HEARING LOSS DUE TO EXTRAPULMONARY TUBERCULOSIS: A CASE REPORT
REGISTRO DOI: 10.69849/revistaft/ra10202511212113
Silmara Inocêncio Silvino da Silva¹
Maria Luiza Peixoto de Rubim Farias²
Maria de Fátima Alécio Mota³
RESUMO
Este relato descreve um caso raro de tuberculose extrapulmonar com acometimento mastoide em paciente jovem e imunocompetente, inicialmente tratado como otite média aguda. A paciente passou por múltiplas abordagens clínicas e cirúrgicas sem sucesso, até que exames complementares (PPD, LAN e radiografia de tórax) indicaram tuberculose mastoideia. O diagnóstico tardio resultou em perda auditiva irreversível, apesar da boa resposta ao tratamento com esquema RIPE. O caso destaca os desafios no diagnóstico diferencial de infecções otológicas crônicas, a importância da suspeição clínica frente a quadros refratários e a necessidade de integração entre exames clínicos, radiológicos e laboratoriais para evitar complicações e garantir melhor prognóstico.
PALAVRAS CHAVES: Tuberculose extrapulmonar; Mastoidite; Perda Auditiva.
ABSTRACT
This report describes a rare case of extrapulmonary tuberculosis with mastoid involvement in a young, immunocompetent patient, initially treated as acute otitis media. The patient underwent multiple unsuccessful clinical and surgical approaches until additional tests (PPD, LAN, and chest X-ray) indicated mastoid tuberculosis. The delayed diagnosis resulted in irreversible hearing loss, despite a good response to treatment with the RIPE regimen. The case highlights the challenges in the differential diagnosis of chronic ear infections, the importance of clinical suspicion in refractory conditions, and the need for integration of clinical, radiological, and laboratory tests to avoid complications and ensure a better prognosis.
KEYWORDS: Extrapulmonary tuberculosis; Mastoiditis; Hearing loss.
INTRODUCTION
Tuberculosis (TB) remains one of the leading causes of morbidity and mortality from infectious diseases worldwide, with approximately 10.6 million new cases and an estimated 1.6 million deaths in 2021, according to the World Health Organization (WHO, 2023). Although the pulmonary form accounts for the majority of cases, extrapulmonary tuberculosis (EPTB) represents approximately 15–20% of infections, occurring more frequently in immunocompromised patients and vulnerable populations (Golden & Vikram, 2005; Brazil, 2021). Mastoid tuberculosis is a rare manifestation of EPTB, accounting for less than 0.1% of cases. It is characterized by infection of the mastoid process of the temporal bone, with a clinical presentation that can mimic other otologic diseases such as chronic otitis media and cholesteatoma (Zhou et al., 2017; Barros et al., 2019).
In the pathophysiology of this condition, tuberculosis may affect the middle ear through three routes: aspiration of mucus via the Eustachian tube, hematogenous dissemination from other tuberculous foci, or direct implantation through the external auditory canal and tympanic membrane perforation (Gupta et al., 2024).
The clinical presentation typically includes local pain, edema, persistent otorrhea, hearing loss, and, in some cases, the formation of fistulas or abscesses, making differential diagnosis essential to exclude other infectious and neoplastic diseases (Barros et al., 2019). Diagnosis is based on the correlation of clinical findings, imaging studies — such as computed tomography (CT) and magnetic resonance imaging (MRI) —, microbiological tests (smear microscopy, Mycobacterium tuberculosis culture), and histopathological confirmation (Prakash et al., 2015).
The treatment of mastoid tuberculosis follows the standard protocol recommended for tuberculosis, which consists of an initial 2-month phase using a combination of four drugs — rifampicin, isoniazid, pyrazinamide, and ethambutol (RIPE) — followed by a continuation phase of 4 to 7 months with rifampicin and isoniazid (Brazil, 2021). The total duration may vary depending on clinical response and disease extent and can be extended in complicated cases or in immunosuppressed patients. In some situations, surgical intervention is indicated for abscess drainage, removal of necrotic tissue, or biopsy for diagnostic purposes (Golden & Vikram, 2005; Barros et al., 2019). Strict adherence to the therapeutic regimen is essential to prevent drug resistance and to ensure complete disease cure.
OBJECTIVE
To report a clinical case of extrapulmonary tuberculosis with mastoid involvement, emphasizing the challenges faced in the differential diagnosis from other otologic conditions, the atypical clinical presentation with auditory repercussions, the complementary methods used for etiological confirmation, as well as the therapeutic approach adopted and its outcomes, aiming to contribute to the expansion of clinical knowledge regarding this rare manifestation of tuberculosis.
METHODOLOGY
This is a descriptive case report with a qualitative approach, based on the clinical experience of managing a patient diagnosed with extrapulmonary tuberculosis with mastoid involvement. The present report was developed to share relevant aspects of diagnosis, treatment, clinical evolution, and outcomes, highlighting the challenges encountered and the management approach adopted.
Data collection was performed retrospectively through the analysis of the medical record, laboratory and imaging tests, outpatient follow-up notes, and hospital course documentation. The information was organized chronologically, maintaining patient confidentiality and anonymity in accordance with the ethical principles established by Resolution No. 510/2016 of the Brazilian National Health Council.
This study was conducted in accordance with ethical principles of clinical practice. As it is an experience report using secondary data, without patient identification or intervention in their care process, it is exempt from submission to a Research Ethics Committee, according to current regulations.
CASE REPORT
A 28-year-old single female nurse, previously healthy, presented to an otolaryngology consultation with symptoms of acute otitis media in the right ear for five days, reporting progressive hearing loss, otalgia, low-grade fever (38°C), and auditory irritability. Otoscopy revealed hyperemia and bulging of the tympanic membrane, associated with opacity and reduced mobility. The patient was prescribed an antibiotic regimen of Amoxicillin 875 mg + Potassium Clavulanate 125 mg for 14 days.
Following completion of the prescribed medication and persistence with worsening of symptoms, the patient sought a second medical opinion, where she was again diagnosed with Acute Otitis Media (AOM) and prescribed Levofloxacin 750 mg for 14 days.
Before completing this second course of antibiotics, the patient developed tympanic membrane rupture with profuse serous otorrhea (Figure 1). She then consulted a third otolaryngologist, who diagnosed Chronic Otitis Media (COM) and prescribed a new treatment regimen with Ciprofloxacin 500 mg for 14 days.
Due to continued symptom refractoriness and clinical deterioration, the patient sought evaluation by a fourth otolaryngologist, who ordered a non-contrast mastoid computed tomography (CT) scan, which revealed right-sided otomastoidopathy, with an associated cholesteatomatous component not being ruled out. In addition, an audiometry test was performed, which showed moderately severe right-sided hearing loss. The physician prescribed six doses of Benzathine Penicillin G 1,200,000 IU administered at 21-day intervals.
After failure of this latest clinical treatment, the patient sought a fifth otolaryngologist, a specialist in refractory COM cases. This physician attempted another medical regimen combining oral and topical Ciprofloxacin 750 mg and indicated surgical treatment via mastoidectomy with tympanoplasty.
The surgery was performed, and a tissue sample was collected for culture. Mucosal cleaning with resection of metaplastic epithelium was undertaken, and the specimen tested negative for all microorganisms (Figure 2). The patient continued to experience worsening symptoms without clinical improvement. New mastoid computed tomography (CT) and audiometry tests were ordered, revealing sequelae of otomastoiditis with evidence of right-sided mastoidectomy. The mastoid cavity and residual mastoid air cells were filled with soft-tissue density material of nonspecific appearance, and recurrence or persistence of a cholesteatomatous component could not be ruled out. Audiometry demonstrated profound hearing loss in the right ear and severe sensorineural hearing loss in the left ear, respectively.
At a follow-up consultation, due to the persistence of symptoms even after surgery, the physician suggested the possibility of extrapulmonary tuberculosis localized in the mastoid — a very rare and difficult-to-diagnose condition, more commonly seen in immunosuppressed patients. Based on this suspicion, serological testing, PPD, LAM, and chest X-ray were ordered, which yielded results consistent with the diagnosis of extrapulmonary TB in an immunocompetent patient: negative serology, positive LAM (Figure 3), and PPD > 18 mm in the anterior region of the left arm (Figure 4)
The patient was referred to a specialized tuberculosis center and underwent six months of treatment with the RHZE regimen (Rifampicin, Isoniazid, Pyrazinamide, and Ethambutol), showing improvement in the infectious clinical condition. However, she developed irreversible hearing loss, likely associated with excessive antibiotic therapy and a non-conservative surgical approach.
The most recent computed tomography (CT) scan revealed signs of previous surgical manipulation in the right mastoid with associated otomastoidopathy and improvement on otoscopic examination. The patient was discharged from tuberculosis treatment after six months and referred for auditory rehabilitation to plan the subsequent use of an external hearing aid.
Figure 1. Tympanic membrane rupture observed on otoscopy
Source: Authors’ archive
Figure 2. Bacterioscopic culture test of secretion collected during mastoidectomy
Source: Authors’ archive
Figure 3. Positive rapid test for LAM antigen Source: Authors’ archive
Source: Authors’ archive
Figure 4. Tuberculin skin test (PPD) > 18 mm
Source: Authors’ archive
DISCUSSION
Tuberculous otomastoiditis is a rare form of infection of the middle ear and mastoid air cells caused by Mycobacterium tuberculosis. It accounts for approximately 4% of tuberculosis cases involving the head and neck region and only 0.05-0.9% of cases of chronic otitis media (de Andrade et al., 2025). This low incidence contributes to delayed diagnosis, as clinical findings are nonspecific and often mimic more common conditions such as chronic mastoiditis, cholesteatoma, necrotizing external otitis, or chronic suppurative otitis media.
High-resolution computed tomography (CT) of the temporal bone is the best imaging modality available to identify features suggestive of tuberculosis, assess the extent of the disease, detect potential complications, and delineate the anatomy prior to surgery. The gold standard for establishing a definitive diagnosis includes culture and histopathological examination of material obtained from the middle ear and mastoid, along with polymerase chain reaction (PCR) analysis (Gupta et al., 2024). However, due to the typically low bacillary load in extrapulmonary tuberculosis, cultures may yield negative results. In such cases, other diagnostic tests, such as the tuberculin skin test (PPD) — performed through intradermal application of bacillary proteins that trigger a hypersensitivity reaction (BRASIL, 2014) — and the LAM antigen test—based on detection of the lipoarabinomannan molecule, a cell wall component of M. tuberculosis found in the urine of infected patients — can aid in diagnosis (BRASIL, 2020).
In the reported case, the diagnostic process was challenging and prolonged, with confirmation achieved only after investigation using the PPD and LAM tests, given the unfeasibility of histopathological examination, which commonly identifies latent tuberculous infection.
Treatment is based on multidrug therapy using the RIPE regimen during the intensive phase and the RI regimen during the maintenance phase. Surgical intervention is reserved for cases involving complications such as abscess formation, associated cholesteatoma, therapeutic failure, or diagnostic necessity (de Andrade et al., 2025). In the present case, the patient demonstrated a good response to pharmacological treatment, although an adjuvant surgical procedure for abscess drainage had been erroneously performed prior to the initiation of drug therapy.
The prognosis of extrapulmonary mastoid tuberculosis depends on early recognition and timely initiation of appropriate therapy. Possible complications include ipsilateral peripheral facial paralysis, severe hearing loss, and bone destruction (de Andrade et al., 2025). The unfavorable clinical course observed in the described patient underscores the importance of including tuberculosis in the differential diagnosis of chronic, treatment-resistant mastoiditis.
Therefore, this case contributes to the literature by highlighting a rare and diagnostically challenging clinical presentation, emphasizing the need to maintain a high index of suspicion when evaluating chronic, refractory otologic conditions. Furthermore, it illustrates the importance of integrating clinical, radiological, and laboratory findings to achieve a definitive diagnosis and ensure early treatment initiation—factors that have a direct impact on patient prognosis, given the high morbidity associated with this condition.
CONCLUSION
Extrapulmonary mastoid tuberculosis is a rare entity, often difficult to suspect clinically, with diagnosis frequently delayed due to its similarity to more common otologic conditions. This case reinforces the need to include tuberculosis in the differential diagnosis of chronic, refractory mastoiditis, particularly in immunocompromised patients. Early recognition and prompt initiation of antituberculous multidrug therapy are essential to prevent complications and ensure a better prognosis. The present report contributes to the literature by describing an uncommon clinical presentation and alerting healthcare professionals to the importance of maintaining clinical suspicion in atypical cases.
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¹ Graduanda em Medicina pelo Centro Universitário Cesmac. E-mail: enfasilmara@hotmail.com
² Graduanda em Medicina pelo Centro Universitário Cesmac. E-mail: malupeixotof2@gmail.com
³ Especialista em Pneumologia e Tisiologia pela Sociedade Brasileira de Pneumologia, Supervisora do internato de Clínica Médica 2 e professora de Pneumologia, do Curso de Medicina do Centro Universitário CESMAC. E-mail: mariaalecio@hotmail.com