Erkul et al., Otolaryngology 2012, 2:3
http://dx.doi.org/10.4172/2161-119X.1000119
Otolaryngology
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Tuberculous Mastoiditis: Report of an Uncommon Case in Morocco
Abada RL*, Nadef N, Elkhiati G, Rouadi S, Mahtar M, Roubal M, Essaadi M and Kadiri F
E.N.T Department, 20 August Hospital, Casablanca, Morocco
Abstract
Although tuberculosis is a major problem of public health in Morocco, the tuberculous mastoiditis remains extremely
rare, and its diagnosis is often delayed. We report here the case of a 3-year-old child who had unusual chronic left
mastoiditis and retro-auricular fistula, associated with spontaneous discharge of bony sequestrum. CT scan of temporal
bones showed complete destruction of left mastoid cells. A left mastoidectomy confirmed the tuberculous mastoiditis
diagnosis after histopathological examination. The clinical outcome was favorable after anti-tuberculosis treatment.
Otologic tuberculosis of the ear is well described in the literature and symptoms include chronic otorrhea with
audio-vestibular symptoms. The specificity of this case is that the child had an isolated involvement of the mastoid with
spontaneous bony sequestrum discharge, but without otorrhea.
Keyswords:
Tuberculosis; Tuberculous
sequestrum; Fistula; Mastoidectomy
mastoiditis;
Bony
Introduction
In Morocco, tuberculosis is a major public health problem. It is
a contagious infection with endemic and epidemic transmission.
According to WHO, about 10 million people are infected in the world
and 3 million die every year mainly in developing countries [1,2].
The main germ “mycobacterium tuberculosis” becomes very
aggressive when associated with local and/or general immune
deficiency. The main risk factors include elderly, malnutrition and HIV
infection [1,3].
Common infections are mainly located in the pulmonary system,
lymph nodes and visceral organs. Middle ear infections and tuberculous
mastoiditis are rare manifestations. They represent less than 0.1% of all
chronic suppurative otitis media [1,2].
strictly normal. Biological results revealed hyperleukocytosis at 25000/
µl, with 39% of lymphocytes. The C-reactive protein (CRP) was 30
mg/l. Chest X-ray was normal. The audiogram showed a left ear
conductive loss (35 dB), with an air bone-gap of 25 dB. CT scan of the
temporal bones showed left middle ear filling cavities associated with
irregular destruction in mastoid air cells and bony sequestrum, but no
intracranial expansion (Figure 2).
In regards to the atypical clinical presentation, a left mastoidectomy
was therefore performed. Granulomatous inflammation of mastoid
mucosa was found and a bony sequestrum was removed (Figure 3).
Histological examination of the resected material revealed the presence
of a tuberculous granuloma with caseous necrosis, confirming the
diagnosis of tuberculous mastoiditis.
The most common tuberculous mastoiditis may be secondary to
spread of infection through the Eustachian tube, the haematogenous
route or the tympanic membrane [1,2,4]. The diagnosis of tuberculous
mastoiditis can be difficult for a number of reasons including the wide
range of symptoms. This often results in prolonged delays between the
onset of symptoms and the diagnosis [1]. We present here a case report
of tuberculous mastoiditis which underlines some of the diagnosis
difficulties and potential complications.
Case report and Clinical Examinations
A 3-year-oldboy, vaccinated at birth, with no medical or surgical
history, presented to our ENT department with left retro-auricular
fistula, as a result of a progressive swelling for the past five months.
There was no history of tuberculosis exposure. The child complained
of hearing loss. There was no otorrhea, vertigo, facial nerve palsy or
fever. The evolution was marked by spontaneous discharge of bony
sequestrum from the retro-auricular fistula.
Clinical examination showed a painful left mastoiditis fluctuant
to palpation, with a cutaneous purulent fistula discharging bony
sequestrum (Figure 1).
Otoscopy showed an inflammatory bulging tympanic membrane
without purulent secretions or perforations. The Ear, Nose and Throat
(E.N.T) examination was normal, with no right ear abnormalities
or lymph nodes. Neurological and pulmonary examinations were
Otolaryngology
ISSN:2161-119X Otolaryngology an open access journal
Figure 1: Retroauricular fistula on the left side.
*Corresponding author: Abada Redallah Larbi, E.N.T Department, 20
August Hospital, Casablanca, Morocco, Tel: 00212-6-61235170; E-mail:
[email protected]
Received July 12, 2012; Accepted July 30, 2012; Published August 03, 2012
Citation: Abada RL, Nadef N, Elkhiati G, Rouadi S, Mahtar M, et al. (2012)
Tuberculous Mastoiditis: Report of an Uncommon Case in Morocco. Otolaryngology
2:119. doi:10.4172/2161-119X.1000119
Copyright: © 2012 Abada RL, et al. This is an open-access article distributed under
the terms of the Creative Commons Attribution License, which permits unrestricted
use, distribution, and reproduction in any medium, provided the original author and
source are credited.
Volume 2 • Issue 3 • 1000119
Citation: Abada RL, Nadef N, Elkhiati G, Rouadi S, Mahtar M, et al. (2012) Tuberculous Mastoiditis: Report of an Uncommon Case in Morocco.
Otolaryngology 2:119. doi:10.4172/2161-119X.1000119
Page 2 of 3
Anti-tuberculosis treatment including rifampicin, isoniazid,
pyrazinamide and ethambutol, was started. At follow-up two months
later, clinical examination showed the disappearance of the fistula, the
complete healing of the mastoid wound and the normalization of the
tympanic membrane (Figure 4), but the patient showed tuberculous
cervical lymph nodes with necrosis (Figure 5). The complete healing
was observed by the end of the anti-tuberculosis treatment maintained
for 9 months. Today, the child is declared cured, at 30 months followup.
Discussion
This case highlights a number of potential issues leading to the
delay in diagnosis, which is a hallmark of tuberculous mastoiditis.
Although rare, the classical description of tuberculous otitis, reported
in literature, includes painless otorrhea, facial palsy and multiple
perforations [1,3,5,6]. Contrary to this classical description, in our
Figure 5: Tuberculosis in cervical lymph nodes.
case there was no evidence of otorrhea or facial paralysis, and any
perforation was observed by otoscopy. However, the patient was
suffering from hearing loss. In literature, it might range from moderate
conductive hearing-loss tocophosis [1].
One or multiple perforations in the tympanic membrane, with
polypoid middle ear mucosa are typical of the disease. Our patient
had an inflammatory bulging of the tympanic membrane, without
perforations.
Figure 2: CT scan of the temporal bones showing bone destruction and
sequestrum of the left ear.
At an advanced stage of the disease, the eardrum or the atrium
can present a granulomatous or necrotic aspect, and bony sequestrum
occurs frequently [4]. The occurrence of pre-auricular or cervical
lymph nodes is not uncommon, and development of retro-auricular
fistulais usual [1,2,3,4]. Our patient had a mastoiditis associated with
left retro-auricular fistula and cervical lymph nodes.
Tuberculous mastoiditis may cause serious complications. When
the infection spreads from the ear canal to the nearby tissues such as
the skull base or the tegmen tympani, tuberculous mastoiditis could
lead to skull base osteomyelitis or tuberculous meningitis [1].
According to the study reported by Rho et al. [7], CT scan of the
temporal bones showed, in most cases, soft tissue attenuation in the
entire middle ear cavity, preservation of the mastoid air cells without
sclerotic change, and soft tissue extension to the external auditory
canal (EAC) or mucosal thickening of the bony EAC. In our case, the
CT scan showed total destruction of mastoid air cells with multiple
bony sequestrae, and bone cavities filled in the left middle ear. Table 1
resumes some CT scan results reported in literature.
Figure 3: Bony sequestrum removed during mastoidectomy for histological
examination.
Figure 4: Complete healing after anti-tuberculosis treatment.
Otolaryngology
ISSN:2161-119X Otolaryngology an open access journal
According to Samuel and Fernandes [8], the incidence of bony
sequestrum could reach 30% of cases. Therefore, CT scan is the
imaging tool of choice to identify the bony sequestrum and the extent
of the disease before surgical intervention. MRI can be also used for
diagnosis; it helps identifying intracranial extension, but has a limited
role for various complications of otologic tuberculosis [9]. Tuberculosis
of the middle ear and mastoid may be associated with pulmonary
involvement in 50% of cases; therefore a chest X-ray may facilitate the
diagnosis [1,3,7]. Finally, laboratory diagnosis can be problematical.
The tuberculin intradermal test (also known as Mantoux test) is
usually positive, but a negative test does not exclude the diagnosis.
The diagnosis of tuberculous mastoiditis remains difficult, and is
discussed and confirmed during the pre and post-operative period by
bacteriological and histological findings [6].
The treatment is mainly medical, based on anti-tuberculosis drugs
for a period ranging from 6 to 12 months. The role of surgery in the
treatment of tuberculous mastoiditis is limited. Indeed, surgery is
Volume 2 • Issue 3 • 1000119
Citation: Abada RL, Nadef N, Elkhiati G, Rouadi S, Mahtar M, et al. (2012) Tuberculous Mastoiditis: Report of an Uncommon Case in Morocco.
Otolaryngology 2:119. doi:10.4172/2161-119X.1000119
Page 3 of 3
Reference
n
Age (years)
Gender
Symptoms
Otoscopy
CT-scan
Hamouda et al. (2008)(3)
1
13
F
Otorrhea and cervical lymph node
Polypoid of the external
Filled mastoid
auditory meatus
Chmielik et al. (2007)(2)
1
4
M
Acute otitis media with fever
Inflammatory bulging of Filled mastoid and bone
the eardrum
erosion
Saunders et al(2002)(4)
1
7
F
Reccurent otorrhea
Anterior retraction of
eardrum
Filled mastoid without bone
erosion
Vital and Al (2002)(6)
4
19-56
3F-1M
Otorrhea
Multiple perforations of
eardrum
-
Meher et al. (2006)-10
5
3-13
2F-3M
Retroauricular swelling (3)
Retroauricular fistula (1)
Facial palsy (1)
Eardrum perforation,
polypoid and
granulation
-
Our patient (2010)
1
3
M
Retroauricular swelling and fistula
Bulged eardrum with
Spontaneous discharge of bony sequestrum inflammation
Filled mastoid and destruction
with bony sequestrum
Table 1: Main cases of auricular tuberculosis reported in literature.
indicated only for loco regional complications, such as subperiosteal
abscess evacuation or bony sequestrum removal. In the case of a
suspected diagnosis, surgical exploration could be proposed for biopsy
[4,5]. Finally, in case of facial paralysis, surgical decompression of the
facial nerve may be beneficial, although this issue remains under debate
[4]. However, the evolution of the facial paralysis is generally favorable
under treatment.
Conclusion
Tuberculous mastoiditis is a rare clinical manifestation but
potentially dangerous. The diagnosis is difficult therefore frequently
delayed. In otologic infections when imaging results show significant
destruction of mastoid air cells and presence of bony sequestrum,
tuberculous mastoiditis should be suspected. The anti-tuberculosis
therapy remains the main stay of treatment for mastoid and middle
ear tuberculosis. Surgery aims to provide the samples required for
bacteriological and histological examinations, allowing subsequently
early diagnosis.
References
1. Duclos JY, Darrouzet V, Ballester M, Bebear JP, Bebear CM (1999)
Tuberculose de l’oreille moyenne ; Encycl Med Chir ( Elsevier,Paris ), Otorhino-laryngologie, 20-235-A-10, 4 p.
2. Chmielik LP, Ziolkowski J, Koziolek R, Kulus M, Chmielik M (2008) Ear
tuberculosis: clinical and surgical treatment. Int J Pediatr Otorhinolaryngol 72:
271-274.
3. Hamouda S, Opsomer H, Delattre A, Thumerelle C, Flammarion S, et al. (2008)
Tuberculous otitis media. Med Mal Infect 38: 608-611.
4. Saunders NC, Albert DM (2002) Tuberculous mastoiditis: when is surgery
indicated? Int J Pediatr Otorhinolaryngol 65: 59-63.
5. Singh B (1991) Role of surgery in tuberculous mastoiditis. J Laryngol Otol 105:
907-915.
6. Vital V, Printza A, Zaraboukas T (2002) Tuberculous otitis media: A difficult
diagnosis and report of four cases. Pathol Res Pract 198: 31-35.
7. Rho MH, Kim DW, Kim SS, Sung SY, Kwon JS, et al. (2007) Tuberculous
otomastoiditis on high-resolution temporal bone CT: comparison with
nontuberculous otomastoiditis with and without cholesteatoma. Am J
Neuroradiol 28: 493-496.
8. Samuel J, Fernandes CM (1986) Tuberculous mastoiditis. Ann Otol Rhinol
Laryngol 95: 264-266.
9. Munoz A, Ruiz-Contreras J, Jimenez A, Maté I, Calvo M, et al. (2009) Bilateral
tuberculous otomastoiditis in an immmunocompetent 5-year-old child: CT and
MRI findings. Eur Radiol 19: 1560-1563.
10.Meher R, Singh I, Yadav SP, Gathwala G (2006) Tubercular otitis media in
children. Otolaryngol Head Neck Surg 135: 650-652.
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