ILS, a 44-year-old female homemaker complained of sudden fullness in the left ear a year before, followed by daily serosanguineous to purulent otorrhea, with progressive hearing loss and tinnitus. She denied prior otorrhea, vertigo, or contact with tuberculosis. She had received prior treatment with amoxicillin/clavulanate, ciprofloxacin, and topical gentamicin/betamethasone. The patient had SLE, controlled with prednisone 10 mg/day. She had no cervical lymphadenopathy and the oral cavity, pharynx, and rhinoscopy were normal, with normal VII function bilaterally. The right otoscopy was normal; the left otoscopy disclosed whitish mucous secretion at the bottom of the ear canal. Laboratory tests were normal. Computed tomography (CT) showed pneumatized mastoids, with the left appearing opaque without erosions. Audiometry showed ipsilateral moderate mixed hearing loss. Chronic suppurative otitis media (CSOM) was suspected. A tympanomastoidectomy was performed, which disclosed friable whitish tissue in the mastoid and middle ear without cholesteatoma, anvil erosion, or misidentified stirrup. A mastoid debridement was performed, followed by specimen collection and fascia graft. Ossiculoplasty was left for a subsequent procedure.
The patient evdeveloped tinnitus, progressive wound dehiscence, otorrhea, and afacial paresis that recovered in three weeks. She was started on azathioprine and prednisone 40 mg. Two months later, the mastoid was fully exposed (Fig. 1), and tuberculosis was suspected. The material collected during surgery was insufficient to establish the diagnosis. She had a non-reactive PPD and normal chest X-ray. A biopsy performed through the dehiscent incision showed extensive granulomatous reaction with, giant multinucleated epithelioid cells with focal necrotic areas. Fungus and AFB culture results were negative. Considering these data, the physicians decided to establish an early antituberculosis regimen: rifampicin, isoniazid, pyrazinamide, and ethambutol for two months, followed by isoniazid and rifampicin for seven months. Improvement in healing was observed after 30 days (Fig. 1). After three months, the incision was closed.
One year later, she remained with tinnitus, discrete otorrhea, and tympanic perforation. Audiometry showed no responses at 6 and 8 kHz, with preservation of thresholds at the other frequencies.