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AM ER IC AN JOURNAL OF OT OLARYNGOLOGYH E A D A N D NE CK M E D IC IN E A ND S U RGE RY 3 6 (2 0 1 5) 5 755 7 7

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Case reports

Primary tuberculosis of the eustachian tube causing


otitis media with effusion
Se-Joon Oh, MD a , Keun-Ik Yi, MD a , Chang-Hoon Lee, MD, PhD b , Kyu-Sup Cho, MD, PhD a,
a
b

Department of Otorhinolaryngology and Biomedical Research Institute, Busan, Republic of Korea


Department of Pathology, Pusan National University School of Medicine, Pusan National University Hospital, Busan, Republic of Korea

ARTI CLE I NFO

A BS TRACT

Article history:

Eustachian tube (ET) dysfunction may cause pathological changes in the middle ear,

Received 20 March 2015

including recurrent acute otitis media and otitis media with effusion (OME). Mechanical
obstruction of the ET may be caused by primary tumor-like lesions arising from ET or
secondary ET infiltration due to nasopharyngeal and parapharyngeal space tumor.
Tuberculosis is known to affect almost every organ in the body, and it should be a
concern of each and every medical practitioner. However, tuberculosis of the ET has not
been reported in the literature previously. This article reports primary tuberculosis arising
in the ET that presented as aural fullness and hearing disturbance in a patient with OME.
2015 Elsevier Inc. All rights reserved.

1.

Introduction

The eustachian tube (ET) is a short but complex hourglassshaped structure which connects the nasopharynx with the
middle ear cavity. Therefore, ET may be deeply associated
with otologic and rhinologic symptoms. It is well known that
ET dysfunction or occlusion is an important factor leading to
otitis media with effusion (OME) [1]. Although ET dysfunction
may be triggered by many causes, including viral infection,
chronic sinusitis, allergic rhinitis, adenoid hypertrophy, and
cleft palate [2], mechanical obstruction of the ET should be
considered. Tuberculosis is known to affect almost every
organ in the body, but tuberculosis of the ET has not been
reported in the literature, to the best of our knowledge. Herein
we describe this rare clinical presentation of primary tuberculosis arising in the ET associated with OME. This study was
approved by the institutional review board of Pusan National
University Hospital.

2.

Case report

A 41-year-old female presented left-sided aural fullness


and hearing disturbance for 6 weeks. The patients medical
history was otherwise unremarkable. Her left tympanic
membrane was amber and its mobility was decreased
under the pneumatic otoscopic examination (Fig. 1A). Pure
tone audiogram showed mild conductive hearing loss in her
left ear (Fig. 1B). Tympanogram was B type in left ear and A
type in right. Although she received antibiotics treatment,
aural fullness and hearing disturbance were continued.
Myringotomy with ventilation tube insertion and nasal
endoscopy were performed. Nasal endoscopy revealed the
necrotic lesion around the ET orifice and mucopurulent
discharge (Fig. 2A). A computed tomography (CT) scan of the
paranasal sinus showed an asymmetric thickening of the
left Rosenmullers fossa with obliteration of the left
parapharyngeal space (Fig. 2B). However, there was no

Corresponding author at: Department of Otorhinolaryngology, Pusan National University School of Medicine, Pusan National University
Hospital, 179 Gudeok-Ro, Seo-gu, Busan 602-739, Republic of Korea. Tel.: + 82 51 240 7824; fax: +82 51 246 8668.
E-mail address: choks@pusan.ac.kr (K.-S. Cho).
http://dx.doi.org/10.1016/j.amjoto.2015.04.004
0196-0709/ 2015 Elsevier Inc. All rights reserved.

576

AM ER IC AN JOURNAL OF OT OLA RYNGOLOGYH E A D A N D NE CK M E D ICI N E AN D S U RGE RY 3 6 (2 0 1 5) 5 75 5 7 7

Fig. 1 Otoscopic examination and pure tone audiometry (PTA). (A) Otoscopy shows thick and glue-like fluid collection in the
middle ear cavity. (B) PTA shows left conductive hearing loss.

evidence of significant lymphadenopathy. Laboratory tests


including anti-neutrophil cytoplasmic antibodies (ANCA),
cANCA or pANCA, showed no significant abnormality.
Chest radiography revealed the evidence of old tuberculosis
lesion at right upper lung zone. She underwent a transnasal
endoscopic biopsy and histopathologic examination revealed chronic granulomatous inflammation with extensive
necrosis, consistent with tuberculosis (Fig. 3A). Furthermore,
acid-fast bacilli (AFB) staining were positive for Mycobacterium
tuberculosis (Fig. 3B), which confirmed the diagnosis of primary
tuberculosis arising in the ET. The patient received HERZ
regimen (isoniazid 300 mg, rifampin 600 mg, ethambutol 800
mg, and pyrazinamide 1500 mg daily) for 9 months. After antituberculosis medication, the patient exhibited complete resolution of necrotic lesion around the ET and her aural fullness
was disappeared (Fig. 4).

3.

Discussion

Primary ET tuberculosis is defined as an isolated tuberculosis


infection of the ET in the absence of pulmonary tuberculosis and

usually occurs in countries in which tuberculosis is endemic [1],


although ET tuberculosis may be associated with pulmonary or
lymph node tuberculosis. In this case, Korea is an endemic
area of the tuberculosis and the patient had no active lesion on
the chest radiography, suggesting primary ET tuberculosis. It
may be ambiguous to differentiate between nasopharyngeal
tuberculosis and ET tuberculosis definitely. Nasopharyngeal
tuberculosis can infiltrate ET lumen secondarily, and this is
often reported [3]. However, primary ET tuberculosis means
primary tumors arising from ET, which is a very rare clinical
entity. Anatomically, ET boundaries were defined as the limit
delineated by the edge of the torus tubarius at the nasopharyngeal orifice. Clinically, otologic signs and symptoms were
considered as possibly suggesting an ET origin mass. In this
case, the center of lesion was within ET boundary and the
patients chief complaints were mainly otologic symptoms such
as aural fullness and hearing disturbance [4,5]. Although the
most common presenting symptoms of nasopharyngeal tuberculosis is cervical lymphadenopathy (91.3%) [3], no significant
cervical lymphadenopathy was observed in this case. From
these findings, we concluded this case as primary tuberculosis
arising in the ET, not the nasopharynx.

Fig. 2 Nasal endoscopy and computed tomography (CT) findings of eustachian tube (ET) tuberculosis. (A) Nasal endoscopy
reveals the necrotic lesion around the ET orifice. (B) A CT scan of the paranasal sinus shows an asymmetric thickening of the
left Rosenmullers fossa with obliteration of the left parapharyngeal space.

AM ER IC AN JOURNAL OF OT OLARYNGOLOGYH E A D A N D NE CK M E D IC IN E A ND S U RGE RY 3 6 (2 0 1 5) 5 755 7 7

577

Fig. 3 Histopathologic findings of Eustachian tube mass. (A) Microscopic finding shows extensive caseous necrosis rimmed by
mixed inflammatory cells and some epithelioid cells (H&E stain, 400). (B) Acid-fast bacillus stain reveals acid-fast, pink-colored
bacilli against the sea of necrosis (ZiehlNeelsen stain, 1000).

OME is characterized by the presence of nonpurulent fluid,


usually serous or mucoid, in the middle ear cavity. Symptoms
always involve a feeling of aural fullness and some degree of
hearing loss [6]. ET dysfunction is the main precursor of OME in
the adult patient. Therefore, the nasopharyngoscopy should be
necessary in adult-onset OME, especially unilateral in nature,
for possible primary or secondary tumors and tumor-like
lesions of ET [6]. However, the diagnosis of ET tuberculosis
cannot be made solely on the basis of a nasopharyngeal
examination. Although specific literature on ET imaging is
lacking, it is well known that CT is the most reliable imaging
tool for the evaluation of middle ear, temporal bone, and bony
portion of ET [1]. Magnetic resonance imaging (MRI) is superior
to CT for displaying soft tissues and for differentiating tumors
form normal tissues [1]. In the present case, CT image showed
asymmetric mucosal thickening and enhancement of the left
Rosenmullers fossa. However, on CT or MRI, ET tuberculosis
can mimic benign or malignant tumor, and a biopsy is
mandatory for definite diagnosis. Histopathologic examination
typically reveals granulomatous inflammation with epithelial
giant cells and caseous necrosis. ZiehlNeelsen staining may
directly detect acid-fast bacilli.

Fig. 4 Follow-up nasal endoscopy at 2 months after


anti-tuberculosis medication. Nasal endoscopy shows complete
resolution of necrotic lesion around the ET.

The basic principles of treatment for extrapulmonary


tuberculosis are the same as pulmonary tuberculosis. The
goals of treatment for tuberculosis are to cure the patient
clinically and minimize the chance of relapse, and to prevent
further transmission of tuberculosis to others. Therapy for
extrapulmonary tuberculosis requires a minimum of 6
months of treatment [7]. In our case, patient has taken HERZ
regimen during 9 months for prevention of relapse.

4.

Conclusion

ET tuberculosis may be associated with OME causing hearing


disturbance and aural fullness. In the patients who have OME
and no other identified cause, careful examination of the ET
would give an additive information for diagnosis. Although ET
tuberculosis is very rare, tuberculosis infection should be
considered in the necrotic ET occupying lesion, especially in
endemic areas.

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