A 24-year-old Asian female patient was admitted to our hospital, with left ear fullness and otorrhea. At an outpatient clinic, she was previously diagnosed with otitis media with effusion (OME) that was unresponsive to a three-week course of antibiotics. Otoscopic examination revealed perforation of the tympanic membrane and profound amber-colored discharge, behind the eardrum (Figure 1A). On physical examination, no palpable neck lymph nodes were noted. Routine hematologic examination revealed normal erythrocyte sedimentation rate (ESR) and C-reactive protein (CRP) levels. Initial ear culture studies did not identify any pathogens. After one week of further antibiotic medication, she underwent ventilation tube (V-tube) insertion to maintain aeration of the middle ear and prevent fluid reaccumulation.
However, the presence of purulent discharge from the V-tube was again noted on the third follow-up visit (Figure 1B). At this visit, the patient also presented with new-onset ipsilateral facial nerve palsy. Facial paralysis was identified as grade IV, using the House-Brackmann grading system, due to presence of incomplete eye closure and mouth drooping, with maximum effort. She was then hospitalized for further evaluation.
After hospitalization, the patient underwent a flexible nasopharyngoscopy, which revealed a polypoid mass, with severe inflammation, in the roof of the nasopharyngeal wall. Extensive purulent granulation tissue was also noted, along the left posterolateral nasopharyngeal wall (Figure 2). A biopsy was taken from the polypoid mass of the nasopharyngeal roof. The chest radiography was normal (Figure 3). The patient had no underlying disease, no history of pulmonary TB or contact with TB patients. Because the patient had no pulmonary symptoms and the chest radiography was normal, we excluded primary pulmonary TB. We did not perform sputum acid-fast bacilli (AFB) staining.
The computed tomography (CT) examinations were performed using a 64 channel multi-detector computed tomography (MDCT) (Brilliance 64, Philips Medical System, Cleveland, OH, USA) or 16 channel MDCT (Light Speed, GE Healthcare, Milwaukee, WI, USA) with intravenous administration of contrast medium (iohexol, Omnipaque 350 mg, GE Healthcare, Milwaukee, WI, USA). Magnetic resonance (MR) examinations were performed using a 3.0-T MR system (Intera Achieva 3.0-T; Philips Medical Systems, Best, the Netherlands) with intravenous administration of a total volume of 15 mL contrast medium (gadoteridol, ProHance, Bracco Diagnostics Inc., Princeton, NJ, USA). Contrast-enhanced CT and MR of the paranasal sinuses showed a polypoid mass, with necrotic foci, at the roof of the nasopharyngeal wall (Figure 4A and B). It also revealed diffuse mucosal enhancement and low attenuated polypoid masses, obliterating the left torus tubarius and pharyngeal opening of the Eustachian tube (Figure 5A and B). Unenhanced temporal CT showed fluid filled middle ear cavity, mastoid antrum and mastoid air cells, without sclerotic changes (Figure 6). Contrast-enhanced temporal MRI showed avid enhancement at the canalicular, labyrinthine, anterior genu, tympanic and mastoid segments of the left facial nerve, which confirmed left facial neuritis (Figure 7).
Histopathology of the biopsy specimen, taken from the nasopharyngeal roof and mastoid antrum confirmed caseating granulomatous inflammation, consistent with TB (Figures 8 and 9). However, the specimen from the nasopharyngeal mass showed negative in AFB staining and polymerase chain reaction (PCR) tests. Considering the low sensitivity of AFB smear and PCR in extrapulmonary specimens, the results from this case report were not unusual. We have reached final diagnosis of primary nasopharyngeal and middle ear TB, on the basis of clinical, radiologic and histopathologic examination, against those from cytology and microbiology examination. The patient was started on four antituberculous medications (rifampicin, isoniazid, pyrazinamide and ethambutol) and underwent left canal wall up (CWU) mastoidectomy, with tympanoplasty. During the operation, multiple polypoid masses were observed in the entire middle ear cavity, mastoid antrum and mastoid air cells. In addition, the pharyngeal opening of the Eustachian tube was obstructed by polypoid masses. All ossicles were surrounded by granulation tissue and an ossiculoplasty was performed. Furthermore, bony canal dehiscence was noted, at the tympanic segment of the facial nerve, and surgical decompression was performed, as well. Histopathology of the biopsy specimens taken from the middle ear cavity and mastoid antrum during the operation also confirmed caseating granulomatous inflammation, consistent with TB. Electrodiagnostic testing, needle electromyogram and nerve conduction studies, were performed three weeks after the operation, which revealed the remaining left facial neuropathy.