Primary tuberculosis of the eustachian

tube causing otitis media with effusion

Se-Joon Oh, MDa, Keun-Ik Yi, MDa,
Chang-Hoon Lee, MD, PhDb,, Kyu-Sup
Cho, MD, PhDa
a Department of Otorhinolaryngology and Biomedical Research Institute,
Busan, Republic of Korea
b Department of Pathology, Pusan National University School of Medicine,
Pusan National University Hospital, Busan, Republic of Korea

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

Anatomy

Cause of ET dysfunction

Viral infection
Chronic sinusitis
Allergic rhinitis
Adenoid hypertrophy
Cleft palate
Tumor
Tuberculosis

Case Report

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

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).

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

Discussio
n

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.

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.

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