Background: Otogenic skull base osteomyelitis (SBO) is a life-threatening condition that requires timely diagnosis and treatment. It is most commonly seen in the elderly diabetic or immunocompromised patients. The role of nuclear medicine imaging in diagnosis of SBO remains controversial.Methods: This paper presents two unusual cases of otogenic SBO in elderly nonimmunocompromised patients. A review of the relevant literature from 1986 to 2016 was performed via the Medline database using search terms 'skull base osteomyelitis', 'otogenic', 'malignant otitis externa' and 'imaging'.Results: Both patients presented with chronic mild otalgia and ear discharge, and were subsequently diagnosed with otogenic SBO based on nuclear medicine imaging. Nuclear medicine imaging was essential for diagnosis and localization of SBO in both patients as CT and MRI either failed to detect or accurately localize SBO. Conclusion: SBO can occur in non-immunocompromised elderly patients with normal CT and MRI scans. Nuclear medicine imaging is essential in the diagnostic workup.Keywords: skull base osteomyelitis, nuclear medicine, bone scan, computed tomography, magnetic resonance imaging, otogenic, single-photon emission computed tomography