Abstract
Objective
To demonstrate the different neuro-otologic clinical presentations of tuberculosis.
Study design
Retrospective clinical analysis.
Result
83.3% of the cases of ear or central nervous system TB were without concomitant lung disease. 2 cases had primary infection in the central nervous system. The neuro-otologic manifestation was as follows: 85.7% sensorineural hearing loss; 42% polyneuropathy. 71.4% had granulation tissue. 2 had normal otoscopy. In 6 patients the histopathology and Ziehl Neelsen were confirmatory. One case was confirmed by the positive response to treatment with antituberculosis drugs.
Conclusions
Tuberculosis has a wide variety of neurotologic manifestations from chronic otitis media cadres to vestibular, audiological and neurological manifestations as well as a large variability in imaging studies.
1
Introduction
Tuberculosis (TB) is in pulmonary pattern in 75% of the cases and extrapulmonary 25%, 10%–35% which corresponds to head and neck affecting in the following order: 95% cervical lymphadenitis, and throat, tonsils, nose, ears, sinuses, salivary glands in 1% . The otic TB Just coexite with pulmonary TB in 10-20% of the cases .
The otic TB affects pinna in 1% and is cause of otorrhea in 0.05% to 0.09% . The infection reaches the ear by the primary pathway: direct through the external auditory canal (EAC) and perforation of the tympanic membrane (TM) and Secondary implantation: retrograde aspiration through the Eustachian tube or hematogenous in 79% . The classic features of the otic TB were described by Wallmer in 1953: painless otorrhea, multiple perforations of MT, exuberant granulation tissue, hearing loss and bone necrosis. Skolnik et al. reported facial paralysis in 16% of cases and multiple MT perforations only in initial stages . The main feature of the otic TB is the formation of granulation tissue in well pneumatized mastoid .
Complications include: profound sensorineural hearing loss (HL), cranial nerve palsies, especially facial nerve, abscesses, mastoid internal or external fistulas and intracranial complications. CAE cultivations are positive just in 5%–35% of cases because the presence of other organisms such as Staphylococcus , Pseudomonas , Klebsiella , Proteus and Streptococcus may interfere with the growth of the bacillus; negative PCR does not exclude the diagnosis .
To Weiner et al. TB treatment is not enough. In 2000 Sangeta et al. suggested that medical treatment is sufficient in uncomplicated cases, but in combination with surgery has a better prognosis .
3
Material and method
Clinical records of patients diagnosed with pure aural or central nervous system TB with neurotologic manifestations in the period 2006–2013 were reviewed. The data are listed in Table 1 and cases’ images.
| Case No. | Sex/ages | Area affected | Evolution time | Manifestations | Positive findings | Diagnosis | Management |
|---|---|---|---|---|---|---|---|
| 1 | M/75 | Left ear | 2 months | Otorrhea, hearing loss, otalgia VII peripheral paralysis, left neck lymphadenopathy in zone II and III. | Full perforation, granulation tissue | histopathology ZN +. | Radical mastoidectomy + anti-tuberculosis drugs |
| 2 | M/18 | Left ear | 1 month | Otorrhea, otalgia, hearing loss, lymphadenopathy and involvement of cranial nerves II, III, V, VII. VIIII, IX, X, meningeal signs | Total perforation, granulation tissue. | histopathology ZN +. | Biopsy by cortical mastoidectomy + anti-tuberculosis drugs |
| 3 | M/26 | Left ear | 15 days | fever, drowsiness, unsteadiness, lateropulsión right sphincters loss control. | Normal Otoscopy, left Romberg | histopathology ZN +. | Biopsy by cortical mastoidectomy + anti-tuberculosis drugs |
| 4 | M/68 | Left ear | 1 year | Hearing loss, otorrhea, otalgia, tinnitus | 15% TM Perforation, granulation tissue. | histopathology ZN +. | anti-tuberculosis drugs |
| 5 | M/35 | Left ear | 1 year | Hearing loss, otorrhea, otalgia, tinnitus, meningoencephalocele, cerebrospinal fluid fistula otic | complete perforation of TM with granulation tissue. | response to medical treatment with anti-tuberculosis drugs | Radical mastoidectomy + anti-tuberculosis drugs |
| 6 | M/26 | Right ear cerebral abscess in temporal lobe | 1 year | Right otorrhea, hearing loss, dizziness. New symptoms: intense, nausea, vomiting, headache. | exuberant granulation tissue occupying middle ear and external ear canal | ZN + | anti-tuberculosis drugs |
| 7 | F/36 | inferior left Cerebellar peduncle | 2 months | Normal Otoscopy, horizontal spontaneous nystagmus, Dix Hallpike: downbeat bilateral nystagmus inexhaustible. Romberg and left lateropulsión Fukuda. hypometric, disdiadocinesias | Normal Otoscopy, horizontal spontaneous nystagmus, Dix Hallpike: downbeat bilateral nystagmus inexhaustible. Romberg and left lateropulsión Fukuda. hypometric, disdiadocinesias | Stereotactic biopsy ZN + | Abscess drainage. Right radical mastoidectomy, lateral semicircular canal plasty |
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