Tuberculous otitis media: Clinical challenges and long-term complications in three cases

Tuberculous otitis media (TOM) represents a rare extrapulmonary manifestation of tuberculosis, typically presenting with nonspecific early symptoms that make diagnosis challenging. The aim of this report is to present three cases of TOM and to review their clinical manifestations, diagnostic work-up, therapeutic management, and complications. We describe two patients with isolated TOM and a third who developed pulmonary tuberculosis during the course of the disease. In all three cases, symptoms followed a similar progression: Eustachian tube dysfunction, conductive hearing loss, and recurrent, painless otorrhea refractory to antibiotic therapy, accompanied by tympanic membrane (TM) perforations. Facial nerve palsy (FP) developed in two patients, either as a complication of untreated infection or following antromastoidectomy. Household exposure to Mycobacterium tuberculosis was confirmed in two of the three patients. The time from symptom onset to diagnosis was 6, 11, and 14 months, with the shortest delay observed in the patient who developed concurrent pulmonary symptoms. All patients received the standard four-drug regimen recommended by the WHO. Despite treatment, permanent complications persisted, including hearing loss, TM perforations, FP, postauricular fistula, and skin defects of the external auditory canal. These cases underscore that recurrent, painless otorrhea unresponsive to antibiotic therapy should prompt evaluation for TOM, particularly when accompanied by FP. Intraoperative identification of necrotic tissue in such cases warrants not only histopathological examination but also smear microscopy for acid-fast bacilli (AFB). The nonspecific clinical presentation and rarity of TOM contribute to initial misdiagnoses, leading to delays in establishing the correct diagnosis and initiating appropriate treatment.