Tuberculous Otitis Media with Facial Paralysis Combined with Labyrinthitis
A 44-year-old woman visited our department for evaluation of progressive left facial paralysis, dizziness, and hearing loss for 7 days with a 3-month history of an intermittent discharge from the left ear. On physical examination, facial paralysis was identified as Grade V using the House-Brackmann grading system. Endoscopic exam revealed total perforation of the tympanic membrane, edema of the middle ear mucosa, and profound discharge from her left ear (). Initial ear culture studies did not identified pathogens. On electronystagmography, spontaneous nystagmus toward the right side was identified and left-sided caloric weakness of 71% was found (). She denied a history of diabetes mellitus, hypertension, or pulmonary tuberculosis. Pure-tone audiometry showed deafness of the left ear. A temporal bone CT scan revealed that a soft tissue density filling the middle ear cavity and mastoid, and dehiscence of the tympanic segment of the facial nerve was suspected (). She was initially treated with an intravenous 3rd generation cephalosporin and a 4 day course of oral prednisone (60 mg/d) was started on the day of presentation and tapered off between days 10 and 12. Preoperative eletroneurography demonstrated 75% degeneration of the facial nerve. An emergent surgical procedure was scheduled to improve facial nerve paralysis and resolve dizziness. Under general anesthesia, retroauricular incision was performed. We removed a significant amount of granulation tissue with the consistency of cheese from the middle ear and mastoid by canal wall down mastoidectomy. During the operation, dehiscence of the facial fallopian canal and a swollen facial nerve were identified and facial nerve decompression was performed to resolve the facial nerve paralysis (). Intraoperative finding, all ossicles were surrounded by granulation tissues and incus was partially eroded. After malleus and incus were removed, tympanoplasty was performed using temporalis fascia. The most prominent finding on histopathologic examination was chronic caseating granulomatous inflammation and many bacilli were identified on AFB stain (). The chest X-ray was normal, but polymerase chain reaction testing for middle ear mucosa was positive for Mycobacterium tuberculosis. The patient was started on a 12-month course of empirical four-drug anti-tuberculosis treatment with oral rifampin, isoniazid, ethambutol, and pyrazinamide. The post-operative course was unremarkable and dizziness resolved by post-op day 7. The patient was discharged by post-op day 14. Nystagmus was un-remarkable on electronystagmography at a 3 month follow-up visit. The facial paralysis slowly improved until it had com-pletely resolved by 4 months post-op. However, there was no change in hearing threshold by 6 months post-op.