A 27-year-old Somalian man, who had immigrated to the Netherlands in 1998, was referred in March 2005 with persistent bilateral otitis media, progressive hearing loss, and tinnitus since eight months, which had been unresponsive to several courses of antibiotics. Other complaints were malaise, fever, anorexia, and weight loss for two weeks accompanied by dizziness and unsteady gait, one week later followed by diplopia and drooping mouth. His sister had been diagnosed with TB during screening on immigration in 1998. At that time, the patient's chest radiography showed abnormalities consistent with past healed TB infection. On physical examination, a malnourished man was seen with complete deafness of both ears. Neurological examination confirmed a right facial palsy and left abducens palsy. Otoscopy showed an extensive polypous inflammatory mass in both external ear canals. During fiber endoscopy a similar mass with purulence was seen in the left middle nasal passage extending up to the left Eustachian tube. The remainder of the examination was unremarkable. Laboratory investigation showed a hemoglobin level of 7.2 mmol/L after hydration, an ESR of 56 mm/first h, and mild elevation of serum transaminases. HIV serology was negative. Tone audiometry showed symmetric mixed hearing loss of 80 to 120 dB. On chest radiography, fibrosis in the apex of the left inferior lobe was seen, unchanged compared to 1998. An MRI showed an inflammatory process of both mastoid and petrous bones with abscess formation on the left extending downwards into the parapharyngeal space resulting in a bulge of the contour of the nasopharynx (Figure 1). An extensive bilateral temporal pachymeningitis was observed as well as bilateral involvement of the inner ear. A low-grade infectious disease process such as TB was suggested. Awaiting further test results, empirical treatment with corticosteroids was started. Histology of biopsies from the external ear canals as well as from the mass extending from the nasopharynx and skull base to the nose showed necrotizing granulomatous inflammation with giant cells. Auramine staining was positive with one acid-fast rod in the nasopharyngeal biopsy, and Ziehl-Neelsen staining and PCR of all biopsies were negative. The Quantiferon TB Gold in-tube assay (Cellestis, Carnegie, Australia), performed three days after starting prednisone, was positive (>10 IU/mL interferon-gamma, cut-off value 0.35 IU/mL). Hence, the patient was diagnosed with tuberculous otitis media with petrositis extending via the skull base to the nasopharynx. Treatment with four antituberculous drugs (rifampicin, isoniazide, pyrazinamide, and ethambutol) and pyridoxine was initiated. Within several weeks there was clinical improvement with functional recovery of the nervus facialis and abducens. However, severe hearing loss persisted (>90 dB in both ears at all frequencies), requiring a hearing aid. Culture of the nasopharyngeal biopsy yielded susceptible M. tuberculosis.  Isoniazide and rifampin were continued for a total duration of 12 months.
In 2005, a 35-y-old man from Sudan, who resided as a refugee in the Netherlands since 3 years, presented with pain in the neck since several months, a sore throat, problems with swallowing, and torticollis to the right. He reported weight loss of five kg in two months. Three months earlier he had been analyzed for unproductive cough, but chest radiography was without abnormalities, and no specific diagnosis was made. On physical examination an ill, transpiring man without a fever was seen. There was a repositionable torticollis to the right shoulder and deviation of the uvula to the right due to paresis of the right N. IX and N. XI. On nasendoscopy, an asymmetric mass with a glazed aspect was seen on the right side of the nasopharynx. The remainder of the examination and the routine laboratorium examination were unremarkable. HIV serology was negative. The Quantiferon TB Gold in-tube assay was positive (>10 IU/mL interferon-gamma; cut-off value 0.35 IU/mL). Chest radiography showed no abnormalities. CT and MRI showed abscess formation and surrounding edema in the retropharyngeal space and prevertebral muscles on the right, accompanied by usurpation of the clivus and C0-C1 joint (Figure 2). The differential diagnosis included TB. Biopsies of the nasopharyngeal mass obtained during nasendoscopy were not diagnostic. Next, a CT-guided biopsy of the prevertebral mass was obtained under complete anesthesia, showing necrotic material with chronic active inflammation. Auramine and Ziehl-Neelsen staining and PCR for M. tuberculosis were negative. Based on the positive Quantiferon test result in the absence of an alternative diagnosis, treatment with four anti-TB drugs was started followed by rapid clinical and radiological improvement with recovery of cranial nerve function. The culture yielded fully susceptible M. tuberculosis.  Isoniazide and rifampicin were continued for a total of 12 months. At the end of treatment, only partial destruction of the right C0-C1 joint persisted.