Chronic Suppurative Otitis Media Complicated With Mastoiditis: An Unusual Presentation of Tuberculosis

Abstract

CASE PRESENTATION A 28-year-old African male presented with a 6-month history of severe right ear pain after a root canal procedure of a right mandibular tooth. He was diagnosed with otitis media of the right ear and, despite extended treatment with wide-spectrum antibiotics, his symptoms did not improve. The patient's symptoms progressed to complete hearing loss of the right ear, right-sided facial paralysis and continuous ear discharge following tympanic membrane perforation. Computed tomography of the temporal bones showed opacification of the right middle ear and mastoid air cells, consistent with otomastoiditis (Figure A, arrow). Subsequently, the patient underwent right tympanomastoidectomy and tympanostomy. Initial biopsies revealed nonspecific inflammatory changes and blood cultures were negative. Repeated bone biopsy a few weeks later revealed caseating granulomas (Figure B, white arrow) and multinucleated giant cells (Figure B, black arrow). The differential diagnosis of granulomatous mastoiditis includes autoimmune diseases such as sarcoidosis, granulomatosis with polyangiitis (Wegener's granulomatosis) and mycobacterial infections. Laboratory tests were negative for antineutrophil cytoplasmic antibodies. The serum angiotensin-converting enzyme was within normal limits and the quantiFERON-tuberculosis test was positive. Chest radiograph showed a right lower lobe calcified granuloma without evidence of hilar adenopathy. Repeated cultures from the mastoid lesion were consistent with Mycobacterium tuberculosis infection. Treatment with rifampin, pyrazinamide, ethambutol, isoniazid and pyridoxine was initiated, with no adverse events. Facial weakness, ear pain and ear discharge improved, but hearing loss was deemed permanent and the patient required a hearing aid device. Tuberculous otomastoiditis is a rare manifestation of mycobacterial infection. Patients typically present with otorrhea, tympanic membrane perforation, hearing impairment and facial paralysis due to granulomatous inflammation of the middle ear and mastoid air cells. This case report highlights the importance of considering M tuberculosis as a possible etiologic agent of otitis media complicated with chronic mastoiditis in a patient who is not responding to conventional antibiotic therapy. Bone biopsy with cultures for acidfast bacilli is an important diagnostic step in patients with persistent chronic suppurative otitis media or mastoiditis.