Primary tuberculosis of the middle ear cleft: diagnostic and therapeutic considerations

Abstract

Tuberculosis remains one of the most challenging infectious diseases, which rarely manifests in the middle ear cleft exclusively. Typical symptoms of tuberculosis have become more and more confusing due to the genetic evolution of different Mycobacterium species. In the diagnosis of tuberculous otitis media (TOM), clinical suspicion plays a fundamental role, when topical and/or systemic antibiotic treatment cannot lead to improvement in ear discharge and inflammation. If there is no other reason of persisting otorrhea, microbiological sampling and culturing are the subsequent steps of diagnosis. These investigations, however, have low sensitivity; therefore a canal wall-up mastoidectomy is recommended, which includes the removal of necrotic bone and multiple histological sampling from various locations. Currently, histopathological analysis is the most robust and reliable method in the diagnosis of TOM. Tuberculin skin test, Mycobacterium-specific PCR and interferon-gamma release assay cannot distinguish between active, inactive or post-infective conditions. According to these considerations, these methods may serve as supplementary assays for the final diagnosis. Having the appropriate diagnosis after surgical intervention and laboratory analysis, medical management should be continued by anti-tuberculosis chemotherapy. Hereby, we demonstrate two cases with primary TOM and provide an overview of the literature in the light of diagnostic and therapeutic guidelines in the management of TOM.

Tuberculous Otitis Media—A Rare Entity or a Missed Diagnosis

“…In our study we used molecular genetic studies to facilitate detection of bacteria in low counts, and they have the advantage of labelling drug resistance. But Mycobacterium-specific PCR and interferon-gamma release assay cannot distinguish between active, inactive or post-infective conditions [15].…”

Chronic Tuberculous Otomastoiditis: A Case Report

“…We note that the role of surgery with therapeutic intent remains controversial and that the effectiveness of surgery has not been definitively proven. Some authors oppose this practice unless complications are present and there is no indication of ossicular chain reconstruction, at least prior to symptom resolution [9,10] . On the other hand, Kwon et al [11] recently demonstrated that higher rates of dry ear are achieved when surgery preceded chemotherapy than with chemotherapy alone.…”

“…The tuberculin (PPD or Mantoux) and Quantiferon tests have very low specificity due to their potential for positive results in cases of previous infection or vaccination [9] . CT imaging studies could detect inflammatory tissue within the tympanic cavity and mastoid cells with or without bone erosion, and in chronic infection, they may identify ossicular resorption and mastoid sclerosis.…”

“…Canal wall up tympanoplasty is useful for removing the necrotic bone and granulation tissue and collecting analytical samples. Finally, histopathological examination is the most effective diagnostic tool for chronic tuberculous otomastoiditis [9] . We note that the role of surgery with therapeutic intent remains controversial and that the effectiveness of surgery has not been definitively proven.…”

Tuberculosis of Middle Ear

“…Approximately one-third of total human population is infected by Mycobacterium tuberculosis. 1 India is the country with the highest burden of TB, with the World Health Organization statistics for 2013 giving an estimated incidence figure of 2.1 million cases of TB for India out of a global incidence of 9 million. 2 Tuberculosis can be pulmonary or extrapulmonary.…”