Central skull base osteomyelitis: new insights and implications for diagnosis and treatment

Abstract

Central skull base osteomyelitis (SBO) is a life-threatening disease originating from ear and from sinonasal infections. The intention of this study was to evaluate contemporary trends in etiology, diagnosis, management, and outcome of SBO and to draw the clinician's attention on this probably underestimated disease. Over a 6-year period we performed this systematic study in an academic quaternary medical care and skull base center including 20 patients (mean age 63.7 years) with central SBO, which is one of the largest series from a single center. In contrast to previous studies we explicitly excluded infections limited to malignant external otitis only but did not restrict central SBO to conditions unrelated to aural pathology. Fifteen patients had otogenic and five sinugenic SBO; four patients had fungal or mixed fungal infections. Pre-existing illnesses altering bone vascularization were detected in 70 % of the patients and had a negative effect on the improvement of cranial nerve palsies that were found in 14 patients. In relation, patients with otogenic SBO more often had local and systemic predisposing factors. Contrary to previous studies 16 patients (80 %) underwent surgical therapy and none of our patients died. A meta-analysis of five recent studies was done and compared with our own data and two previous meta-analyses. The present study highlights several important aspects with major implications for diagnosis and treatment of SBO that have not been adequately addressed as yet. In contrast to the restrictive attitude towards surgery in literature we recommend early and radical operative treatment to reduce its mortality.

Are CT and MRI Scanning Reliable in Diagnosing Otogenic Skull Base Osteomyelitis in Non-Immunocompromised Elderly Patients? A Case Series and Review of the Literature

“…We suspect that cohort studies that used only CT and MRI in the diagnosis of SBO might have missed the diagnosis in some patients compared to if nuclear medicine imaging was employed. 13 These two cases highlight the importance of considering a diagnosis of SBO in non-diabetic elderly patients who present with even a mild chronic otalgia. This group of patients might not mount an adequate immune response as evident by lack of raised levels of inflammatory markers.…”

“…19 Given that neither test is diagnostic, most studies recommend a CT and MRI together in order to obtain as much information as possible. 13,16,17,20 Another imaging option is a radionucleotide scan, including 99m Tc or gallium-67 bone scans. Though not standard practice at present, these imaging modalities have some advantages over CT and MRI.…”

Atypical skull base osteomyelitis in the intensive care unit: A case report

“…Typically, skull base osteomyelitis is preceded by a destructive malignant otitis externa, but atypical cases which present without aural symptoms are also reported. [1,2,6] In a study of forty-two such atypical cases, headaches, facial pain and palsy of cranial nerves were the commonest presenting features. [3] The radiological findings of bony erosion of base of skull and soft tissue swellings often raise a suspicion of a malignant process such as nasopharyngeal carcinoma or skull base metastases.…”

“…[3] The commonest causative organism is Pseudomonas aeruginosa and less commonly, fungal and mixed bacterial infections. [2,3] Complications of skull base osteomyelitis include thrombosis of the cerebral venous sinuses and the internal jugular vein. There is a potential risk of carotid artery thrombosis as well.…”

“…[1] As such, the patient initially presents with auditory symptoms including persistent ear discharge, ear pain and loss of hearing, or with cranial nerve palsies involving the oculomotor (III), trigeminal (V), abducens (VI), facial (VII), vestibulocochlear (VIII), glossopharyngeal (IX), vagus (X), accessory (XI) and hypoglossal (XII). [2,3] This disease usually occurs in diabetes mellitus and elderly patients with high cerebrocardiovascular risks.…”