Malignant otitis externa moe is an invasive granulomatous infection of the external auditory canal commonly caused by the pseudomonas aeruginosa bacteria. Treatment of culturenegative skull base osteomyelitis. In partially treated cases of malignant otitis externa, atypical symptoms and findings of unilateral severe otalgia, unremitting headache, and presence of high esr, unilateral ome, constitute diagnostic clues of skull base osteomyelitis. Skull base osteomyelitis is classically documented as an extension of malignant otitis externa. A woman in her early forties presented with seizures and multiple cranial nerve palsies. Santorini to the skull base and through venous channels to other portions of the temporal bone, now acceptably called necrotizing otitis externa. Imaging of mucormycosis skull base osteomyelitis american. The imaging appearances can be misinterpreted as malignancy but consideration of this diagnosis, both radiologically and clinically, is imperative to avoid the need for. Skull base osteomyelitis malignant otitis externa is an uncommon complication caused by the spread of an outer ear infection commonly seen in people with compromised immunity most often diabetes. On evaluation with ct and mri scans, he was found to have pan sinusitis with erosions of the skull base in the floor of sphenoid near lateral recess. Distinguishing between fungal and bacterial aetiologies of sbo has significant therapeutic implications. As a result of having treated patients with skull base osteomyelitis over a 4. This disease is difficult to manage, often requiring longterm antibiotic therapy. We present a rare atypical case of skull base osteomyelitis originating from infection of the middle ear and causing the colletsicard.
Rhinocerebral mucor infection is characteristically an acute, fulminant, and deadly infection also affecting the orbits. Osteomyelitis of the skull base is a potentially life threatening condition if it is not diagnosed and treated early. Skull base osteomyelitis presenting as villarets syndrome. The objective of this article is to present an over view regarding the identification and management of osteomyelitis. It commonly affects elderly diabetics and those immunocompromised. Clival osteomyelitis presenting as a skull base mass. Despite this, the disease has a significant mortality and morbidity rate. Osteomyelitis more commonly affects people younger than 20, or adults older than 50 years of age. First described in 1959 by meltzer and kelemen, skull.
Osteomyelitis is a severe inflammation within the bone, bone marrow and surrounding soft tissue, that develops secondary to infection with microbial organisms. Skull base osteomyelitis sbo is a serious, lifethreatening condition seen most commonly in elderly diabetic or immunocompromised patients. There is high morbitity and mortality associated with skull base osteomyelitis. Management of osteomyelitis of the skull base journal. Skull base osteomyelitis sbo is an unusual complication of. Osteomyelitis is an infection that most often causes pain in the long bones in the legs. Malignant otitis externa with skull base osteomyelitis. He was operated upon by functional endoscopic sinus.
The infection can spread further leading to brain parenchymal involvement 6. Nonotologic osteomyelitis of the skull base and craniovertebral junction is a locally aggressive disorder causing lytic destruction of skull base bone often with underlying dural enhancement. Combining anatomic imaging t1 and t2 weighted images with dwi, early changes within primary and metastatic sites. The infection causes damage in the region around the ear and skull base. Atypical skull base osteomyelitis arising from the sphenoid or occipital bones without associated external otitis occurs much less frequently and initially may have headache as the only. Common etiologies of villarets syndrome are parotid gland tumor, increased. Anatomy and pathology of the skull base, ct and mri imaging. Skull base osteomyelitis and potential cerebrovascular complications in children. Other bones, such as those in the back or arms, can also be affected.
Subsequently, our understanding of sbo is derived from case reports or small series in the surgical literature 115. Typical osteomyelitis is reportedly caused by pseudomonous aeruginosa in elderly diabetic patients after malignant external otitis. Rhinocerebral mucor infection is characteristically an acute, fulminant, and deadly infection also affecting the orbits and deep face and is. There are no pathognomic findings on clinical or radiographic examination which confirm skull base osteomyelitis.
Skull base osteomyelitis caused by an elegant fungus. Skull base, osteomyelitis, malignant otitis externa, pseudomonas aeruginosa, cranial nerve palsy. Pseudomonas aeruginosa is the most common causative organism. Osteomyelitis is an infection of bone that can occur in any age group.
Osteomyelitis tends to occlude local blood vessels, which causes bone necrosis and local spread of infection. Case report open access severe skull base osteomyelitis. Introduction osteomyelitis is acute and chronic inflammatory process. Skull base osteomyelitis sbo is a potentially lifethreatening inflammation of cranial base bony structures of variable origin. Spectct in the diagnosis of skull base osteomyelitis. Management of osteomyelitis of the anterior skull base and. It is usually secondary to infections beginning in the external auditory canal and is caused almost uniformly by the gram negative pseudomonas aeruginosa bacteria. Osteomyelitis is an inflammatory bone disorder caused by infection, leading to necrosis and destruction of bone.
Typically, the inflammation of the skull base results from infection from neighboring tissues. Case report a case of skull base osteomyelitis with multiple. Osteomyelitis article about osteomyelitis by the free. Initial presentation commonly includes aural symptoms and cranial nerve dysfunctions. A 99mtc mdp bone scan with spectct was carried out on a patient with. There are variety of names for this condition, including necrotizing external otitis, and malignant otitis externa. Sbo generally arises from ear infections and infrequently complicates sinonasal infection. Two patients had skull base osteomyelitis sbo complicating malignant otitis externa.
How is skull base osteomyelitis monitored and treated. A male in his 70s with diabetes mellitus and chronic renal failure presented with left hemiparesis. Systemic immunocompromise, such as diabetes mellitus, with or without a history of previous radiation therapy is usually noted. Skull base osteomyelitis in the emergency department.
Pulling, md, maine medical center, portland, maine o steomyelitis is generally categorized as acute or chronic based on histopathologic find. Skull base osteomyelitis can involve the jugular foramen and its associated cranial nerves resulting in specific clinical syndromes. Osteomyelitis of the skull base is a rare occurrence. 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. Bilateral skull base osteomyelitis in an immunocompetent.
Currently, there is no consensus about the best therapeutic option. Skull base osteomyelitis sbo is an infection of the bone or bone marrow, typically caused by bacteria or sometimes fungus. Atypical osteomyelitis of the skull base occurs much less frequently. Bilateral skull base osteomyelitis in an immunocompetent patient introduction skull base osteomyelitis is a relatively uncommon medical condition. Pseudomonas osteomyelitis of skull base presenting as intractable headache and nasopharyngeal abscess.
Fractures and trauma can also be a gateway for infectious bacteria to enter the bone or bone marrow. Here we report a patient with uncontrolled diabetes, who presented with giddiness and fall due to an episode of seizure. It affects predominantly diabetic and immunocompromised males and has a high mortality rate. We demonstrate here the utility of spectct in diagnosing this entity, which was not obvious on a planar bone scan. Pdf objective the pathogeny of osteomyelitis of the skull base has evolved over time with the emergence of ciprofloxacinresistant. Treatment of osteomyelitis is challenging particularly when complex multiresistant bacterial biofilm has already been established. If ct or mri results are inconclusive, then a bone scan with high inflammatory markers would be highly suggestive of skull base osteomyelitis. Skull base osteomyelitis from otitis media presenting as the. Osteomyelitis can be primary osteomyelitis due to hematogenous spread or secondary due to contiguous spread. It usually goes away if treated early with antibiotics. Treatment of osteomyelitis can include antibiotics, splinting, or surgery. To document diagnostic and management difficulties inmasked skull base osteomyelitis secondary to malignant otitisexterna, emphasis on establishing. Distinguishing between fungal and bacterial aetiologies of sbo has signi.
Skull base osteomyelitis is a rare but serious infection. In case of malignant otitis externa, inflammation disseminates from the external auditory canal. Recently, complications have arisen due to the emergence of atypical osteomyelitis. Hybrid techniques petct and petmri are the newest modalities which combine imaging strengths. Diagnosis and management of osteomyelitis of osteomyelitis. It can affect all ages, involve any bone, become a chronic disease and cause persistent morbidity. Skull base osteomyelitis is a serious disease with a high risk of complications including neuroinfection. Ear disorders skull based osteomyelitis california ear. We have experiensed 5 cases of skull base osteomyelitis at our hospital. Despite the availability of antibiotics, the occurrence of osteomyelitis is still prevalent in developing countries.
A diagnostic dilemma of central skull base osteomyelitis. Diagnostic and therapeutic challenges among various presentations muhammad adnan khan 1, syed abdul qader quadri 1, abdulmuqueeth syed kazmi 2, vishal kwatra 1, anirudh ramachandran 3, aaron gustin 4, mudassir farooqui 5, sajid sattar suriya 1, atif zafar 6 1 department of neurosurgery. Criteria for diagnosis and treatment are still controversial. The sphenoid bone is a main sharer in the central skull base. Differing from limited cranial nerve lesions, such as prominent facial nerve paralysis and jugular foramen syndrome, extensive involvement villarets syndrome was observed in this patient17.
The intention of this study was to evaluate contemporary trends in etiology, diagnosis, management, and outcome of sbo and to draw the clinicians attention on this probably underestimated disease. Osteomyelitis of the base of the skull chandler 1986. It is often caused by pseudomonas and sometimes by fungus. Malignant otitis externa associated with skull base osteomyelitis is a rare but life threatening condition. Central skull base osteomyelitis is a rare, lifethreatening complication of necrotizing or malignant otitis externa noe, which results in destruction of the skull base. Infection may expand through the bone cortex and spread under the periosteum, with formation of subcutaneous abscesses that may drain spontaneously through the skin. Skull base osteomyelitis sbo is a complex and fatal clinical entity that is often misdiagnosed for malignancy. Osteomyelitis of the skull base is the most severe form of malignant otitis externa. Janani baskaran, mbbs 2 and renuga vivekanandan, md 1. Pseudomonas osteomyelitis of skull base presenting as. Atypical skull base osteomyelitis suspected of spreading inflammation from the ear canal with unilateral multiple cranial neuropathy and cerebral infarctions.
Skull base osteomyelitis secondary to malignant otitis exter. This disease is difficult to diagnose and manage, although advances have been seen with antibiotics and hyperbaric oxygen. Central skull base osteomyelitis as a complication of. In this study, we present our experience with seven patients diagnosed. In vertebral osteomyelitis, paravertebral or epidural abscess can develop. Usually, it is a complication of otitis externa when repeated episodes fail to resolve with topical medications and aural toilet. Central skull base osteomyelitis in patients without. Ct and mri findings in skull base osteomyelitis a pictorial. Technetium and gallium scintigraphy help in the early detection of such infections while ct. Since then, advances have been made in the diagnosis, treatment, and clinical outcomes of this condition. Advanced imaging techniques in skull base osteomyelitis due to. Osteomyelitis nord national organization for rare disorders. Skull base osteomyelitis is an uncommon disease that usually complicates a malignant external otitis with temporal bone involvement.
We discuss skull osteomyelitis associated with special conditions skull base, fungal, pediatric, syphilitic, tuberculous osteomyelitis, and skull osteomyelitis associated with immunodeficiency virus infection hiv. The skull base is formed by two paired bones, frontal and temporal, and 3 unique, ethmoid, sphenoid and occipital. Osteomyelitis is a prevalent condition that affects males and females in equal numbers. Definition the word osteomyelitis originates from the ancient greek words osteon bone and muelinos marrow inflammation process of the entire bone including the cortex and the periosteum, recognizing that the pathological process is rarely confined to the endosteum.
It was termed malignant, due to the high mortality rate and poor response to treatment. Acute osteomy elitis often results in rapid lytic destruction of the skull base bone commonly associated with cranial nerve palsyparalysis, and rarely, with. Atypical skull base osteomyelitis arising from the sphenoid or occipital bones without associated external otitis occurs much less frequently. Here we present a case that emerged with multiple infarctions in the right cerebrum. The typical clinical scenario involves a diabetic or immunodeficient patient with otitis externa that was either inadequately treated or refractory to standard antibiotic therapy. It typically afflicts immunosuppressed patients and should be suspected in patients with persistent otitis complicated by cranial nerve palsy vii, ix and xii. As a result of having treated patients with skull base osteomyelitis over a 4year period, we have developed a method of staging and monitoring this malady using. A case of skull base osteomyelitis with multiple cerebral.
Central skull base osteomyelitis in patients without otitis. The condition was first described by chandler in 1968. We present a case which illustrates the diagnostic difficulty in distinguishing between osteomyelitis of the central skull base and base of skull tumours. Most commonly encountered clinical scenario is, an elderly diabetic with inadequately treated chronic external otitis who presents with temporooccipital pain.
Articles chronic osteomyelitis of base of skull br med j 1961. Classically, destructive malignant otitis externa is thought to precede and cause central skull base osteomyelitis, but atypical cases in which aural symptoms are not mainly manifested or are unrelated to auricular etiology, have also been reported. It is usually secondary to infections beginning in the external auditory canal and is caused almost. Otolaryngology head and neck surgeryvolume 3, issue 1, july 2005. Tissue diagnosis is the key to both diagnosis and management of this rare entity. While there is a higher incidence of bone infections in adults that live in developing countries, hemodialysis patients, injection drug users, and patients with. The initial inflammation has now eroded the tegmen tympani inflaming the dural lining, eroded the jugular foramen, resulting the venous sinus thrombosis. Skullbase osteomyelitis sbo occurs secondary to invasive bacterial and fungal infection. The long standing left middle ear mastoid inflammation can lead to a multitude of complications, the severe one being skull base osteomyelitis. Skull base osteomyelitis ie, malignant otitis externa is a severe osteogenic infection usually observed in elderly patients with diabetes mellitus or patients who are immunocompromised.
Request pdf central or atypical skull base osteomyelitis. Skull base osteomyelitis sbo is typically bacterial in origin and caused by pseudomonas, although the fungus aspergillus has also rarely been implicated. Skull base osteomyelitis is a relatively uncommon condition. Skull base osteomyelitis is a potentially fatal disease. Causes of osteomyelitis include bacteria in the bloodstream from infectious diseases that spread to the bone, an open wound from a trauma over a bone, and recent surgery or injection in or around a bone. Severe skull base osteomyelitis caused by pseudomonas aeruginosa with successful outcome after prolonged outpatient therapy with continuous infusion of ceftazidime and oral ciprofloxacin. Severe skull base osteomyelitis caused by pseudomonas.
At times, skull base osteomyelitis follows the partial antibiotic treatment of. Malignant otitis externa is also known as necrotizing otitis externa or skull base osteomyelitis due to the aggressive and. Temporal bone osteomyelitis and temporoparietal abscess secondary to malignant otitis externa. Skull based osteomyelitis can be secondary to severe otitis externa swimmers ear, also associated with exostosis, meaning that the infection begins in the lining of the ear canal and then progresses to the petrous apex. The colletsicard syndrome describes the clinical manifestations of palsies involving cranial nerves ix, x, xi, and xii. Aug 02, 2018 if the patient is medically unstable and unable to tolerate general anesthesia, highdose iv antibiotics may be attempted to eradicate the infection in place of surgery underlying sepsis as a result of the infection may be life threatening, and the patient should be stabilized as quickly as possible for anticipated surgical drainage of the infecti. Osteomyelitis musculoskeletal and connective tissue. No single modality is able to address the scope of sbo.
She also had a background of chronic otalgia and poorly controlled diabetes mellitus. Malignant otitis externa moe mri protocols and planning. It is divided in anterior, middle and posterior cranial. The list of acronyms and abbreviations related to sbo skull base osteomyelitis. Infection in the marrow of the temporal, occipital, and sphenoid bones is an uncommon, but increasing occurrence. Skull base osteomyelitis secondary to malignant otitis. As a result of having treated patients with skull base osteomyelitis over a 4year period, we have developed a method of staging and monitoring this malady using gallium and technetium scanning techniques. Osteomyelitis of the skull base neurosurgery oxford. Here we present such a case, seen in a 74 yearold lady.
Skull base osteomyelitis case discussion extensive enhancement of the skull base, with associated soft tissue, involvement of the right zygomatic arch. Osteomyelitis medical conditions rush rush university. Skull base osteomyelitis case discussion extensive enhancement of the skull base, with associated soft tissue, involvement of the right zygomatic arch and the pterygoid muscles on the right. Skull base anatomy the anatomy of the skull base is complex and its knowledge is essential for the treatment planning of the different processes that could affect this area. Sbo is commonly a direct complication of otogenic, sinogenic, odontogenic, and rhinogenic infections and can present as central, atypical, or pediatric clival sbo. Management of osteomyelitis of the skull base benecke. Skull base osteomyelitis can lead to a number of complications like cranial neuropathy, cavernous sinus thrombosis, meningitis. Skull base osteomyelitis sbo is a rare clinical presentation and usually occurs as a complication of trauma or sinusitis. Therapy for malignant otitis externa has changed since this entity was first described. May 01, 2011 malignant otitis externa associated with skull base osteomyelitis is a condition seen classically in the elderly, diabetic patient. Osteomyelitis of the base of the skull journal article. Malignant otitis externa progressing to skull base osteomyelitis is an aggressive infection of the temporal bone and skull base, associated with possible involvement of the facial nerve, carotid artery, jugular vein and mastoid. Central skull base osteomyelitis sbo is a lifethreatening disease originating from ear and from sinonasal infections.
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