Learning Objectives: Present a case of atypical presentation of middle ear tuberculosis.
Introduction: A 47 yo woman, with no medical history, presents to A&E with a tinnitus and blocked left ear for 2 weeks.
On physical examination there is inflammation and whitish exudate on the back wall of the pharynx. Left ear has opaque eardrum with hyperemic annulus.
Nasal endoscopy shows inflammated adenoids with abundant exudate and PTA conductive hearing loss in the left ear. Tympanometry is type B curve in the left ear.
Evolution: The patient is given deflazacort, cefuroxime and nasal irrigation but 2 weeks later she reports no improvement.
CT scan is ordered to rule out neoplasm. It shows hyperplasia in the left side of nasopharynx that doesn't capture contrast. Left middle ear cleft is opacificated with no signs of osteolysis. The neck scan reveals irregular consolidation in the right upper lobe so a torax CT is performed. It shows scarring, tree-in-bud pattern in right lung, all suggestive of tuberculosis.
PPD test is positive and so are acid-fast staining and culture of the sputum. The patient is diagnosed with pulmonary tuberculosis and 4-drug regimen is initiated (ethambutol, isoniazid, pyrazinamide, rifampin). A month later (so she is no longer contagious) the patient has an adenoidal biopsy and left myringotomy. There is no effusion in the middle ear. The microbiology (swabs) confirms adenoidal and middle ear tuberculosis.
The patient's otic symptoms resolves but 6 months later she reports tinnitus and blocked left ear. Otoscopy is normal but PTA shows small conductive hearing loss. Wait and see attitude is proposed and the patient agrees. 5 moths later the patient is free from pulmonary tuberculosis but her left ear remains blocked. Myringotomy reveals very thick transparent fluid and a grommet is inserted. The microbiology is negative for tuberculosis. The patient's symptoms get better.
If the problem recurs once the grommet falls out should we think about scarring of the Eustachian tube? Would a balloon dilatation of the tube be feasible?
