Tuberculous otitis media (TOM) is a rare cause of chronic suppurative infection of the middle ear and mastoid. The increasing incidence of tuberculosis in the United States may be associated with more cases of TOM than recognized previously. Patients typically have a chronic tympanic membrane perforation and ear drainage associated with progressive and profound hearing loss. The correct diagnosis starts with consideration of the disease in a patient with a chronic middle ear infection that is unresponsive to routine therapy. TOM should be strongly considered in patients with known or suspected tuberculosis and a chronic ear infection; however, the lack of evidence of tuberculosis elsewhere does not exclude the possibility of TOM. Appropriate evaluation for TOM includes a chest film, purified protein derivative (PPD) skin testing, and smears or cultures of otic secretions for mycobacteria. Operative biopsy may be required. Facial nerve paralysis is highly suggestive of TOM. Medical therapy with antituberculous drugs is usually effective, and surgery is rarely needed.