Silent Tubercular Otitis Media Presenting as Zygomatic Abscess: A Rare Case Report

Tuberculous otitis media (TOM) is a rare form of chronic otitis media caused by Mycobacterium tuberculosis and may be misdiagnosed because of its nonspecific clinical presentation. Zygomatic abscess is an exceptionally uncommon extracranial complication of TOM. A case is reported of a 45-year-old man presenting with a gradually enlarging left preauricular swelling for 4 months, associated with chronic painless otorrhea and progressive hearing loss. Otoscopic examination revealed a large central tympanic membrane perforation with moderate-to-severe mixed hearing loss. Contrast-enhanced computed tomography demonstrated sclerosis and multiple erosions involving the mastoid and petrous temporal bone, with extension into the preauricular soft tissue and formation of a zygomatic abscess. The patient underwent left mastoid exploration, during which pus was drained from the zygomatic abscess. Intraoperative findings included pus tracking from the root of the zygoma and extensive bony erosions. Histopathological examination of the mastoid mucosa revealed epithelioid cell granulomas and multinucleated giant cells, with occasional acid-fast bacilli demonstrated by Ziehl–Neelsen staining. Cartridge-Based Nucleic Acid Amplification Test (CBNAAT) was positive for Mycobacterium tuberculosis. Antitubercular therapy was initiated, and the patient showed satisfactory clinical recovery. This case highlights the importance of considering TOM in patients with chronic painless otorrhea, hearing loss, and destructive temporal bone lesions, particularly in tuberculosis-endemic regions.