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Acosta Boett Ligia3, Marian Fuentes1 Bastidas Yanet2, Arrieta Noraima2, Rodríguez Olira1, Rivas Carlos1 and Delgado Beatriz1
1Residente del Postgrado de Otorrinolaringología. Hospital de Niños “Dr. José Manuel de los Ríos”, South America
2Adjunto del Servicio de Otorrinolaringología. Hospital de Niños “Dr. José Manuel de los Ríos”, South America
3Jefe de Servicio de Otorrinolaringología. Hospital de Niños “Dr. José Manuel de los Ríos”, South America
Submission: February 16, 2017; Published: February 28, 2017
*Corresponding author: Acosta Boett Ligia, Jefe de Servicio de Otorrinolaringología. Hospital de Niños “Dr. José Manuel de los Ríos”, Vicepresidenta de la Junta Directiva SVORL, Venezuela, South America,Email:email@example.com
How to cite this article: Acosta B L, Marian F, Bastidas Y, Arrieta N, Rodríguez O et.al. Tuberculous Otomastoiditis. Glob J Oto 2017; 4(2): 555634. DOI: 10.19080/GJO.2017.04.555634
Introduction: Otomastoiditis tuberculosis is a very rare clinical presentation of TB ranging from 0.05 % to 0.9 %. Clinical triad includes painless serous otorrhea, perforated eardrum and facial paralysis. It begins slowly and insidiously and is associated with bacterial super infection and hearing loss. The diagnosis requires sputum smear, cultivation of biological material, intradermal Mantoux reaction and chest radiography.
Clinical Case: Preschool female 4 years old, resident in Miranda, current disease with 26 days of duration, characterized by otodynia, purulent, green and odorless left otorrhea and hyperthermia. Goes to doctors who suggest oral antibiotics with Amoxicilina/Ac. Clavulanate, Cefadroxil and topical antibiotics like Ciprofloxacin. Symptoms persist so she receives parenteral ceftriaxone also unsuccessfully so she is hospitalized.
Physical Exam: retroauricular increased volume, soft, without signs of styes, left stenotic ear canal, hyperemic, abundant green odorless otorrhea, not evaluable tympanic membrane. Laterocervical left lymphadenopathy, mobile, painless, of 1.5 cms. Patient receives parenteral antibiotic therapy with no improvement.
Functional Study: moderate left conductive hearing loss.
Computed Tomography middle ear and mastoid: isodensity, occupying left middle ear and mastoid with erosion of the mastoid cortex. Tympanoplasty with mastoidectomy and left open biopsy is performed.
Anatomopathological report: Chronic granulomatous Otomastoiditis. PPD is done: positive (18 mm), anti TB treatment is initiated: Isoniazid, Rifampicin, Piperazinamida and ethambutol.
Conclusion: suspect tubercular etiology in cases of painless otomastoiditis that do not respond to the usual antibiotic treatment. The PPD as a valuable tool should be used routinely for early diagnosis and lower risk of complications.
Acute and Chronic Otitis Media; Constitute a public health problem on a global scale, resulting in high morbidity, medical consultations, prescriptions and sequelae . In the pediatric population otitis media is a frequent reason for consultation . In Venezuela, it is among the first causes of consultation and occupies the thirteenth position within the group of notifiable diseases . About 84% of children have at least one episode of otitis media during childhood . About 40% of these will continue with recurrent chronic suppurative otitis media .
Diseases of the ear and mastoid process are grouped into 4
pathologies: Otitis Externa, Acute Otitis Media in children under 5 years, Acute Otitis Media in children over 5 years, and Otitis Media Chronic . As mentioned earlier, the volume of annual consultations for otitis is very high. Most of these visits are for acute otitis media, with a daily average of 648 visits. However, it should be noted that Otitis Media Chronic with only an average of 28 consultations per day has greater complications and is responsible for a high percentage of school and work absenteeism; As well as hearing loss .
As for the sequels; The group that studied the burden of
Acute Otitis Media around the world, estimates hearing loss less
than 25 dB as the most important. For our region, this study
registers between 4 and 6 cases per 10,000, reaching a figure of
14,000 hearing-impaired patients per year due to this etiology
. Otitis Media is defined as the sudden appearance of signs
and symptoms of infection of the middle ear mucosa [1,2].
Depending on the evolution time, they are classified as:
Acute Otitis Media: up to 3 weeks of evolution .
Subacute Otitis Media: 3 weeks to 3 months duration
Otitis Media Chronic: more than 3 months of Evolution
When the inflammatory process of the middle ear mucosa
extends to the underlying bone, otomastoiditis occurs. Osteitis
affects the cortical of the mastoid and causes signs of flogosis
in the retroauricular region, with the installation of a cellulite,
phlegmon or abscess. Otomastoiditis can be a complication of
otitis media or constitute the first manifestation of ear disease
. In general, the microorganisms involved are Streptococcus
pneumoniae, Streptococcus pyogenes, Staphylococcus aureus,
Haemophilus influenzae and Pseudomonas aeruginosa .
Otomastoiditis requires hospitalization, supportive measures
and parenteral antibiotic therapy to avoid the risk of intracranial
complications, such as meningitis, sigmoid sinus thrombosis and
brain abscess .
The selection of antibiotic therapy depends on the severity
of the case and the conditions of the patient. Empirical treatment
with third generation cephalosporins such as cefotaxime,
ceftriaxone, is recommended. In case of torpid evolution or
isolation of resistant germs, glycopeptides such as vancomycin
or teicoplanin are used . In those cases where the infectious
process exceeds 3 months of evolution, we can refer to a chronic
otitis media (chronic otomastoiditis). In Otitis Media Chronic the
most frequent manifestations are recurrent otorrhea, tympanic
perforation and hearing loss. The alteration in anatomical
structures and physiology varies widely from one patient to
The etiology of chronic infection is polymicrobial. The germs
of greatest growth in the cultures are: Pseudomona aeruginosa,
Proteus mirabilis, Staphylococcus aureus, Streptococcus
pyogenes, Escherichia coli, Klebsiellas spp, Anaerobic Germs:
Peptostreptococcus spp, Prevotella, Bacteroides fragilis,
Propionibacterium species. Other: Mycobacterium tuberculosis,
Nocardia, Aspergillus . Chronic otitis media are classified as:
Chronic otitis media Cholesteatomatous
Chronic otitis media Cholesteatomatous:
Otitis media suppurative
Otitis media effusion
Chronic atelectasic otitis media
Adhesive otitis media
The otitis media with effusion is considered a non-infectious
disease, however in recent studies the presence of germs is
reported, evidenced by PCR in the effusion, Haemophylus
influenzae being the dominant pathogen in 51% of the cases .
In patients with chronic non-cholesteatomatous suppurative
otitis, ear cleansing, application of antiseptic solutions and topical
antibiotics (5% iodinated solutions and 0.2% ciprofloxacincontaining
drops) have shown effectiveness in drying the
ear; Even more than the use of systemic antibiotic therapy. In
children with chronic exudative otomastoiditis, intravenous
treatment with: third generation cephalosporins Antiepileptic
(ceftazidime) or fourth generation (cefepime) with clindamycin,
carbapenems (imipenem or meropenem), piperacillin /
tazobactam. In adults, oral therapy with ciprofloxacin with or
without clindamycin may be administered .
The time of medical treatment oscillates between 2 and 3
weeks. Once the infection is controlled, patients must undergo
surgical treatment to repair the sequelae and avoid further
complications . Patients with chronic otitis media with
cholesteatoma require surgical treatment. Cholesteatoma is an
avascular pseudotumor, with great lytic capacity, which must
be resected as soon as it is identified. The benefit of topical and
systemic antibiotics is relatively poor and is recommended only
to improve local conditions prior to surgery. In complicated cases,
the patient requires hospitalization and parenteral treatment
with third or fourth generation cephalosporins. In some cases
it may be necessary to associate vancomycin or clindamycin .
Regarding tuberculosis (TB), it is important to note that it is
still a public health problem in Venezuela and a diagnosis that
must be considered during daily medical practice in the country’s
hospitals. It is one of the earliest human diseases to be known;
Although its age is estimated between 15,000 and 20,000 years,
it is accepted that the microorganism that originated it evolved
from other more primitive microorganisms within the genus
Mycobacterium itself .
International organizations such as the World Health
Organization (WHO), the United Nations (UN), the Pan American
Health Organization (PAHO) and the International Union
Against Tuberculosis and Respiratory Diseases (UICTER) have
recognized tuberculosis (TB) as a threat of suffering and death
in several countries of the world. Most recent international
statistics and latest publications. A third of the world’s
population is affected by it, and that 9 million new cases and
3 million deaths are recorded every year because of it. Latin
America does not escape its havoc; And in our country, along
with other pathological entities, it is considered a reemerging
disease that must be diagnosed and treated early .
Tuberculosis is an infectious and opportunistic disease that
primarily affects individuals of lower socioeconomic status, as well as those with compromised immune systems due to age
(children or the elderly), infections (HIV) or treatment with
modulators Immune system (organ transplantation, collagen
disease) . Mycobacterium tuberculosis is the most frequently
responsible bacillus of tuberculosis in humans, although other
bacilli of the M tuberculosis complex (bovis, africanum, microti)
have also been reported as causative agents. The most common
form of presentation of the disease is Pulmonary Tuberculosis.
However, this agent can affect other organs of the economy
through its extrapulmonary manifestations [5,6].
The extrapulmonary form accounts for 15 to 25% of all cases of
the disease. Its location is very diverse, but occurs less frequently
in some areas (meninges, otorhinolaryngological area, abdomen,
pelvis) than in others (pleura, kidney, bone, brain). Due to the
lack of clinical manifestations characteristic of the pulmonary
form and / or antecedents of the same, the extrapulmonary form
is frequently confused with other pathologies leading to delays
and costly errors in the diagnosis and definitive treatment
. In this regard, a clinical case corresponding to one of the
infrequent expressions of extrapulmonary tuberculosis in the
otorhinolaryngological area, such as that corresponding to aural
tuberculosis, will be presented.
Female pre-school, 4 years old, from Miranda, with current
disease of 26 days, characterized by otodynia, left green otorrhea,
purulent, non-fetid and hyperthermia. It refers to clinicians
who indicate oral antibiotic therapy with Amoxicillin / Ac.
Clavulanic, Cefadroxil, topical antibiotics such as Ciprofloxacin.
Persist symptomatology, receives ceftriaxone parenteral without
response so it is entered. Prenatal and Obstetric Antecedents:
Product of 29 years old mother, I gesta, poorly controlled
pregnancy, obtained at 38 weeks’ gestation by instrumental
delivery (forceps) does not specify cause.
Temporal bone tumor Left in study: Histiocytosis of
Langerhans A / D cells.
Work Plan: It was decided to hospitalize in our service
and start treatment with Ceftriaxone at a dose of 75 mg /
kg / day order day, Quinoftal (drops) BID, Dexamethasone at0.6 mg / kg / day TID for 3 days, profenid 2 mg / kg / dose
TID, irtopan at 0.5 mg / kg / day in case of nausea and / or
vomiting, omeprazole at 1 mg / kg / day OD. Laboratories, functional study, and middle ear and mastoid tomography
11/27/2014: Patient is reevaluated with an increase
in the volume increase in the retroauricular region with the
same characteristics as described above (soft without signs
of floosis in the left mastoid region). In view of laboratoryresults, the diagnosis of hypochromic microcytic anemia is
11/28/2014: Performed Functional Study: Tonal
Audiometry where it is evidenced: Right Ear: Normal Hearing.
Left ear: Moderate conductive hearing loss (Appendix 1).
01/12/2014: Due to the persistence of the clinic,
Ceftriaxone is omitted and treatment with Cefepime at a
dose of 150 mgs / kg / day and Clindamycin at a dose of 30
mg / kg / day is given and received for 7 days.
02/12/2014: In view of diagnostic presumption,
an evaluation by the Oncology Service is requested, which
suggests Abdominal Echo, Chest Tomography, Abdomen and
Pelvis with double contrast and Bone Gammagram.
03/12/2014: Tomography of the middle ear and
mastoid is received: evidencing mastoid asymmetry, loss of
the cortical mastoid of the left ear that impresses secondary
to an erosive - infiltrative type process that compromises the
superficial mastoid ipsilateral cells. Obliteration of the left
external auditory canal at the expense of volume increase
at the ceiling level, isodense characteristics, occupation
of antrum, epitympanum and mesotympanum by soft
tissue density, with preservation of ossicular elements and
thickening of the left tympanic membrane (Appendix 2).
10/12/2014: Patient persists with abundant
otorrhea of the same characteristics as those described
and intermittent hyperthermia of 39°C, which is why
reevaluation is requested by the infectology service, who
suggests omitting previous antibiotic therapy and initiating
Teicoplanin at doses of 10 mg / Kg / dose every 12 hours for
three days and then order day and Meropenem at doses of
120 mg / kg / day every 8 hours.
12/12/2014: Thorax, Abdomen and Pelvis Tomography
are present where: bilateral mediastinal and axillary lymphadenopathies that reach up to 20 mm, no lesions of
the pulmonary parenchyma, no parenchymal involvement of
upper abdominal structures, bilateral inguinal adenopathies
of Up to 12mm.
12/16/2014: The patient is taken to the operating
room where tympanoplasty and left open mastoidectomy
are performed with a biopsy. Surgical findings: whitish
lesion, protruding cerebroid aspect in mastoid lateral
wall with extension to the posterior wall and CAE roof,
temporal scale, mastoid cells, antrum, epitympanum and
mesotympanum with preservation of ossicular elements.
Excision is performed.
18/12/2014: Anatomopathological report: Macroscopic
description: The specimen consists of four irregular fragments
of tissue, the largest measuring 1.3 x 0.6 x 0.4 cm, brown,
reddish, homogeneous, soft. They are included in their totality
for histological study concluding:
Diagnosis: Chronic Granulomatous Otomastoiditis
12/23/2014: It is evaluated by the Pneumology
Service in view of anatomopathological results, mediastinal
lymphadenopathy and epidemiological contact with
maternal uncle with pulmonary tuberculosis one year ago. It
is requested: PPD, BK and culture of gastric content, HIV.
12/26/2014: PPD reading is performed: 18 mm which
is positive, 2 BK of gastric contents and HIV: Negative.
28/12/2014: In view of the results, anti - tuberculosis
treatment begins with: Rifampicin at a dose of 20mg / kg /
day, Isoniazid at doses of 15mg / kg / day, Piperazinamide at
doses of 20mg / kg / day and ethambutol At a dose of 15 mg
/ kg / day.
1/8/2015: Immunohistochemical study: Using the
peroxidase-labeled secondary antibody conjugated dextran
polymer using appropriate positive controls and antigen
retrieval methods, the following antigens were investigated
in the tumor: CD 68, CD 1a.
CD 68: Diffuse positive immuno-reaction in histiocytes.
CD 1a: Negative immunization
NOTE: CD1a study was performed and no marker positive
Langerhans cells were observed. Histology seems to correspond
to a granuloma by an infectious agent; However, the stains for
acid resistant fungi and acid bacillus were negative.
09/01/2015: Maintained treatment with Teicoplanin
at 10 mg / kg / day and meropenem at 120 mg / kg / day
TID for 27 days and supervised antituberculosis treatment
for 9 days. In view of satisfactory clinical evolution, medical discharge with outpatient antituberculosis treatment was
01/20/15: It is valued by our consultation evidencing
to the patient in stable general conditions. Denies otodynia,
otorrhea and hyperthermia. At the physical examination:
Left ear: Normally implanted auricular pavilion, there is no
evidence of increased volume in the retroauricular region,
postoperative scar without signs of flogosis. Permeable
external auditory canal, tympanic membrane with cellular
detritus on its surface. It remains receiving outpatient
02/19/15: Persist in good general conditions.
Denies otodynia, otorrhea and hyperthermia. At physical
examination: Left ear: Normally implanted auricle, without
volume increase in the retroauricular region, unscathed
postoperative scar. Pervious external auditory canal,
tympanic membrane with few cellular detritus on its surface.
Remain receiving outpatient antituberculosis treatment.
05/15/15: Remains in good general condition.
Denies otodynia, otorrhea and hyperthermia. At physical
examination: Left ear: Normally implanted auricle, without
volume increase in the retroauricular region, unscathed
postoperative scar. Permeable external auditory canal,
tympanic membrane undamaged. Continue to receive
outpatient tuberculosis treatment.
In the pediatric population otitis media is a frequent reason
for consultation. About 84% of children have at least one
episode of otitis media during childhood . Tuberculosis (TB)
is one of the most studied infectious pathologies in the history
of medicine, both in the past and in the present era, as this is
a public health problem. During much of the twentieth century,
its high incidence and mortality was disturbing. Currently, the
emergence of strains resistant to anti-tuberculosis drugs, and
the increase in the frequency of this disease in recent years, is
what keeps health teams alert . Although tuberculosis can
affect any organ, only 15 to 25% of cases are extrapulmonary.
These are much more common in immunosuppressed patients,
in whom between 50 and 80% of the cases the involvement is
It is an entity that predominates in both developed and
underdeveloped countries and has a predilection for the male
sex, with a 3: 1 ratio. It usually affects young adults and early
childhood . Tuberculous otomastoiditis shows that it occurs
more frequently in pediatric age, with up to 84% of cases
reported in children under 15 years of age . The bacilli
penetrate the lungs carried by the aerosol droplets, where
they are phagocytosed by the macrophages and transferred to
the regional lymph nodes, where their diffusion is neutralized;
Or reaching the bloodstream and disseminating widely. At the locations where plantings occur, monocytes are transformed into
macrophages and histiocytes, and eventually form granulomas.
Microorganisms remain alive within macrophages, but they do
not spread any more, unless there is a reactivation .
In 95% of the cases; Tuberculosis, is caused by human
Mycobacterium tuberculosis and the rest is divided between
Mycobacterium bovis and atypical Mycobacteria. At 2 to 8 weeks
of the primoinfection, the host creates a cellular hypersensitivity,
which can be recognized by a skin test that measures the reaction
to purified tuberculin protein derivative (PPD), a mixture
of unpurified antigens [8,9]. As far as otorhinolaryngology
is concerned, the most common form of extrapulmonary
tuberculosis involving head and neck structures is cervical
lymphadenitis, accounting for 95% of cases. This disease can
also affect areas such as the middle ear, nasal cavity, oropharynx,
nasopharynx, parotid and submandibular gland, esophagus,
palate, tongue, trachea, larynx, thyroglossal canal and oral
mucosa in which only 1% ) [6,10].
Within this group, tuberculous otomastoiditis is a rare
complication of pulmonary tuberculosis. However, it ranks
second among the most frequent causes of extrapulmonary
tuberculosis of otorhinolaryngological origin after laryngeal
tuberculosis [6,11]. Chronic otitis media for tuberculosis was
first described in 1853, and it was Eschle who in 1883 isolated
the bacillus in optic secretion [12,13]. At the beginning of the
20th century, 3 to 5% of chronic otitis media were produced by
TB with 9.5% of them occurring in children under 5 .
Since then, the universal literature only mentions reports of
isolated cases of tuberculous otitis media. Attempts to conduct
major literature reviews, such as the Royal National Throat,
Nose and Ear Hospital of England with 22 cases in a 30-year
review , Grewald et al.  With 18 patients , Ukai
And associated with 48 patients , Mojen and his group
who; In 1992, performed a review of tuberculous otitis media
throughout the century reporting only 320 patients  and
more recently Nishiike et al. With seven cases  (in which
the pathological mechanism was aspiration of bacilli through
Eustachian tube), have served to highlight how little documented
and underdiagnosed this disease is.
Tuberculous otitis media (OMT) is a very rare form of clinical
presentation of TB, whose incidence currently ranges from
0.05% to 0.9% of chronic otitis media [12,14]. In most cases
tuberculous Mycobacterium is the causative agent, infections
secondary to atypical mycobacteria such as Mycobacterium
avium and Mycobacterium fortuitum may occur occasionally
. The decline in this clinical form of TB is due to several
factors, such as: progress in the area of public health, Calmette
Guerin bacillus vaccine, availability of anti-TB drugs and
improvement of quality of life . On the other hand, since the
signs and symptoms of tuberculous otitis media are difficult to
differentiate from chronic otitis media caused by other agents, and that the frequency of this pathology has declined, there has
been a significant decrease in clinical suspicion, With the risk
of a late diagnosis with the implications and complications that
this entails. By way of example, one can cite hearing loss, which
may become permanent [11,20].
During the last years; In spite of a decrease in its incidence,
an increase of cases has been observed worldwide. This is due
to different causes, some of them being the AIDS epidemic,
increasing migrations from endemic areas, overcrowding
in different geographical areas, and partial control of the
administration of medicines by health authorities [12,20]. In
a patient with chronic otitis media, a suspicion of OMT should
always be maintained, especially if antibiotic treatment fails,
if it has had any contact with TB, or if it has pulmonary or
extrapulmonary TB. The latter association is observed between
40% and 65% of the cases [12,14].
Infection of the middle ear by the tuberculous bacillus may
be primary or secondary . In the pediatric population, the
most frequent form of clinical presentation is that of the primary
complex [11,19]. The possible routes of transmission are diverse,
but the most frequent is the hematogenous secondary to a
miliary TBC in which a primary infection would occur with later
cantonment of the bacilli in the middle ear with its subsequent
reactivation. Other possible routes are those that occur directly,
ie from the nasopharynx through the Eustachian tube especially
in chronic expectorants or by the regurgitation of unpasteurized
milk especially in infants and malnourished, by lymphatic
extension. Direct inoculation to the external ear has also been
mentioned through tympanic perforation, by direct extension to
adjacent structures, such as the central nervous system, and by
congenital infection, either by placental route or by the placental
canal especially In mothers with urogenital TB [7,8,12,21,22].
Tuberculosis of the middle ear; With no other apparent
tuberculous focus, occurs primarily in the pediatric population
following the intake of unpasteurized milk, where the bacillus
would reach the ear through the external auditory canal or
the eustachian tube. While tuberculosis of the middle ear
occurs mostly in adults, in whom infection of the middle ear
by hematogenous dissemination or contamination of the nasal
cavities and Eustachian tube is evidenced from contaminated
sputum from a distant, usually pulmonary [11,14,23].
Miliar form, begins as a tuberculosis in the submucosa
of the middle ear and subsequently involves the periosteum
and the bone.
Granulomatous form: manifests as a circumscribed
granuloma or as a proliferative lesion involving the bone.
Caseous form, showing tuberculous formations,
caseification and sometimes necrosis and bone sequestration
(Lederer 1973) .
With respect to the clinic, the classic triad described since
the discovery of tuberculous otitis media has been painless
otorrhea, tympanic perforation and facial paralysis. It is
necessary to emphasize that at present it is presented in a more
heterogeneous form, characterized by a slow and insidious
evolution of serous otorrhea, which may become purulent by
bacterial superinfection, with or without otalgia, and hearing
loss at diagnosis [13,20,24]. It is usually unilateral .
Hyperthermia is uncommon in uncomplicated cases and otalgia
is associated with bacterial superinfection [25,26].
Otorrhea, unlike suppurative otitis media, does not occur due
to the accumulated tension at the retrotimpanic level, but rather
due to the granulations formed on the areas of the tympanic
membrane as a result of the tuberculous process . Physical
examination; In otoscopy, it is possible to confirm serous or
purulent otorrhea from the middle ear which may have weeks or
years of evolution, with signs suggestive of CBT infection: thick
and hyperemic tympanic membrane, single broad or multiple
tympanic perforation (typically tend To coalesce forming a
large central perforation) as a result of caseous necrosis ,
the mucosa of the middle ear case looks pale or pink with
granulation tissue or granulomas are evident in the external
auditory canal, destruction of the ossicles Can sometimes be
observed through the perforated tympanic membrane, erosion
of the cortical mastoid bone and involvement of the facial nerve
sheath. Lymphadenopathy can be found in the periauricular
Active TB is diagnosed by demonstrating the microorganisms
in the sputum, tissues or body fluids, by direct examination
(Ziehl-Neelsen technique or fluorescent auramine-rhodamine
staining) or culture, either with the classical Löwestein-Jensen
technique Which takes 4 to 8 weeks to be isolated or using
more modern techniques for rapid diagnosis, such as molecular
biology (polymerase chain reaction) or high quality liquid
chromatography . Radiometric techniques allow it to grow
in 1 to 2 weeks, but more time is needed for its identification
. However, even the aetiological confirmation of TBC for OMT
poses a challenge. Mycobacterial direct observation tests have
poor performance .
First, in children infected with Koch’s bacilli, the bacillary
population is minimal, so they usually have negative sputum
smear and gastric aspirate. Second, as in other extrapulmonary
forms, the middle ear has a low concentration of bacilli, and
in addition the frequent use of optical drops with neomycin
(weakly antituberculous) , or other antibiotics, results in
bacteriological analyzes of secretions and histological tissue
of Low yield [14,24,28]. Third, the characteristics of the slow
growth of this agent, and the interference of its development
by other varieties of bacteria, make the probability of sputum
smear microscopy and positive culture in optic secretion less
than 20% and between 5 and 35% respectively [12,20,21].
A positive skin test may be helpful, but a negative result does
not exclude tuberculosis. As for its interpretation; Tuberculin test
(PPD) can be reported as: 0-4 mm (negative or non-reactive), 5-9
mm (weakly reactive) that can be seen in tuberculosis infections
by atypical mycobacteria or secondary to a response generated
by immunization with BCG and 10 mm or more (positive or
reactive) that may be seen in active infection by the tuberculous
bacillus or in response to non-immunized patients. The
observation of the acid-fast bacillus in Ziehl-Neelsen staining in
the ear fluid is a strong predictor of tuberculosis [9,26-29].
The imaging is fundamental, since it not only allows orienting
itself to a diagnosis, but also it can show possible complications. A
normal chest x-ray does not exclude the diagnosis of tuberculosis
. The method of choice is computed tomography, where
the opacification of the middle ear and mastoid, sclerosis of
the mastoid cortex, increased density and radiolucency of the
mastoid cortex can be objectified if there is bone resorption,
destruction of ossicles and mastoid bone destruction or Petrous
bone [28,30]. Likewise, a CT scan helps us to rule out chronic
granulomatous otitis media [8,31,32].
On the other hand, the pathological anatomy plays a
primordial role in relation to the etiological diagnosis of this
disease. A concordant histology with a TBC infection, with a
granulomatous tissue with epitheloid cells and giant cells of
Langhans with caseous and necrotic areas, together with a clinical
suspicion, are sufficient to confirm the diagnosis, independently
of the results of the cultures, taking into account Account the poor
performance of these. Another alternative available for diagnosis
is the polymerase chain reaction (PCR) technique for the genetic
analysis of the bacillus in optic secretion or tissue biopsy, with a
high sensitivity and specificity. However, a negative result does
not rule out TBC infection . In formulating the diagnosis of
all chronic otitis media should be kept in mind; And discard as
possible causes, fungal infection, cholesteatoma, histiocytosis,
Wegener’s granulomatosis, eosinophilic granulomatosis, syphilis
and sarcoidosis [20,24,31,33].
The criteria for the diagnosis of tuberculous otitis media
are: chronic otitis media that does not respond to conventional
treatment with oral or parenteral antibiotics, presence of
large granulation tissue in the middle ear, facial paralysis,
history of pulmonary tuberculosis, Tuberculin test (PPD) and
regional lymphadenitis. The presence of three of these criteria
establishes the diagnostic suspicion, whereas with five or more
of these criteria the diagnosis is considered . The presence
of casein granulomas should make us suspect infection with
mycobacteria and establish tuberculostatic treatment with the
objective of avoiding progression to the central nervous system
and permanent auditory sequelae [23,34]. Complications of
tuberculous otitis media are numerous. Its reversibility, and
the severity of its sequelae, are directly related to the time
of initiation of treatment, which reinforces once again the
importance of a suspicion and an early diagnosis .
The most frequent of these complications is hearing loss,
occurring in 90% of cases. This can be conductive type in 90%
due to tympanic perforation and destruction of the ossicles
chain, sensorineural in 8% with healthy tympanum related to
fistulas of the optical capsule at promontory level, and mixed
in 2% [21,23-25,35]. Patients may also have facial paralysis
and other cranial nerve palsies. Facial paralysis in the context
of chronic non-cholesteatomatous otitis media should lead to
suspicion of tuberculous etiology [23,27]. This is produced by
compression or by infiltration of its sheath. It is observed in
16% up to 35% of cases and is reversible. Other complications
include labyrinthitis, ossicular chain necrosis, otomastoiditis,
bone sequestration and destruction of the mastoid, and petrous
bone, retroauricular fistula, and temporo-mandibular joint
involvement. Among intracranial complications it is important to
mention: meningitis, tuberculoma, cerebral abscesses, multiple
cranial nerve palsies, labyrinthitis, and lateral thrombosis of the
sigmoid sinus [13,20,23,27,25].
The treatment of this entity can be medical or surgical.
However, most of the literature mentions that the treatment is
medical, with good results, and that a multidrug regimen should
be used for periods of not less than 6 months. The indicated
antibiotic scheme is the simplified primary of TB for pulmonary
or extrapulmonary forms, consisting of a daily phase of isoniazid,
rifampicin and pyrazinamide for 50 doses, and a biweekly phase
of isoniazid and rifampicin for 32 doses. The association with
corticosteroids has been used in some cases for the management
of granulations, control of the fibrotic scarring process, and
treatment of intracranial complications and facial paralysis .
After successful medical treatment, surgery may be
considered; Especially in those cases of patients who suffered
prolonged clinical signs before starting effective treatment.
Surgical exploration offers the ideal opportunity to make a
histological diagnosis . Necrotic tissue can be removed
through a mastoidectomy . Surgery is also indicated for the
resolution of those cases with subperiosteal abscesses, bone
sequestration and facial paralysis or paralysis of other reversible
cranial nerves . It is incorrect to suppose that all cases of
tuberculous otitis media should have a protracted evolution or
that a diagnostic presumption can not be made prior to extensive
destruction of the bone. However, for this to be possible, the
index of diagnostic suspicion should be raised especially in any
prolonged middle ear infection that does not respond to the
usual management and in those patients from countries where
the disease is endemic [11,23].
Early diagnosis of aural tuberculosis is of considerable
practical importance. Tuberculosis is a curable disease. Timely
and early treatment will prevent the loss of potentially normal
hearing as well as the development of serious neurological
complications [11,37-40]. Although tuberculous otomastoiditis
is a rare manifestation of extrapulmonary tuberculosis, it
should always be considered in cases of persistent otitis mediaor refractory to conventional treatment. There are typical
clinical characteristics that are not exclusive to tuberculosis
otomastoiditis, so the basis of the diagnosis is a well-founded
suspicion. Thus we can show that in our case the clinic focuses
on an abundant, non-feted otorrhea accompanied by otodynia,
hyperthermia and moderate left conductive hearing loss. There
was no evidence of involvement of the facial nerve. In addition,
it is worth noting that the biochemical tests performed to detect
the presence of the tuberculous bacillus were negative and that
the definitive diagnosis was made postoperatively after the
processing of the material sent to biopsy and the result of the
PPD, obtaining; Once the antituberculous treatment has started,
a satisfactory evolution of the clinical picture that allows the
discharge of the patient with outpatient follow-up.
Otitis is a public health problem of great importance
in Venezuela that warrants a rigorous and permanent
epidemiological surveillance. Doctors and the Venezuelan health
system have all the resources for their primary, secondary
and tertiary prevention to significantly reduce the frequency,
complications and sequelae of these infections. The primary
prevention is through immunizations, since the prevention
of viral infections (influenza, measles, rubella, mumps)
and bacterial infections (Haemophilus influenzae type b,
pneumococcus, meningococcus) is avoided.
Tuberculosis is a pathology that has evolved along with
advances in medicine since the last century. If it has very high
incidences to face the resistance in its treatment, the world
public health has had to adapt to new challenges to control
it. Tuberculous chronic otitis media is a very unusual form of
presentation. The clinical presentation is variable, the multiple
perforations that previously were characteristic features are no
longer seen so frequently. At present the typical characteristic of
the disease is a painless, profuse, non-fetid otorrhea that does
not respond to topical or systemic antibiotic treatment. It is
often accompanied by disproportionate hearing loss compared
to clinical findings and in most cases exuberant pale granulations
At the moment it is considered an entity of difficult diagnosis
by several factors:
The index of suspicion is very low as they occur in less
than 0.9% of the cases of otitis media reason why it is often
not considered in the differential diagnosis;
The clinical signs are variable and do not usually
coincide with the classic descriptions;
It is not usually associated with pulmonary involvement;
False negatives in the culture are very frequent
because of the nature of the Mycobacteria and because other
pathogens interfere in its growth. Therefore, the diagnosis is
usually made postoperatively in many cases.
Complications are significantly greater than those occurring
in the context of chronic suppurative otitis media or chronic
non-cholesteatomatous otitis including: hearing loss that may
be permanent, labyrinthitis, facial paralysis, ossicular chain
necrosis, otomastoiditis, abduction And bone destruction of the
mastoid, and of petrous bone, retroauricular fistula, temporomandibular
joint involvement, and lateral thrombosis of the
sigmoid sinus, among others. It is for this reason that this
etiology should be suspected in any case of otitis that does not
respond to the usual antibiotic treatment, or that presents as
non-painful otorrhea. The test of P.P.D. Routinely. Performing an
early diagnosis is vital, as; The earlier antituberculosis treatment
begins, the fewer complications. This review aims to raise in
the medical community a concern about this condition, since
at present, Koch’s bacillus infection is increasing worldwide,
so that every professional should be attentive and prepared to
perform a complete Differential diagnosis.