Infectious Diseases in Clinical Practice:
From the Section of Infectious Diseases & Host Defense (KK, CL, DL), Department of Pathology (JK), and Department of Otolaryngology (JG), Washington Hospital Center, Washington, DC.
Address for correspondence: Daniel R. Lucey, MD, Infectious Disease Service, Room 2A-56, Washington Hospital Center, 110 Irving Street NW, Washington, DC 20010.
The total number of tuberculosis (TB) cases among foreign-born persons in the United States increased from 24% (6,262) of the 25,701 total TB cases reported in 1990 to 43% (7,553) of the 17,531 total TB cases reported in 1999 . Middle ear infections and mastoiditis are rare manifestations of extrapulmonary tuberculosis in the United States and therefore many physicians do not include these manifestations of TB in their differential diagnoses . In their comprehensive 1986 review, Skolnik and colleagues  found 125 cases of tuberculous otitis media in the literature before 1953, and 101 cases between 1953 and 1985. They estimated that tuberculous otitis media was found in less than 0.3% of patients with tuberculosis, and that less than 0.1% of all otitis media and mastoiditis infections were caused by tuberculosis . We report a case of tuberculous otitis media and mastoiditis in a Nigerian man in whom the diagnosis was not initially suspected, and summarize the major characteristics of the disease.
A 31-year-old Nigerian male noted right ear “fullness,” yellow otorrhea, and diminished hearing in April 2000. His left ear was normal. He denied any fevers, night sweats, upper respiratory symptoms, dizziness, weight loss, prior ear infections, or history of tuberculosis. He emigrated from Nigeria 3 years earlier and worked in Washington, DC. He was initially admitted in May 2000. At that time, he was afebrile and had no lymphadenopathy. His right ear revealed granulation tissue extruding through the tympanic membrane with extensive periauricular swelling and mild conductive hearing loss in the right ear. He was prescribed ciprofloxacin and referred to an otolaryngologist. Computed tomography (CT) of the head showed right mastoid opacification, and the patient underwent right mastoidectomy with biopsy of the extensive granulation tissue. Bacterial, fungal, and acid-fast bacilli (AFB) stains were negative, but no cultures were done. He was discharged and given multiple antibacterial antibiotics, but his symptoms worsened and he was readmitted in July 2000. He again had extensive swelling around the right ear and mastoid. A repeated CT scan of the head showed recurrent opacification of the right middle ear and mastoid (Fig. 1). No other lesions were seen. A repeated mastoidectomy with biopsy was performed, and an infectious disease consult was obtained. Review of the biopsies from May and July revealed necrotizing granulomas (Fig. 2). The AFB stain was positive on the biopsy from the second admission and eventually yielded Mycobacterium tuberculosis. His chest radiograph was normal. Results of a human immunodeficiency virus (HIV) antibody test were negative. He was discharged on isoniazid, rifampin, ethambutol, and pyrazinamide for tuberculous otomastoiditis. His isolate was sensitive to all four drugs, so after 2 months of four-drug therapy, he continued taking isoniazid and rifampin for an additional 7 months. By January 2001, he was asymptomatic, except for mild right-sided hearing loss. He is being considered for a tympanic membrane transplant.
We report a case of tuberculous otitis media complicated by mastoiditis. The pathogenesis of tuberculous otitis media originates either with hematogenous spread or by direct extension from the nasopharynx. Historically, the latter was considered most likely when cases of otitis media caused by Mycobacterium bovis were associated with regurgitation of infected bovine milk through the eustachian tube .
Classic presentations of tuberculous otitis media include painless otorrhea, multiple perforations of the tympanic membrane, beefy red granulation tissue, hearing loss, preauricular adenopathy, and an ipsilateral facial nerve palsy [4–6]. More recently, however, most authors have reported that patients with tuberculous otitis media typically do not present with most of these findings [3,4,7]. Complications of tuberculous otitis media can include mastoiditis, conductive hearing loss, periauricular fistulae, and central nervous system involvement [3–7]. Yaniv  reported 31 cases of tuberculous otitis media seen from 1984 to 1985 in South Africa, of which 7 were also diagnosed with mastoiditis. Later, Singh  reported 43 cases of tuberculous otitis media from South Africa, with 13 having confirmed mastoid involvement.
The diagnosis of tuberculous otitis media requires a high index of suspicion. Most patients (88 to 94%) have a positive purified protein derivative skin test, although the proportion with pulmonary TB varies widely [3–4]. Stains and cultures of ear drainage are often negative. Yaniv  reported only 4 of 28 cases had positive AFB stains from ear discharge, and only 2 had positive cultures. Singh  noted that only 1 of 43 cases had positive AFB stains and culture from the ear discharge. The diagnosis is often made by biopsy of the granulation tissue in the middle ear [3,7], and mastoidectomy is not always necessary . CT scans are superior to both radiographs and magnetic resonance images for demonstrating the extent of disease and excluding complications [8,9].
In summary, tuberculous otomastoiditis is rare in the United States. However, it should be suspected in patients with otitis or mastoiditis who have a history of TB, are from TB-endemic areas, or have any history of TB exposure. The diagnosis is often made by AFB staining and culture of middle ear or mastoid tissue, and occasionally from external ear drainage. Treatment with appropriate antituberculous chemotherapy is usually curative, with surgery being required for mastoiditis, facial nerve palsy, cholesteatoma, abscesses, or tympanoplasty [3–6,10].
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© 2001 Lippincott Williams & Wilkins, Inc.
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