tuberculous otitis media 20100326

8/3/2019 Tuberculous Otitis Media 20100326

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Tuberculosis Otitis MediaTuberculosis Otitis Media

2010/3/262010/3/26

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IntroductionIntroduction

85% TB

lungs, 15%

extrapulmonaryor both

Tuberculosis otitis media is rare 0.9 to0.04% of all TB, or 0.04% of all COM, or4% of the head and neck TB

40~50%40~50% TOM have no evidence of TBTOM have no evidence of TBelsewhereelsewhere


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History

Wilde: the first to describe 1915: Turner and Fraser 2.8% insuppurative otitis media

1960: Friedman 0.09% in COM 1983: Jeang and Fletcher 0.04% in

COM


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EpidemiologyEpidemiology

Annual incidenceAnnual incidence5.5/100000 before5.5/100000 before1953 to 2.3/100000 after 19531953 to 2.3/100000 after 1953


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ENT local findingENT local finding Intact TM pale, tense, thickened and immobile, with

a strong vascular (hyperemic) pattern Thick ear drumThick ear drum earlyearly multiple perforationmultiple perforation withwith

abundantabundant pale granulationpale granulation, and late fused to, and late fused to a largea large

singlesingle Pale-yellow, avascular polypoid or granulation tissue inthe middle ear and EAC

Discharge may beDischarge may be

serousserous

, if bacterial, if bacterial

superinfectionsuperinfection

(79%),(79%), mucoidmucoid or purulentor purulent

Destruction of theDestruction of the ossiclesossicles may be visiblemay be visible conductivehearing loss


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The pathogenesisThe pathogenesis

Spread to the middle ear through the E tubeSpread to the middle ear through the E tube

HematogenousHematogenous spreadspread from another TB focusfrom another TB focus

Direct implantationDirect implantation through the EAC and TMthrough the EAC and TMperforationperforationAfter grommet tube insertionAfter grommet tube insertion

Aspiration of infected milkthrough the E tube was a verycommon way between 1900-1950


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CharacteristicsCharacteristics

Ear discharge does not react to abxAminoglycoside otics alter the smear andculture


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ExaminationExamination EAC smears are positive inEAC smears are positive in 20%20%, and cultures are, and cultures are

positive inpositive in 5 to 35%5 to 35%

Inoue et al :Inoue et al :PCRPCRprovides a more rapid and reliableprovides a more rapid and reliablediagnosisdiagnosis

Inoue et al : diagnosisInoue et al : diagnosis cannotcannot rest on staining ofrest on staining ofsecretionssecretions alone; it more likely requires aalone; it more likely requires a biopsybiopsy withwith

staining and culturestaining and culture

Tissue culture : 2Tissue culture : 2--6 weeks6 weeks


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Clinical presentation Otorrhea:Otorrhea: near 100%near 100%, thick or, thick or mucoidmucoid or thin andor thin and

watery, acute or chronic, constant or intermittent, lightwatery, acute or chronic, constant or intermittent, lightor profuse, and either serous or purulentor profuse, and either serous or purulent

Otalgia:Otalgia: about 30%about 30%

Profound hearing loss: (Profound hearing loss: (conductiveconductive--90%, SNHL90%, SNHL--8%,8%,mixedmixed--2%2%))

Vertigo,Vertigo, labyrinthitis

Peripheral facial palsy:Peripheral facial palsy: 15~40%15~40% PreauricularPreauricular adenopathiesadenopathies, cervical, cervical adenopathiesadenopathies ((7%7%))

oror retroauricularretroauricular fistulas,fistulas, retroauricularretroauricular bulging (bulging (20%20%))

Toxic signToxic sign---- extraduralextradural abscess orabscess or tuberculoustuberculous meningitismeningitis TemporalTemporal petrositispetrositis


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CT image


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ENT local findingENT local finding


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Intraoperative


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DiagnosisDiagnosis Biopsy withBiopsy with stainingstaining andand cultureculture should be consideredshould be considered Difficult:Difficult:

1)1) Less than 0.9% of COMLess than 0.9% of COM thethe lowlow incidenceincidence2)2) Clinical signs areClinical signs are variablevariable and often different from theand often different from the

classic descriptionclassic description

3)3) False negativeFalse negative culturescultures 1)1) The fastidious nature ofThe fastidious nature ofMycobacterium tuberculosisMycobacterium tuberculosis

(M. Tb)(M. Tb)

2)2) Other bacteria in the specimen interfering with itOther bacteria in the specimen interfering with itgrowthgrowth

3) Neomycin: weak anti-TB activity

The culture of the tissue or secretion is usually negative

Positive (AFB) smears are uncommon (2-14%)


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Differential diagnosisDifferential diagnosisInfectious:Infectious:

Fungal infections (e.g.Fungal infections (e.g. histoplasmosishistoplasmosis andand

blastomycosisblastomycosis), congenital or acquired syphilis,), congenital or acquired syphilis,

nocardiosisnocardiosis, chronic bacterial otitis, and necrotizing, chronic bacterial otitis, and necrotizing

external otitisexternal otitisNoninfectious:Noninfectious:

Wegener'sWegener's granulomatosisgranulomatosis,, sarcoidosissarcoidosis,,

cholesteatoma. lymphoma. andcholesteatoma. lymphoma. and histiocytosishistiocytosis XX

Trauma may cause CSF fluid to leakTrauma may cause CSF fluid to leak chronic serouschronic serous

drainagedrainage

Foreign bodies, tumors as SCC,Foreign bodies, tumors as SCC, rhabdomyosarcomarhabdomyosarcoma,,andand LangerhansLangerhans cellcell histiocytosishistiocytosis


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HistopathologicHistopathologic examinationexamination Nonspecific changes consistent with chronicNonspecific changes consistent with chronic

inflammationinflammation

May also reveal more specific signs such asMay also reveal more specific signs such as massivemassivelymphocyte andlymphocyte and langhanlanghan giant cell infiltrationgiant cell infiltration andand chronic

granulomatous inflammation with multinucleated giantwith multinucleated giantcellscells,, central cassationcentral cassation, or, or epitheloidepitheloid cellscells


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Duration of symptomDuration of symptom


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Clinical presentation

(TOM vs cholestetoma)

The incidence of complications with cholesteatomawas significantly lower than in TOM


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Hearing lossHearing loss


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Laboratory findingLaboratory finding The number of Mycobacteria is very low in

clinical specimens than sputum; pus swabfor culture (+) 5~35% or AFS(+)


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Laboratory findingLaboratory finding Tuberculin test: positive in 94% patients: Mastoid X-ray and chest X-ray Culture: positive tuberculous culture was

obtained in


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Laboratory findingLaboratory finding


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TreatmentTreatmentEffective anti T.B chemotherapy possible

to cure the infection without the surgery

Medication:Medication:

The same as that recommended forThe same as that recommended forextrapulmonaryextrapulmonary T.BT.B

4 anti4 anti--T.B drugs:T.B drugs: isoniazidisoniazid,, rifampinrifampin,,pyrazinamidepyrazinamide,, ethambutolethambutol for at leastfor at least 6 months6 months

Surgery without antiSurgery without anti--T.B therapyT.B therapy

development ofdevelopment offistulaefistulae and a failure of woundand a failure of wound


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Medication Treatment delay13.2 months Excellent result of anti-T.B drug for

otorrhea, closure of TM perforation,

disappearance of facial palsy Effects of hearing: unpredictable

Failure of drug treatment (HIV,preciously treated for TB)considermultiresistant M. tuberculosis strain


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Surgery Provide histological material for diagnosis

For the complication of post-auricular abscess,facial nerve palsy, subperiosteal abscess,fistulae, CNS involvement

For mastoid exploration After failure of medical treatment Anti-TB drug after surgery appeared to achieve

a dry ear earlier than those without surgery(Yang-Sun Cho et, Korea)


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ConclusionConclusion Microbiological and histolopathological

verification should be conducted, butnegative results do not rule out TB

PCR testing represents a most reliable, butstill controversial diagnostic method


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ConclusionConclusion The progression of TOM can beThe progression of TOM can be variablevariable

andand insidiousinsidious

Due to rarityDue to rarity factors that contribute tofactors that contribute tothe difficulty in diagnosing TOM includethe difficulty in diagnosing TOM includethethe unreabilityunreability of smearsof smears,, stainsstains, and, and

culturescultures in identifying AFBin identifying AFB


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ConclusionConclusion Delayed diagnosis and treatment canDelayed diagnosis and treatment can

result in severe complicationsresult in severe complications

The importance of maintaining a highThe importance of maintaining a highdegree of clinical suspicion of TOM,degree of clinical suspicion of TOM,particularly those whose PPD test isparticularly those whose PPD test is

positivepositive


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ReferenceReference Tanya Halvorsen et al: A case of tuberculous otitis media. Clinical

Pediatrics2006; 45:83-87

Victor Vital, Athanasia Printza et al: Tuberculous Otitis Media: Adifficult diagnosis and report of four cases. Pathl Res Pract2002.198: 31-35

Yang-Sun Cho: Tuberculous Otitis media: A Clinical and Radiologic

Analysis of 52 patients. Laryngoscope2006; 116:921-927 Ashwani Sethi et al: Primary tuberculoua petrositis.Acta

Otolaryngol2005; 125: 1236-1239 Mohammad Sohail Awan, et al: Tuberculous otitis media: Two

case reports and literature review. Ear Nose and Throat J2002;81: 792-794 Jacob Kahane and Benjamin T. Crane: Temporal Bone

Histopathology Case of the Month, Tuberculous Otitis Media,Otology & Neurotology, Vol. 30, No. 6, 2009

Ravi Meher, MS, Ishwar Singh et al: Tubercular otitismedia in children, OtolaryngologyHead and NeckSur er 2006 135 650-652


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ReferenceReference Chang Woo Kim et al: Tuberculous otitis media developing as a

complication of tympanostomy tube insertion. Eur ArchOtorhinolaryngol2006; accepted: 23 August

Lisa M. Chirch et al: Tuberculous otitis media: Report of 2 caseson Long Island, N.Y., and a review of all cases reported in the

United States from 1990 through 2003. Ear Nose Throat J2005;84: 488-497


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tuberculous otitis media 20100326

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