Title : A case of tuberculous mastoiditis presented as CSOM with subperiosteal abscess- A rare occurence
Tuberculous mastoiditis is a rare form of presentation of tuberculosis. Here we are presenting a case of left ear CSOM with post mastoidectomy status. Biopsy results came as granulomatous lesion with AFB Stain positive.
Tuberculous mastoiditis was first described by Jean Louis Petit in the 18th century. Wilde in 1853 presented the classical picture of tuberculosis otitis media as a disease characterized by painless, insidious onset of ear discharge, multiple perforations in the tympanic membrane, and pale granulations in middle ear cleft. Politzer discussed the destructive nature of this disease in 1882. The incidence of tuberculosis otitis media has been reported to be 0.04% to 0.9% of all Chronic Suppurative Otitis Media (CSOM) in the developed countries. Tuberculosis affects the middle ear through three routes; aspiration of mucus through the Eustachian tube, blood borne dissemination from other tuberculous foci or direct implantation through the external auditory canal and tympanic membrane perforation.
16 year old male presented with complaints of left sided ear pain and swelling in the left mastoid region for past one month. History of hard of hearing present. History of low grade fever with evening rise of temperature present. History of loss of weight around 4kgs in 2months.Contact history of PTB in his father. CT of the left mastoid shows extensive bony destruction. Examination of the left ear shows perforation in the tympanic membrane.
He was initially diagnosed as left ear chronic suppurative otitis media with subperiosteal abscess, for which he underwent left mastoidectomy with tympanoplasty. They found bony destruction with pale granulation tissue. Tissue was sent for histopathological examination. The results came as Granulomatous inflammation with caseous necrosis compatible with Tuberculous etiology, also positive for AFB stain. CT-Chest shows Multifocal centrilobular nodules with tree in bud appearance in bilateral upper lobes with distal areas of air trapping. Enlarged pretracheal nodes largest measuring around 1.3*1 cms. He was diagnosed as a case of Disseminated TB and started on Anti tuberculous treatment. He took ATT for 9 months. The follow up after treatment showed resolution of the symptoms and improvement of the lesion.
TB of the middle ear and mastoid may occur as a result of haematogenous or lymphatic spread or by extension to the middle ear cleft through the eustachian
tube. Tuberculous mastoiditis is very rare and has a classical presentation. It should be considered in patients with chronic middle ear infection unresponsive to routine antibiotic therapy with painless ear discharge, hearing loss disproportionate to the extent of disease and Single or multiple perforations, in some cases central or total perforation. Facial nerve palsy is rare. Tuberculosis of the mastoid include the presence of caseous material and granulation tissue seen on otoscopy extending into the mastoid and may sometimes be confused with a cholesteatoma. Tuberculous otitis media requires a high index of suspicion even in the absence of pulmonary tuberculosis. Demonstration of (Acid Fast Bacilli) AFB in the ear discharge is difficult. The positivity for AFB in ear discharge varies from 5 to 35% and on repeated examinations it improves to 50%. Diagnosis of extra pulmonary tuberculosis is essentially clinical and antitubercular therapy can be started on clinical or histopathological suspicion as done in our case. It’s essential to start the treatment early to avoid serious complication. The role of surgery is limited and indications for surgical intervention include cases unresponsive to medical therapy and extensive disease with bony sequestration.
Tuberculous mastoiditis should be considered in the differential diagnosis of patients presenting as CSOM with fever,loss of weight, with or without pulmonary involvement in endemic regions of tuberculosis and in poor socio-economic group population. Early diagnosis and prompt institution of antituberculous treatment is essential to avoid facial nerve paralysis and grave complications.