma: Tuberculous otomastoiditis
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
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 [Figures 2 and 3]. At the time of surgical exploration,
granuloma was removed and tympanomeatal flap was elevated.
Figure 1: Otoscopy showing granuloma in the deep external auditory canal
Figure 3: Computed tomography showing no bone erosion
Indian Journal of Otology  ¦  Volume 23  ¦  Issue 4  ¦  October-December 2017
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.
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
Figure 2: Computed tomography showing soft tissue in middle ear,
external ear canal
Figure 4: Case 1 otoscopy posttreatment
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Verma: Tuberculous otomastoiditis
Figure 5: Computed tomography of case 2 showing soft tissue in mastoid
and middle ear
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.
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
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.
262
Figure 6: Computed tomography of case 2 after cortical mastoidectomy
showing cavity full of soft tissue
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.
Indian Journal of Otology  ¦  Volume 23  ¦  Issue 4  ¦  October-December 2017
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Verma: Tuberculous otomastoiditis
Conclusions
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.
Indian Journal of Otology  ¦  Volume 23  ¦  Issue 4  ¦  October-December 2017
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