Atypical otosyphilis presenting as chronic suppurative otitis media with isolated conductive hearing loss

Otosyphilis is an uncommon manifestation of Treponema pallidum infection that typically causes sensorineural hearing loss, tinnitus, and vertigo. Conductive hearing loss resulting from middle ear involvement is exceptionally rare. A 32-year-old Ethiopian woman presented with a 6-month history of persistent left ear discharge and progressive hearing loss. Otoscopy revealed two central tympanic membrane perforations. Pure tone audiometry demonstrated moderate conductive hearing loss with an air–bone gap of 35 dB. Serum VDRL and TPHA were positive; HIV and GeneXpert MTB/RIF were negative. Cerebrospinal fluid analysis was unremarkable. Biopsy of granulation tissue at the edge of the tympanic membrane perforation demonstrated organisms morphologically consistent with spirochetes on Warthin-Starry staining, supporting a diagnosis of syphilitic middle ear involvement in the appropriate clinical context. The patient received benzathine penicillin for 3 weeks due to resource limitations precluding IV therapy, followed by tympanoplasty. At 6 months, the air–bone gap improved from 35 to 12 dB, and VDRL titers declined fourfold from 1:16 to 1:2. This case illustrates that syphilitic middle ear disease may rarely present as chronic suppurative otitis media with isolated conductive hearing loss. Clinicians should consider syphilis in patients with persistent chronic otitis media that fails conventional therapy, even in the absence of classical systemic or cochleovestibular manifestations.