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.
1
Introduction
The eustachian tube (ET) is a short but complex hourglass-shaped 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) . Although ET dysfunction may be triggered by many causes, including viral infection, chronic sinusitis, allergic rhinitis, adenoid hypertrophy, and cleft palate , 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.
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Case report
A 41-year-old female presented left-sided aural fullness and hearing disturbance for 6 weeks. The patient’s medical history was otherwise unremarkable. Her left tympanic membrane was amber and its mobility was decreased under the pneumatic otoscopic examination ( Fig. 1 A ). Pure tone audiogram showed mild conductive hearing loss in her left ear ( Fig. 1 B). 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. 2 A ). A computed tomography (CT) scan of the paranasal sinus showed an asymmetric thickening of the left Rosenmuller’s fossa with obliteration of the left parapharyngeal space ( Fig. 2 B). 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. 3 A ). Furthermore, acid-fast bacilli (AFB) staining were positive for Mycobacterium tuberculosis ( Fig. 3 B), 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 anti-tuberculosis medication, the patient exhibited complete resolution of necrotic lesion around the ET and her aural fullness was disappeared ( Fig. 4 ).
