The case report describes a 23-year-old man with bilateral, gradually worsening hearing loss, initially assessed as chronic purulent otitis media. Persistent general symptoms led to chest examination, which showed bilateral cavitary pulmonary infiltrates. Next-generation metagenomic sequencing (NGS) of broncho-alveolar lavage confirmed the presence of the Mycobacterium tuberculosis complex. After transfer to a specialized center, targeted NGS of middle ear serous fluid also identified Mycobacterium tuberculosis complex. The rpsL K43R mutation causing streptomycin resistance was found, identical in both lung and ear isolates, confirming dual localization of infection by the same strain. After initiation of standard four-drug antituberculosis treatment, cough and fever subsided within 4 weeks, inflammatory markers normalized, and lung cavities shrunk. The authors emphasize that unexplained hearing loss may be an early manifestation of disseminated tuberculosis and that NGS of middle ear effusion allows rapid diagnosis of tuberculous otitis media and detection of drug resistance.