A-5-year-old girl with 17 kg weight and 104 cm height came to Otolaryngology Outpatient Clinic with the chief complaint of yellow-greenish, foul smelling discharge from right ear. The complaint had lasted for about 3 years. There was also a nonpainful post aural swelling with discharge for the past 6 months. The parents also complained that the patient's weight was decreased about 1 kg in the past 2 months. She had a history of inadequate weight increment. There was no night sweating, cough for more than 2 weeks, or low grade fever for more than 2 weeks. The patient had a history of tuberculosis contact with her father and uncle. The father underwent TB treatment at about 7 year ago but was declared to be healthy at the end of the 6 months treatment 2 years before the patient was born. The patient's uncle died due to TB about 6 months ago and had already had TB treatment for about 2 months. Contact investigation for TB had not been done.
The patient had been brought to general practitioners and otolaryngologists since the complaint started. The complaint usually resolved for about 1 month after the patient had eardrops prescribed by the previous clinicians, but it usually happened again every 3-4 months since 3 years ago. On the last examination with the otolaryngologist about 6 months ago, the patient was referred to the district hospital due to the perforated tympanic membrane and from there, the patient was finally referred to our hospital. On the physical examination, we found post aural swelling about 2 x 3 cm, mobile with no pain. There was some greenish discharge came out from the right ear. Other physical examinations were within normal limits.
The blood examination and chest X-ray revealed no abnormality. On physical examination, mucopurulent ear discharge and hyperemic posterior auricle at right ear were found. There was no cranial nerve paresis. Audiometry examination revealed moderate conductive hearing loss at right ear (33.75 dB) and no hearing loss at left ear. Head CT scan with contrast was done and the expertise showed right osteomastoiditis with cholesteatoma which destructed right mastoid antrum and right auricle bone. The presence of right posterior auricle abscess was also found. The patient was initially diagnosed with chronic otitis media suppurative right auricle with right mastoiditis and right posterior auricle fistulae.
Afterwards, canal wall up mastoidectomy to remove mastoid air cell and mastoid obliteration continued with canaloplasty to widen ear canal, tympanoplasty to repair tympanic membrane, and rotational flap on the right auricle to close the defect were done. Intraoperatively, we found posterior auricle fistulae, dehiscence with cholesteatoma and granulous tissue at mastoid, subtotal tympanic membrane perforation and destruction of ossicles. Histopathology examination was done on the samples obtained from the ear canal. Upon examination, caseous necrosis and datia langhans cells were found. Due to the histopathological findings, the patient was referred to the pediatric pulmonology division. Mantoux test was done, resulting in 25 mm induration suggesting TB infection. GeneXpert test was done on the patient's gastric lavage sample, and no M. tuberculosis was found. Acid fast staining examination for three times also revealed no M. tuberculosis bacteria in the patient's gastric lavage samples.
The patient was treated using pediatric fixed dose combination tablets intensive phase (isoniazid, rifampicin, pyrazinamide) added with ethambutol for 2 months based on the standard protocol treatment for extrapulmonary tuberculosis. Afterwards, the therapy was continued with fixed dose combination maintenance phase (isoniazid and rifampicin). The whole treatment was given for 6 months duration. After the therapy was done for 1 month, the patient was evaluated and the body weight was increased 0.5 kg. There was no more discharge coming out from the patient's right ear. The patient had no more complaint after the medication had been completed for 6 months. Upon the completion of the therapy, total weight gain was 3 kg and she was in a healthy condition.