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Tubercular otitis media In most of the cases, infection is secondary to pulmonary tuberculosis; infection reaches the middle ear through the eustachian tube. Perforation: Multiple perforations, 2 or 3 in number, are seen in pars tensa and form a classical sign of disease. These may coalesce into a single large perforation. Painless ear discharge: Earache is characteristically absent in cases of tubercular otitis media. Discharge is often foul-smelling because of the underlying bone destruction. (Ref: Textbook of diseases of ENT, PL Dhingra, 7th edition, pg no. 81,82)