Atypical Skull Base Osteomyelitis Research Articles

Central Skull Base Osteomyelitis: Multimodality Imaging and Clinical Findings from a Large Indian Cohort.

Central or atypical skull base osteomyelitis (CSBO) often presents with severe unrelenting headache and progressive mono or polyneuritis cranialis. MRI and CT are used as initial imaging techniques but have a poor specificity and sensitivity. To analyze our cohort of CSBO. Over a 5-year period [2015-2020], we retrospectively analyzed the records of all patients with CSBO who had undergone a 3T MRI Brain, MR angiography, regional FDG PET-CT, and skeletal scintigraphy with 99mTc MDP/SPECT-CT. Surgical biopsy specimens were sent for bacterial and fungal cultures. In total, 17 patients with CSBO were identified. Typically, 88% of patients presented with severe unilateral headache. All patients had at least a cranial mono or polyneuritis. The majority of patients were diabetic [64%]. MRI was normal in 42% of patients, whereas PET-CT and with 99mTc MDP scan and SPECT-CT were abnormal in all patients. Our series of CSBO showed a 40% mortality rate with significant morbidity and relentless progression. Patients required repeated PET CT and bone scans to detect regression of disease activity. The average duration of IV therapy ranged from 3 weeks to 9 months and oral therapy for around 2-3 months. Cure was defined after taking into account the original diagnosis, symptom resolution, and concordant reduction of tissue uptake on PET CT and 99mTc bone scan. The combination of MRI, FDG PET CT, and 99mTc bone scan with concurrent SPECT CT was able to detect disease and disease progression in all patients.

Skull Base Osteomyelitis: A Comprehensive Imaging Review.

Skull base osteomyelitis is a relatively rare condition, generally occurring as a complication of advanced otologic or sinus infection in immunocompromised patients. Skull base osteomyelitis is generally divided into 2 broad categories: typical and atypical. Typical skull base osteomyelitis occurs secondary to uncontrolled infection of the temporal bone region, most often from necrotizing external otitis caused by Pseudomonas aeruginosa in a patient with diabetes. Atypical skull base osteomyelitis occurs in the absence of obvious temporal bone infection or external auditory canal infection. It may be secondary to advanced sinusitis or deep face infection or might occur in the absence of a known local source of infection. Atypical skull base osteomyelitis preferentially affects the central skull base and can be caused by bacterial or fungal infections. Clinically, typical skull base osteomyelitis presents with signs and symptoms of otitis externa or other temporal bone infection. Both typical and atypical forms can produce nonspecific symptoms including headache and fever, and progress to cranial neuropathies and meningitis. Early diagnosis can be difficult both clinically and radiologically, and the diagnosis is often delayed. Radiologic evaluation plays a critical role in the diagnosis of skull base osteomyelitis, with CT and MR imaging serving complementary roles. CT best demonstrates cortical and trabecular destruction of bone. MR imaging is best for determining the overall extent of disease and best demonstrates involvement of marrow space and extraosseous soft tissue. Nuclear medicine studies can also be contributory to diagnosis and follow-up. The goal of this article was to review the basic pathophysiology, clinical findings, and key radiologic features of skull base osteomyelitis.

A Rare Case of Skull Base Osteomyelitis Caused By E.Coli and Candida Albicans in A Patient with Gapo Syndrome: A Case Report

Skull base osteomyelitis is a very rare and life-threatening disease. It has significant mortality and morbidity though appropriate antibiotherapy. Here we report a case of atypical skull base osteomyelitis, which is rarely seen in infectious disease practice, caused by E.coli and Candida albicans in a patient with GAPO syndrome.

Clinical profiling and management outcome of atypical skull base osteomyelitis

Background: Malignant otitis externa or skull base osteomyelitis arises as a complication of otological infection in immunocompromised individuals, especially elderly diabetics. With increasing awareness of the disease and better diagnostic modalities, there has been an increased reporting of atypical osteomyelitis of skull base (AOSB). Atypical osteomyelitis of skull base is a relatively rare yet an emerging clinical entity that also occurs in immunocompromised elderly individuals, however, in the absence of a pre-existing otological or rhinological infection. The purpose of this study was to review the clinical presentation and treatment protocol followed in patients diagnosed with atypical skull base osteomyelitis.Methods: A retrospective audit of medical records of patients diagnosed with AOSB between 2014 and 2018 was done. Clinical presentation and radiological assessment done prior to intervention was noted. All patients underwent transnasal endoscopic biopsy of tissue from clivus. Histopathological and microbiological profiling of biopsied tissue and treatment protocol followed was noted.Results: A total of 10 patients were included in the study out of which eight were male and two female. Eight patients were known diabetics and one patient had been on chronic oral steroid use. Majority presented with a vague dull aching headache and with one or more cranial nerve (CN) palsy(s). Radiological imaging showed clival involvement for all. All were managed conservatively with appropriate antibiotics. Disease resolution was defined as either complete resolution of symptoms and/or no residual lesion noted on follow-up MRI of skull base.Conclusions: Individuals presenting with non-specific symptoms of headache with CN palsy(s) with no obvious otological/rhinological infections, should raise suspicion of atypical skull base osteomyelitis. Histopathological diagnosis and microbiological assessment are an essential aid in conservative management with higher antibiotics. Patient compliance and long-term follow-up is essential for adequate and complete resolution of disease.

A Comprehensive Review of Skull Base Osteomyelitis: Diagnostic and Therapeutic Challenges among Various Presentations.

Skull base osteomyelitis (SBO) is a complex and fatal clinical entity that is often misdiagnosed for malignancy. SBO is commonly a direct complication of otogenic, sinogenic, odontogenic, and rhinogenic infections and can present as central, atypical, or pediatric clival SBO. This review describes the clinical profile, investigational approach, and management techniques for these variants. A comprehensive literature review was performed in PubMed, MEDLINE, Research Gate, EMBASE, Wiley Online Library, and various Neurosurgical and Neurology journals with the keywords including: SBO, central or atypical SBO, fungal osteomyelitis, malignant otitis externa, temporal bone osteomyelitis, and clival osteomyelitis. Each manuscript's reference list was reviewed for potentially relevant articles. The search yielded a total of 153 articles. It was found that with early and aggressive culture guided long-term intravenous broad-spectrum antibiotic therapy decreases post-infection complications. In cases of widespread soft tissue involvement, an early aggressive surgical removal of infectious sequestra with preferentially Hyperbaric Oxygen (HBO) therapy is associated with better prognosis of disease, less neurologic sequelae and mortality rate. Complete resolution of the SBO cases may take several months. Since early treatment can improve mortality rates, it is paramount that the reporting radiologists and treating clinicians are aware of the cardinal diagnostic signs to improve clinical outcomes of the disease. It will decrease delayed diagnosis and under treatment of the condition. However, due to rarity of the condition, complete prognostic factors have not fully been analyzed and discussed in the literature.

Atypical Base of Skull Osteomyelitis Presenting as Bilateral Facial Palsy

Base of skull osteomyelitis is a rare cause of headaches and cranial neuropathies in general, and cranial nerve VII palsy in particular. Both typical and atypical skull base osteomyelitis can have similar presentation and Magnetic Resonance Imaging of the brain is very important to differentiate between them since each is caused by a different organism and requires different treatment. However, bone sampling remains crucial for diagnosis in atypical cases. We hereby report a case of atypical skull base osteomyelitis presenting as bilateral peripheral facial nerve palsy. We also present a new and less invasive diagnostic and therapeutic approach especially when bone sampling is not possible and intravenous empiric treatment cannot be initiated.

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

Base of skull osteomyelitis is commonly seen as a complication of malignant otitis externa, involving the temporal bone. It initially presents with aural symptoms such as ear ache and discharge and cranial nerve palsies. We report an atypical presentation of skull base osteomyelitis that did not show signs of otitis externa. The patient presented with severe headache, drowsiness and signs of bulbar weakness including pooling of oropharyngeal secretions. Computerized Tomography (CT) and Magnetic Resonance Imaging (MRI) studies showed a bony erosion of the left side of base of skull involving the sphenoid bone and surrounding foramina, left sided coalescent mastoiditis and inflammation of the left parapharyngeal space. There was also inflammation of the tissues encasing the internal carotid artery and jugular veins and thrombosis of left jugular vein. These imaging findings along with cranial nerve palsies were suggestive of malignancy. However, tissue biopsy was negative for malignancy. The growth of Pseudomonas aeruginosa in the biopsy material as well as nasopharyngeal and blood cultures along with elevated Erythrocyte Sedimentation Rate (ESR) and C-Reactive Protein (CRP) levels led to a diagnosis of base of skull osteomyelitis. Hence diagnosis in such cases requires that biopsy material be sent for microbiological analysis, in addition to histology.

Atypical culture-negative skull base osteomyelitis masquerading as advanced nasopharyngeal carcinoma

Skull base osteomyelitis typically arises as a complication of otogenic or sinonasal infections in immunocompromised patients. A much rarer entity, atypical skull base osteomyelitis is not associated with an obvious infective source. Atypical and culture-negative skull base osteomyelitis is even rarer and hampers diagnosis, as its clinical presentation is remarkably similar to skull base neoplasms. We report a case of extensive skull base osteomyelitis with orbital apex syndrome and multiple lower cranial nerve palsies which initially masqueraded as possible advanced nasopharyngeal carcinoma. Extensive investigations and consult with an infectious diseases specialist aided in elucidation of the correct diagnosis. Through this article, we emphasize that skull base osteomyelitis must be considered in the setting of headache, cranial neuropathies, elevated inflammatory markers and abnormal imaging findings. Early tissue sampling for histology, stainings and cultures and prompt appropriate treatment may prevent or arrest further complications.

Central or Atypical Skull Base Osteomyelitis Consecutive to Sinusitis Infections

Introduction: Skull base osteomyelitis typically arises as a complication of ear infection in older diabetic patients, involves the temporal bone, and has Pseudomonas aeruginosa as the usual pathogen. Atypical skull base osteomyelitis arising from the sphenoid or occipital bones without associated external otitis occurs much less frequently. The purpose of this study was to review the clinical features and determine efficacy of treatment for nonotologic osteomyelitis of the skull base. Methods: We retrospectively reviewed two cases of central or atypical skull base osteomyelitis. Results: The two patients presented with asthenia, headache, and fever. No patient presented with neurologic deficits. Contrary to malignant otitis externa, our cases were not preceded by immediate external infections and had normal external ear examinations. One patient had an underlying immunocompromising condition. Imaging demonstrated bone destruction, subsequent microbiological analysis diagnosed infection, and a biopsy proved diagnosis of osteomyelitis, a prolonged antibiotic treatment was instored. The two patients were cured with no recurrence of skull base infection over a 12-month follow-up period. Conclusion: Central skull base osteomyelitisis is a rare disease whose treatment requires an early bone biopsy and appropriate treatment to prevent or limit other complications such as intracranial extension, empyema or death.

Atypical Skull Base Osteomyelitis in an Immunocompetent Patient

Objective: 1) Present an abnormal case presentation of an already rare and deadly disease process. 2) Critically review/summarize the literature as it pertained to this case. 3) Increase awareness of a diagnostically challenging reversible deadly disease process. 4) Review current treatment options/recommendations for atypical SBO. Method: This is an unusual case of atypical skull base osteomyelitis in an immunocompetent patient diagnosed in 2010 at the Cleveland Clinic Foundation (CCF). A literature review for “atypical” and “central skull base osteomyelitis” was performed using PubMed. Results: As with other published cases of atypical skull base osteomyelitis, this patient was an elderly male, had no preceding infective source, and presented initially with headache that progressed to multiple lower cranial neuropathies (CN 8, 9, 10, 12). However, our patient is unique because he was not diabetic and had no immunodeficiencies. His work-up initially centered on ruling out a primary headache disorder, temporal arteritis, and oncologic pathology. Biopsy, culture, and an indium tagged WBC scan were pivotal in proving an infectious etiology. Prolonged IV antibiotics were vital in clearing the infection. Conclusion: Skull base osteomyelitis should be considered even in immunocompetent patients presenting with headache and cranial neuropathies. When possible, culture, biopsy, and indium-tagged-WBC scan should be performed to help distinguish an infectious process over malignancy, and guide antibiotic therapy. Early diagnosis and treatment is imperative in managing this life-threatening disease.

A Case of Atypical Skull Base Osteomyelitis with Septic Pulmonary Embolism

Skull base osteomyelitis (SBO) is difficult to diagnose when a patient presents with multiple cranial nerve palsies but no obvious infectious focus. There is no report about SBO with septic pulmonary embolism. A 51-yr-old man presented to our hospital with headache, hoarseness, dysphagia, frequent choking, fever, cough, and sputum production. He was diagnosed of having masked mastoiditis complicated by SBO with multiple cranial nerve palsies, sigmoid sinus thrombosis, and septic pulmonary embolism. We successfully treated him with antibiotics and anticoagulants alone, with no surgical intervention. His neurologic deficits were completely recovered. Decrease of pulmonary nodules and thrombus in the sinus was evident on the follow-up imaging one month later. In selected cases of intracranial complications of SBO and septic pulmonary embolism, secondary to mastoiditis with early response to antibiotic therapy, conservative treatment may be considered and surgical intervention may be withheld.

Central or Atypical Skull Base Osteomyelitis: Diagnosis and Treatment

We report cases of central or atypical skull base osteomyelitis and review issues related to the diagnosis and treatment. The four cases presented, which were drawn from the Oxford, United Kingdom, skull base pathology database, had a diagnosis of central skull base osteomyelitis. Four cases are presented in which central skull base osteomyelitis was diagnosed. Contrary to malignant otitis externa, our cases were not preceded by immediate external infections and had normal external ear examinations. They presented with headache and a variety of cranial neuropathies. Imaging demonstrated bone destruction, and subsequent microbiological analysis diagnosed infection and prompted prolonged antibiotic treatment. We concluded that in the diabetic or immunocompromised patient, a scenario of headache, cranial neuropathy, and bony destruction on imaging should raise the possibility of skull base osteomyelitis, even in the absence of an obvious infective source. The primary goal should still be to exclude an underlying malignant cause.

Two Cases of Skull Base Osteomyelitis after Mastoidectomy

Skull base osteomyelitis is originated from inappropriately treated chronic infections near the skull base. If diagnosis and treatment are delayed, it occasionally causes multiple cranial nerve palsy, with the mortality rate being as high as 60%. Skull base osteomyelitis typically evolves as a complication of external otitis in diabetic patients, so it has been thought as a synonym for malignant external otitis. However, the routes of infection are diverse. We experienced two patients of atypical skull base osteomyelitis after mastoidectomy. It is an unusual complication of mastoidectomy, so we report about these cases. (Korean J Otorhinolaryngol-Head Neck Surg 2009;52:279-83)

Osteomyelitis of the Skull Base

Three cases of osteomyelitis of the skull base with associated problems in diagnosis and therapy are discussed. Patients with atypical skull base osteomyelitis are difficult to diagnose as they have no ear abnormalities, but they often develop multiple cranial nerve deficits mimicking symptoms of a posterior fossa mass. We conclude that computed tomographic scans, magnetic resonance imaging studies, bone scans indium-labeled white blood cell scans, and gallium scans are useful in making the diagnosis. A biopsy of the bony lesion often is needed to identify the causative organism and to rule out a tumor. Intravenously administered antibiotics are the mainstay of therapy and should be continued until 1 week after the gallium scan shows no abnormalities. Follow-up gallium scans then are done at 1 week and 3 months after the cessation of antibiotic therapy to search for a recurrence.