When Otorrhea Hides Something Unexpected: A Challenging Case Report

Tuberculosis remains a major global health concern, predominantly in low and middle-income countries. Tuberculous otitis media (TOM) is a rare form of extrapulmonary tuberculosis, representing a small fraction of tuberculosis and chronic suppurative otitis media cases. The nonspecific and indolent presentation of TOM, besides its rarity, often results in delayed diagnosis, mainly in regions with a low tuberculosis prevalence, with increased risk of irreversible complications. We report a case of TOM in a 36-year-old Portuguese woman with a four-month history of right ear pain, otorrhea, obstruction, and progressive hearing loss. Despite multiple evaluations and empirical antibiotic treatments, symptoms worsened. Otoscopic assessment at our centre revealed chronic necrotizing otitis media with tympanic membrane perforation. Computed tomography demonstrated extensive right-sided mastoid and middle ear opacification without bone erosion. Audiometry confirmed moderate conductive hearing loss, and the patient underwent mastoidectomy and ossiculoplasty. Histopathology showed necrotizing inflammation, but microbiological studies were not performed initially. Two weeks postoperatively, the patient developed respiratory and constitutional symptoms. Chest imaging revealed a cavitary lesion in the right lower lobe. Although initial direct and PCR sputum studies were negative, bronchoscopy confirmed <i>Mycobacterium tuberculosis</i> complex (MTC) through acid-fast bacilli staining and DNA testing. Retrospective PCR analysis of the ear surgical specimen also identified MTC, establishing the diagnosis of TOM with bone involvement. First-line antituberculosis therapy was initiated with rifampicin, isoniazid, pyrazinamide, and ethambutol. The patient completed 12 months of treatment with progressive clinical improvement, full restoration of hearing, and no residual otologic or systemic sequelae. Due to its rarity and similarity to other chronic otologic infections, TOM is often misdiagnosed, leading to delays in correct diagnosis. Definitive diagnosis generally depends on histopathology and mycobacterial culture of mastoidectomy specimens. This case underscores the importance of maintaining a high index of suspicion for TOM in patients with chronic or atypical otitis media unresponsive to conventional therapy, especially in the presence of granulomatous or necrotizing features or relevant epidemiological exposures. Early recognition and appropriate management are essential to prevent irreversible complications and optimize patient outcomes.