A 87-year-old woman with a history of pulmonary fibrosis, chronic heart failure, and hepatitis C infection was admitted at our hospital in April 2010 with right ear otorrhea, otalgia, tinnitus, and peripheral facial nerve paralysis. The patient reported that symptoms gradually appeared over the last two years and for this reason in May 2009 she underwent mastoid curettage with concho-meatoplasty in local anaesthesia due to the high clinical risk of general anaesthesia at another institution. At that stage no serologic, histologic, or microbiologic analysis was performed. 
On admission the patient was apyretic, even if tachycardic (heart rate 98/min). Blood pressure was 110/75 mmHg and oxygenation saturation 98%. Examination of the right ear showed wide conchomeatoplasty, a large (5 cm) postauricular cutaneous mastoid fistula in the region of the previous retroauricular incision. The mastoid bone was partly uncovered and partly lined by granulation tissue that extended in the middle ear region with no tympanic membrane. Periauricular cutaneous lesions were also evident. Facial nerve function was House Brackmann grade III. Left ear was normal as well as the rest of the otolaryngologic examination. Hearing test showed a right dead ear and severe sensorineural hearing loss on the left side. Laboratory values included a white blood cell count of 9.530/mm3 (86.5% segmented neutrophils, 7.9 lymphocytes, 5% monocytes, 0.5% eosinophils, and 0.1% basophils), haemoglobin 13.0 g/dL, and platelets 185.000/mm3. Blood and urine cultures as well as sputum examination were negative. The chest X-ray was normal while high resolution computed tomographic (CT) scan of the lung showed a reticular pattern on all the pulmonary areas, with associated fibrotic areas. CT scan of temporal bones showed the signs of the previous surgery, as well as inflammatory tissue in the right external auditory canal, the middle ear and mastoid (Figure 1). 
These findings along with chest X-ray and HRT-CT lung scan, negative for TBC, allowed to exclude a secondary TBC form. The histological examination of the granulation tissue showed caseous necrosis and specific granulation with epithelioid cells and Langhans type giant cells (Figure 2). 
A swab of the secretion revealed no alcohol-acid-resistant bacilli when Ziehl Neelsen staining method was performed, while the real-time-polymerase chain reaction (rt-PCR) allowed the detection of Mycobacterium tuberculosis. On the basis of the laboratory findings anti-TB treatment including rifampicin and isoniazid was started together with local medications of the mastoid cavity with rifampicin drops. On follow-up facial nerve paralysis resolved after the second month of therapy, and the conditions of the mastoid cavity progressively improved up to the point that the retroauricular fistula was successfully sutured and the granulation tissue disappeared.