Bilateral otitis media, an uncommon entity in adults, may represent the initial manifestation of a life-threatening systemic disease. Prompt recognition and treatment of the underlying disease is needed to preserve auditory function and prevent involvement of other organ systems. We present the case of a thirty-four-year-old male with bilateral serous otitis media and progressive hearing loss, which was refractory to antimicrobial therapy and middle ear drainage. A mastoid biopsy revealed necrotizing granulomatous inflammation. The differential diagnosis and probable cause of this unusual finding are discussed.