Central Skull Base Osteomyelitis Research Articles

Current Evidence in the Management of Central Skull Base Osteomyelitis: A Systematic Review

Objectives Based on current evidence, this systematic review focuses on various gray areas related to these patients' diagnosis, management, and follow-up in central skull base osteomyelitis (CSBO). Study Design A systematic review of all case reports and observational studies. Methods We systematically searched PubMed, Scopus database, Cochrane database, U.K. clinicaltrails.gov registry, and World Health Organization International Clinical Trials Registry Platform and included all reports as per our inclusion criteria. Data was analyzed systematically, and we made essential observations. Results Out of 179 articles, 25 were selected according to inclusion criteria and quality assessment. Among the 44 patients, refractory headache (95%) was the most common presentation, followed by cranial nerve paralysis (82%) and Pseudomonas (32%) as the most common bacteria. Contrary to the available literature the disease cure was worse in those who underwent targeted biopsy (64% vs. 36%, p = 0.023) and surgical debridement (61% vs. 39%, p = 0.013) in the late stages of the disease. Conclusion Otogenic osteomyelitis can spread to central skull bones in the absence of obvious ear symptoms. Early diagnosis and intervention of CSBO before progression to late stages can help decrease significant morbidity and mortality.

Outcome of Total Surgical Debridement of Covid Associated Rhino-Orbito-Cerebral Mucormycosis Based on a New Surgical Staging System: A Cohort Study.

To propose a surgical staging system with management protocol for post-covid Rhino-orbito-cerebral mucormycosis (ROCM) with central skull base osteomyelitis. A prospective cohort study of a total of 193 post-covid ROCM patients was conducted between May 2021 and January 2022 at a tertiary care centre. Patients were assessed radiologically and staged from I to V. Follow up period was 16months and the surgical outcome in terms of recurrent disease was assessed. A total of 193 patients (129 primary and 64 revision) were studied. Maxilla was found to be the epicenter of anterior disease (69.3%) and pterygoid wedge was noted to be the epicenter of posterior disease (85.6%). More than 65% of our patients, at the time of presentation, presented with involvement of the central skull base. Intracranial disease was noted in 13.9% of patients and the mortality rate was 6.2%. This staging system provides a systematic step-by-step protocol for the management of ROCM, with emphasis on meticulous disease clearance at the central skull base.

1364-P: Cinicoradiological and Microbial Spectrum of Skull Base Osteomyelitis and Its relation to Diabetes Mellitus

Skull base osteomyelitis (SBO) is a rare life-threatening disease, which is on the increase specifically the incidence of fungal skull base osteomyelitis. Objectives: To describe the demographic, and clinicoradiological profile, and to assess the outcome of skull base osteomyelitis. Methodology: A prospective study from a tertiary care centre, in Kerala from 1st February 2018 to 31st August 2019 with a minimum follow-up of 6 months. All patients diagnosed with skull base osteomyelitis were included. The demographic profile and relevant investigations, radiological correlations and treatment outcomes were analysed. Results and Discussions: 30 patients (23 males and 7 females) were studied. Incidence was found to be high in the age group 51-60 years. The mean (SD) of Age (Years) was 62.02 (14.21), ranging from 1.5-78 years. The most common presentation was a nocturnal earache (86.7%).13.3% of patients presented with headache alone, these cases were diagnosed to be central skull base osteomyelitis and had a significant association with clival erosion. All the patients were having diabetes mellitus except 1.5 yrs old who had congenital cyclic neutropenia. We could see an association between uncontrolled blood glucose and the severity of the disease (P value <0.001). 63.3% of the participants had Cranial Nerve Palsy at the presentation. The culture yielded Pseudomonas followed by staphylococcus aureus, MRSA & Aspergillus. The ESR and CRP levels were reliable for the detection, progression and resolution of disease status in SBO. All patients were treated with third-generation cephalosporins and fluoroquinolones for a minimum of 6 weeks and of which, 12 patients with fungal SBO were given antifungals also. Conclusions: Skull base osteomyelitis is an entity that requires a lifelong commitment. A high index of suspicion, early diagnosis, and prompt and aggressive management are critical for a positive outcome. Uncontrolled diabetes mellitus was the risk factor recognised. Disclosure S.Radhakrishnan: None. D.C: None. V.Dahiya: None. C.R: None.

Retropharyngeal Abscess in Children: An Uncommon Presentation of a Central Skull Base Osteomyelitis Secondary to A Subclinical Tonsillitis

Retropharyngeal Abscess in Children: An Uncommon Presentation of a Central Skull Base Osteomyelitis Secondary to A Subclinical Tonsillitis

Dysphagia and Tongue Deviation: An Unexpected Cause.

Dysphagia and Tongue Deviation: An Unexpected Cause.

Prolonged headache caused by central skull base osteomyelitis with epidural abscess in type 1 diabetes mellitus

Prolonged headache caused by central skull base osteomyelitis with epidural abscess in type 1 diabetes mellitus

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.

Central Skull Base Osteomyelitis Presenting with Bilateral Abducens Nerve Palsy

Central Skull Base Osteomyelitis Presenting with Bilateral Abducens Nerve Palsy

Imaging of Acute and Chronic Skull Base Infection.

Skull base infections are uncommon but can be life threatening without timely recognition. Imaging plays a crucial role because symptoms can be vague and nonlocalizing. Necrotizing otitis externa in diabetic or immunocompromised patients is the commonest cause of skull base osteomyelitis (SBO), followed by sinogenic infections and idiopathic central SBO. Multiparametric magnetic resonance (MR) and high-resolution CT are the mainstays for establishing a diagnosis and estimating disease extent, with MR being superior in ascertaining marrow and soft tissue involvement. Monitoring treatment response, of which imaging is a fundamental part, is challenging, with emerging promising imaging tools.

A Case of Atypical Central Skull Base Osteomyelitis with Bilateral Alveolar Bone Destruction

Central skull base osteomyelitis (CSBO) is a rare, fatal condition seen mostly in elderly diabetic or immunocompromised patients; it mainly involves the sphenoid or occipital bones and diagnosis is often delayed. A 72-year-old male with diabetes was referred to our department with severe pain in the maxillary gingiva. Endoscopic biopsy of the pterygoid bone confirmed the presence of mucormycosis combined with Klebsiella pneumoniae infection. Sinus surgery was performed with bilateral alveolar bone sequestrectomy. Long-term intravenous broad-spectrum antibiotic therapy using meropenem and ampicillin/sulbactam and antifungal therapy using amphotericin B (100 mg/day) was administered; an oral antifungal agent, posaconazole (800 mg/day), was also prescribed for 11 weeks. At the 6-month follow-up visit, there were no complications and no progression of the CSBO lesion was observed. Timely diagnosis and multidisciplinary treatment including endoscopic surgery, alveolar bone sequestrectomy, and combined antifungal and antibiotic therapy can reduce mortality and minimize complications associated with CSBO.

Polymicrobial Skull Base Osteomyelitis Related to Chronic Sphenoiditis and Endoscopic Sinus Surgery

Skull base osteomyelitis (SBO) secondary to endoscopic surgery for chronic sinusitis and post-operative sphenopalatine artery electrocautery has not been previously reported. This case report details an instance of Central SBO with an unusual microbiology profile and highlights the need to readily consider SBO should patients present with persistent headache and cranial nerve palsies following sinus surgery. Laryngoscope, 131:E1086-E1087, 2021.

The role of imaging in skull base osteomyelitis — Reviewed

PurposeSkull base osteomyelitis (SBO) is difficult to diagnose due to a wide array of clinical presentations. It can be life threatening if not treated promptly.The objective of this study is to identify the various neck spaces involved in skull base osteomyelitis, correlate them with the possible source of infection and identify the related complications. MethodsEighty nine consecutive either culture proven cases of skull base osteomyelitis, or culture negative cases with inflammation on histopathology responding to antibiotic therapy, presenting at a single non-government hospital in south India between January 2016 and December 2018 were included in this study. Images were reviewed by two radiologists and imaging findings were documented by consensus. ResultsInvolvement of the parotid space, retromastoid space and (temporomandibular) TM joint was associated with otogenic source of infection (p value < 0.05); while, retropharyngeal/prevertebral involvement was associated with sphenoid and nasopharyngeal sources (p value < 0.05). Complications such as cavernous sinus thrombosis (p value = 0.023) and ICA involvement (p value = 0.014) were more commonly seen with central skull base osteomyelitis. Abscess formation was seen in all three groups of patients without a significant difference between the groups. ConclusionImaging plays an important role in determining the possible source of infection by identifying the involved neck spaces and this in turn can guide the clinician to a site for biopsy. Complications related to SBO can also be identified on imaging and can guide appropriate management.

USE of PET CT scan for earlier diagnosis of central skull-base osteomyelitis – A step beyond conventional MRI scan

Central Skull base osteomyelitis (SBO) is a rare but life-threatening condition, most often affecting the sphenoid and occipital bones. It is described in a confined set of immunocompromised individuals and elderly diabetics. The fatal outcomes due to delayed initiation of appropriate treatment, demands use of newer methods for faster diagnosis. Currently, MRI is the investigation most commonly used to pick up cases of suspected SBO. We present a series of 13 patients who presented to Aster Medcity, Kochi, India, over a period of 2 years with symptoms of headache and multiple cranial nerve palsy. Initial MRI imaging was found to be normal. However, we performed Regional Scintigraphy (Bone Scan) and PET CT Scan and found lesions suggestive of Central SBO, which was later proven by biopsy. Our study highlights the importance of use of PET CT Scan and Regional Scintigraphy for earlier diagnosis of Central SBO. It also visualizes appropriate biopsy site for confirmation of diagnosis. We also outline PET Scan findings critical for diagnosis, treatment and follow-up of Central SBO. On follow up we found that earlier initiation of appropriate treatment directly correlated with better patient outcomes.

The routes of infection spread in central skull-base osteomyelitis and the diagnostic role of CT and MRI scans

BackgroundCentral skull-base osteomyelitis (CSBO) represents a life-threatening complication of external ear canal infection. Computed tomography (CT) and magnetic resonance imaging (MRI) play key roles in assessment of CSBO progression.MethodsTwelve patients with CSBO were included in a retrospective clinical study. In total, 62 scans (30 CTs and 32 MRIs) were performed to evaluate the extent of inflammatory changes. The scans were read independently by two radiologists specialised in imaging of the head and neck. The regions under the skull base were specified using the online Anatomy Atlas of the skull base. To clarify the timeline, the time period was divided into four parts, and inflammatory changes in the skull-base regions were tracked. Data were statistically analysed.ResultsIn early stages of the disease, CT scan detects inflammatory changes closely related to the stylomastoid foramen and medially to the posterior belly of the digastric muscle, changes which have been proved to be crucial for the diagnosis of CSBO. Later the infection spreads to the contralateral side causing demineralisation of the bones.ConclusionImaging methods play a crucial role not only in establishing the diagnosis, but also in anticipating the direction of infection spread underneath the skull base.

Cranial Osteomyelitis: A Comprehensive Review of Modern Therapies.

Cranial osteomyelitis is a rare but potentially life-threatening condition that requires early diagnosis with prompt and appropriate management by neurosurgeons to prevent further central nervous system complications. The literature in the Medline database was comprehensively reviewed with the keywords "cranial osteomyelitis," "skull base osteomyelitis (SBO)," "central skull base osteomyelitis," and "temporal bone osteomyelitis." Items in the reference list of each article relevant to the objective of this study were reviewed. This review produced 183 articles: 13 book chapters, 24 case reports, 17 case series, 98 original articles, 30 review articles, and 1 meta-analysis. We classified cranial osteomyelitis as sinorhino-otogenic, including anterior, middle, and posterior skull base osteomyelitis; and non-sinorhino-otogenic, including iatrogenic, posttraumatic, hematologic, and osteomyelitis with other causes. New diagnostic modalities, the introduction of broad-spectrum antibiotics, and recent advances in neurosurgical procedures have led to a decrease in the rate of treatment failure in cranial osteomyelitis. Early recognition of initial nonspecific symptoms is key to diagnosing and managing this treatable but life-threatening condition. Early identification of the causative pathogen, appropriate broad-spectrum antibiotic therapy over a period of 8-20 weeks, and aggressive surgical debridement are essential for managing cranial osteomyelitis. On the other hand, inadequate treatment is responsible for refractory cases and poses a great diagnostic challenge. A new classification dividing cranial osteomyelitis into sinorhino-otogenic versus nonsinorhino-otogenic groups could prove valuable for clinical communication and treatment.

Scedosporium apiospermum as a rare cause of central skull base osteomyelitis

We report a case of Scedosporium apiospermum mold causing ear infection, central skull base osteomyelitis and finally, occlusion of carotid artery in a 48-year-old diabetic man. The exact diagnosis was established and the severity of the disease understood several months after the onset of symptoms. Despite of appropriate antifungal therapy, and repeated surgical and otological procedures, the infection progressed to fatal cerebral infarction.

Central Skull Base Osteomyelitis: Diagnostic Dilemmas and Management Issues.

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 6weeks. Three patients followed up over 4years and showed no relapses. One succumbed to other medical co morbidities after 8months 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.

Can computed tomography and magnetic resonance imaging differentiate between malignant pathology and osteomyelitis in the central skull base?

Central skull base osteomyelitis is clinically difficult to distinguish from malignancy. The computed tomography and magnetic resonance imaging scans of six patients with central skull base osteomyelitis were compared with scans from patients with a range of skull base conditions. Computed tomography scans of central skull base osteomyelitis show much less bony destruction relative to the magnetic resonance imaging changes, whereas malignancy cases were associated with similar bony destruction on computed tomography and magnetic resonance imaging. In magnetic resonance imaging scans, it was possible to confirm previous findings of clival hypointensity on T1-weighted images relative to normal fatty marrow. In addition, there were signs of pre- and para-clival soft tissue infiltration, with the obliteration of normal fat planes and frank soft tissue masses in all six central skull base osteomyelitis patients. Signal intensity on T2-weighted images of the clivus was high in five central skull base osteomyelitis patients. With intravenous contrast, fascial plane anatomy appeared restored in central skull base osteomyelitis cases, almost in keeping with that of non-involved areas. This was not a feature in any of the malignant conditions.

Central skull base osteomyelitis: a rare but life-threatening disease

We present the case of a 70-year-old non-diabetic patient who presented to the emergency department with unrelenting otalgia. A severe otitis externa (OE) and mastoiditis were treated with broad spectrum antibiotics and surgical drainage. No bacteria was isolated from surgical samples. Because the otalgia persisted, a magnetic resonance (MR) was performed and showed an infiltrating process at the skull base. Biopsies failed to prove malignancy or granulomatosis. The patient's neurological state deteriorated. The suspicion of a skull base osteomyelitis (SBO) was raised and proven by CT-guided biopsies that grew Pseudomonas aeruginosa. Meropenem and ciprofloxacin, given for 8 weeks, lead to a fast clinical improvement and a full recovery. SBO is uncommon, often complicating severe OE. Pseudomonas aeruginosa is the main pathogen. Prompt diagnosis and adequate antibiotherapy are required to lower mortality and morbidity. The diagnosis may be delayed because of unawareness and large differential diagnosis including solid neoplasic tumours, malignant hemopathies and granulomatosis.

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.