Central Skull Base Osteomyelitis: Diagnostic Dilemmas and Management Issues

Abstract

The aim of this study is to describe the clinical presentation of central skull base osteomyelitis and to discuss the classical imaging findings and various diagnostic and therapeutic challenges faced in the management of this condition. This is a retrospective analysis of inpatient case records, carried out in a multidisciplinary tertiary care hospital. The study subjects included five elderly diabetic patients presenting to the ENT surgeon or neurologist with headache followed by multiple cranial nerve paralysis with no temporal bone involvement in four patients and a past history of otitis externa in one patient. These patients were diagnosed to have an infective pathology of the central skull base detected by imaging and confirmed by biopsy in three. All were treated successfully with antibiotics administered for an average period of 6 weeks. Three patients followed up over 4 years and showed no relapses. One succumbed to other medical co morbidities after 8 months and one diagnosed a month prior is still under follow up. A symptom complex of headache and cranial neuropathies usually raises the suspicion of malignancy. Central skull base osteomyelitis, a relatively uncommon pathology, must also be considered as a possible differential diagnosis despite absence of a definite septic focus. Imaging studies showing bony destruction and adjacent soft tissue involvement should raise the suspicion of this clinical entity. Malignancy needs to be ruled out by biopsy. Early diagnosis and prompt initiation of antibiotics administered for an adequate duration is of paramount importance in successfully treating these patients. A multidisciplinary approach is needed for a successful outcome.

Rare case of a 3-year-old withCandidaskull base osteomyelitis: lessons to be learnt

“…Most otogenic SBO present in older diabetic or immunocompromised patients and are commonly caused by contiguous spread of P. aeruginosa from poorly treated otitis externa 5 7. Less commonly, SBO can also be caused by fungal infections, such as in this case.…”

“…MRI has the greatest sensitivity and specificity in detecting SBO in adults and children, with no radiation risk, and is, therefore, the radiological investigation of choice if suspected. However, limitations lie in the prolonged time needed, which can be problematic for young children who may need sedation or a general anaesthesia in order to keep still 3 4 7 8. An MRI can better accurately delineate soft tissue and marrow involvement whereas a CT scan best shows bony erosion 3 7.…”

“…However, limitations lie in the prolonged time needed, which can be problematic for young children who may need sedation or a general anaesthesia in order to keep still 3 4 7 8. An MRI can better accurately delineate soft tissue and marrow involvement whereas a CT scan best shows bony erosion 3 7. Radiological changes may be subtle or absent initially, and Bolouri et al reports single positron emission CT could be a useful imaging modality if there is a high enough clinical suspicion 9…”

“…As a result, treatment strategies are initially broad in order to cover the most common organisms, but the lack of specificity can delay clinical improvement. Fungal aetiology is often considered after a failure of antibiotic therapy; therefore, it is important to send a tissue sample for histopathological and microbiological analysis so that treatment can be tailored to the organism, once the diagnosis is suspected 2 3 7…”

Fungal Osteomyelitis of Temporomandibular Joint and Skull Base Caused by Chronic Otitis Media

“…P. aeruginosa infection causes headaches, ear pain, facial pain, swelling around the orbital area. SBO can also be caused by fungus, which is a rarer case [7,13]. It may appear in the ear canal or middle ear in the form of acute, COM, which can also cause chronic maxillary sinusitis, pain in the maxillary sinus, and facial, periorbital swelling [6,14,15].…”