Tuberculous otitis media (TOM) is a rare form of chronic otitis media, which presents diagnostic challenges due to nonspecific symptoms.To characterize the clinical features and identify strategies for early diagnosis.A retrospective analysis was conducted on 32 patients (40 ears) diagnosed with TOM between 2002 and 2024. Clinical, audiologic, radiologic, and laboratory findings were reviewed.Mean diagnostic delay was 28.9 months. Persistent otorrhea (90%) and hearing loss (HL) (100%) were predominant. Tympanic membrane findings varied: single perforation (70%), multiple (12.5%), and intact (17.5%). Granulations were universal. Age stratification revealed conductive HL and pneumatized mastoids predominated in patients <40 years, while mixed HL and mixed-type mastoid were more common in patients >40 years (p = 0.016, p = 0.005). Bone destruction was evident in 25% of the cases. Mastoid type correlated with HL patterns in non-destructive cases (p = 0.040). Interferon-gamma release assay (IGRA) and polymerase chain reaction (PCR) showed relatively high detection rates.Early suspicion of TOM in refractory/recurrent otitis media, combined with IGRA/PCR screening, prompt imaging, and consideration of age-specific patterns, facilitates timely diagnosis. Surgical biopsy remains critical for confirmation. Integration of age-stratified clinical, laboratory, and radiological findings improves detection accuracy and patient outcomes.