Tuberculosis usually affects the lungs, although in up to one-third of cases other organs are involved. In order of frequency, the extrapulmonary sites most commonly involved in tuberculosis are the lymph nodes, pleura, genitourinary tract, bones and joints, meninges, peritoneum, and pericardium. However, virtually all organ systems can be affected .
Tuberculous otitis media is a rare disease, usually secondary to transmission from adjacent organs. Early diagnosis of TOM is difficult for various reasons . First, the incidence of TOM induces a low index of suspicion. Second, because its clinical signs are polymorphic and mimic other conditions, many clinicians often overlook it as a possibility. Third, false-negative cultures often occur because of the nature of the Mycobacterium tuberculosis bacillus and also because other bacteria in the specimen can interfere with the growth of the bacillus.
The pathogenesis of TOM is postulated to occur by two mechanisms [5, 6]. One involves the middle ear as the primary focus, in which the organism spreads directly through the eustachian tube, external auditory canal, or perforated tympanic membrane. In the second mechanism, the middle ear is the secondary lesion, to which the organism spreads from a primary focus by the hematogenous or lymphatic systems, or through the eustachian tube. In our patient, the second mechanism was implicated. Organisms in the endobronchus may spread through the eustachian tube during coughing, leading to otitis media.
The primary focus in patients with TOM is mainly the lung. One series reported that pulmonary tuberculosis was diagnosed in 12 of 22 patients with TOM . Skolnik et al.  reported that abnormal chest films were seen in 58% of the cases reviewed. Bone and the central nervous system are concomitant lesions according to the literature . However, to date, there have been no reports of the endobronchus being the primary organ affected by tuberculosis, as in our patient. Approximately 10–20% patients with EBTB may have normal chest radiographs . Bronchoscopy and CT are considered to be the techniques of choice for the diagnosis of bronchial involvement. Bronchoscopic biopsy is the most reliable method for diagnosing EBTB; not only histopathological findings but also bronchoscopic findings can be sufficient to establish the diagnosis of EBTB .
Tuberculous otitis media is difficult to diagnose in the early stage, and the clinician should rely on clinical suspicion with those patients who have not responded to usual therapeutic measures. Because of the low positivity of AFB culture and the interference of growth by other organisms, tuberculosis-positive rates in ear discharge cultures are between 5% and 30%. Moreover, only 20% are shown positive in tissue staining . Polymerase chain reaction (PCR) is a useful method for rapid diagnosis and is highly sensitive and specific for tuberculosis . Biopsy from granulation tissue is the most reliable diagnostic method for TOM. It is recommended that a patient with TOM be treated using the same anti-tuberculous chemotherapy as other extrapulmonary tuberculosis patients and for at least 6 months . Effective anti-tuberculous drugs have dramatically improved the prognosis. With this treatment, improvement in our patient was noted within a few weeks.
The ear is a very rare site of tuberculosis. Although TOM is not a common cause of chronic otitis media, when a patient does not respond to empirical antibiotic therapy, clinicians should consider this disease to avoid severe sequelae.