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Patient No: 3, five months following mastoidectomy and antibiotic treatment: amoxicillin/clavulanic acid, gentamycin, clarithromycin and dalacin. Non-enhanced CT image (bone window) axial scan cross section of temporal and occipital bones. Osteolysis of the compact bone in the left lateral skull base represents a late sign of osteomyelitis (arrow). Minor changes of spongy bone and major changes of compact bone highlight spread of infection under the periosteum, but represents a late sign of the infection
Source publication
Background:
Central 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.
Methods:
Twelve patients with CSBO were included in a retrospective clinical study. In total, 62 scans (30...
Context in source publication
Context 1
... it as a warning sign suggestive of further progression of skull base infection, similarly as reported in malignant otitis externa [15]. Sreepada also recommends CT follow-up for CSBO even though the osteolytic changes of the compact bone on CT represents a rather late sign, as 30% of bone must be demineralized to appear eroded on CT scans (Fig. 11). If soft tissue changes were visible on non-contrast enhanced CT scans, the suspicion of inflammation was raised. MRI is considered essential for CSBO diagnosis [16]. Venous channels and fascial planes facilitate the spread along the dural venous sinuses. Two experienced radiologists were asked to trace the infection spread on CT and ...
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Recent molecular-based studies have suggested that a diverse middle ear microbiome in adults and children can exist in the absence of disease. These studies have been largely unsupported by culture and feature species that commonly contaminate low-biomass sequencing data. While 16S rRNA gene amplicon sequencing has proven to be a highly informative...
Citations
... Positive biopsies for microbiology and negative histopathology for malignancy. [17], [9]. Adekeye et al. published a review of 141 cases of all ages of osteomyelitis of the jaws and reported the incidence of malar bone osteomyelitis to be only 1.42%. ...
Skull bone osteomyelitis in infants is a rare yet serious condition necessitating prompt evaluation and intervention to
prevent complications. This study presents a unique case of zygomatic bone osteomyelitis in a 10- month-old female infant,
a remarkably uncommon occurrence in the literature. The infant exhibited facial swelling and fever, with a history of upper
respiratory tract infection preceding the onset. The diagnostic process involved imaging modalities such as X-ray,
ultrasound, and magnetic resonance imaging, confirming left zygomatic bone involvement with a non-drainable collection.
Positive methicillin-resistant Staphylococcus aureus (MRSA) nasal swab PCR further guided antibiotic therapy. The patient
responded well to conservative management, highlighting the importance of early recognition and appropriate treatment
in infantile osteomyelitis cases. This case contributes to the limited literature on zygomatic bone involvement, emphasizing
the need for vigilance, interdisciplinary collaboration, and thorough follow-up in managing this rare condition.
Keywords: Face, Zygomatic, Skull, Infant, Osteomyelitis, Craniofacial, Swelling, Zygoma, Collection.
... Further spread posteromedially may involve the hypoglossal canal with cranial nerve XII palsy (Collet-Sicard syndrome) [8]. Rarely, infection involving petrous apex of temporal could result in cranial nerve 6 palsy and Granedigo syndrome [7]. Spread through the skull base foramina can result in intracranial CNS infection. ...
Skull base osteomyelitis (SBO) is a late manifestation of complicated otogenic infections that presents a diagnostic challenge. Delayed or missed diagnoses lead to high morbidity and mortality, and can be attributed to non-specific symptoms, subtle early radiologic findings, radiologic mimicry of nasopharyngeal carcinoma (NPC), and under-recognition from clinician and radiologists. This pictorial review aims to emphasize on early imaging recognition and distinction between SBO and NPC.
... Similar to other colleagues, we recommend CT and MRI examination as soon as possible to aid in prompt diagnosis and avoid treatment delay. 5,7,8 Imaging should be ordered as quickly as possible when there is a prolonged persistence of symptoms despite antibiotic therapy. ...
We present a case of a 58-year-old male with type II diabetes managed with metformin and insulin, who presented to the clinic with left chronic otitis media, persistent drainage, a stenotic meatus, and a prior history of 3 canal wall-down mastoidectomies and antibiotic therapy. A revision tympanoplasty with mastoidectomy was performed, and during the postoperative period, the patient had persistent pain and otorrhea, which were managed with opioids and several courses of antibiotic therapy. After symptoms persisted, imaging and culture ultimately led to the diagnosis of fungal skull base osteomyelitis, which was eventually treated successfully. While these complications are rare, their likelihood is increased with treatment delay and in the immunocompromised patient. Close management of immunocompromised patients, including diabetic patients, is vital in identifying complications early to aid in timely diagnosis and treatment to lead to the best possible outcome.
... Considering the relatively rare occurrence of the disease and the small set of studies, the predictive factors of the outcome of ASBO are not entirely clear. Associated diseases are generally the main prognostic factor, and worse disease outcomes have been described in elderly, male, diabetic, and immunocompromised patients, and patients with chronic ear disease [6,76]. The most important independent factor for a more favourable outcome is a multidisciplinary approach to the patient, with early and radical surgical removal of the focus of infection and adjuvant antimicrobial therapy. ...
Atypical skull-base osteomyelitis is a rare but fatal disease that usually involves infection of the ethmoid, sphenoid, occipital, or temporal bones that form the skull base. Unlike typical (so-called otogenic), atypical skull-base osteomyelitis has no otogenic cause. Instead, some authors call atypical skull-base osteomyelitis sinonasal, since the infection most often originates from the nose and paranasal sinuses. Diagnosing and treating this disease is challenging. To assist in managing atypical skull-base osteomyelitis, a review of the most recent literature, with patient cases and multidisciplinary perspectives from otolaryngologists, neurosurgeons, radiologists, infectious disease specialists, pathologists, and clinical microbiologists, is provided in this paper.
... SBO accurately describes the pathophysiology of the disease. 2 In atypical or central SBO, sphenoid and occipital bones are affected. 3 The disease commonly affects people with diabetes with poor chemotaxis, phagocytosis, and humoral immunity. 4 Diagnosis is from clinical features, culture, histopathology, and imaging modalities like CT and MRI scans. ...
Objective: To analyse the role of surgery along with antimicrobials to improve clinical outcomes in treating refractory cases of skull base osteomyelitis (SBO). Study design and setting: A prospective comparative study in a tertiary care centre with 70 SBO patients meeting eligibility criteria. Participants: The study population comprised 35 patients refractory to systemic antimicrobials of at least four weeks duration who later underwent surgery in addition to medication (surgical group). They were compared with a medical group that responded to medications alone. Main outcome measures: The outcome variables studied were the resolution of clinical features (pain, discharge, radiology, and inflammatory markers), culture yield, and total duration of treatment. Results: According to our study, relief of pain was faster in the surgical group(1.66 against 4.57 months) with statistical significance (p< 0. 001). Relief of symptoms (p< 0.001), radiological improvement (p= 0.001), and normalizing of inflammatory markers (p<0.001) were better in the surgical group than in the medical group. The duration of treatment was an average of 9. 2 months in the surgical group compared to 11.3 months in the medical group (p= 0.019). Microbial culture from deep tissue sampling was positive in 24 surgical patients (68.57%). Conclusion: The treatment response to surgery and antimicrobials in treating refractory cases of SBO was better than the group who responded to antimicrobials alone. Surgery provided higher microbial yield resulting in culture-specific antimicrobials. The surgical group observed faster relief of symptoms, reduced hospital stay, and total treatment duration.
... Based on our observation, the final character of MOE is observed as the inflammation spreads to the contralateral skull base (Phase V) even after completing the initial treatment. Similar pattern in the spread of disease to the central skull base was observed in the previous literature [9]. Although some patients were reportedly stable with the treatment, some of them exhibited evolvement of disease despite receiving appropriate treatment. ...
Objectives
This study aims to assess the clinical trends of malignant otitis externa (MOE) and classify MOE based on the findings related to high-resolution computed tomography (HRCT) of the temporal bone and 99−Tech3-Phase Bone Scintigraphy (TPBS). We also reconstruct a treatment algorithm for MOE in our institution.
Methodology
A 10-year retrospective review was carried out on MOE in a single otology institution from January 2011 to December 2020. The MOE was classified based on proposed Tengku’s radiological stratification according to HRCT and TBPS findings. Phase I is defined as inflammation limited to the soft tissue in the external auditory canal, without involvement of the bone. Phase II is the inflammation beyond the soft tissue, involving bone, but limited to the mastoid. Phase III is when the inflammation extends medially, involving the petrous temporal bone or temporomandibular joint, with or without parapharyngeal soft tissue involvement. Phase IV refers to inflammation extending medially to involve the nasopharynx, with or without abscess formation. Finally, Phase V is inflammation that further extends to the contralateral base of the skull.
Results
A sample of 49 patients was involved in this study. Majority of the patients were having Phase III (36.7%) of the disease, followed by Phase V (24.5%), Phase II (18.4%), Phase IV (16.3%), and Phase I (4.1%). A comprehensive treatment algorithm was drafted based on our institution’s experience in managing MOE. The mortality rate was low (8.2%), mainly involving patients in advanced phase of the disease (Phases IV and V).
Conclusion
This study has revealed the evidence of progression of MOE based on the proposed radiological stratification. This stratification is simple and practically applicable in clinical settings. We suggest the use of our proposed treatment algorithm as a standard diagnostic and treatment protocol for MOE.
... 5,19 Additionally, neuroimaging through CT and MRI scanning is crucial to determine disease extension for a prognostic evaluation and in posttreatment monitoring. 3,5,[20][21][22][23][24] Computed tomography describes bone details, whereas MRI enriched with diffusion-weighted intensity sequences identifies soft tissue abnormalities. [22][23][24] Recently, some authors have shown that 18 showing thickened right external auditory canal extending to ipsilateral nasopharynx and parapharyngeal space through the Eustachian tube (black arrows); retrocondylar tissue, masticator space, and retrocondylar soft tissues were also involved. ...
Skull base osteomyelitis (SBO) is an invasive infection refractory to therapy, closely linked with malignant otitis externa (MOE). It is characterized by a mild clinical presentation that can delay cross-sectional imaging considered as the key to revealing it. Skull base osteomyelitis typically affects elderly diabetics and immunocompromised patients (>70 years). It most commonly has an otogenic origin due to an extension of MOE. The prognosis can be very poor without the administration of adequate and timely therapy at an early disease stage. Nowadays, Pseudomonas aeruginosa remains the most common pathogen associated with SBO. Fungi are a rare cause of MOE. This report documents a rare case of otogenic SBO caused by Candida parapsilosis in a diabetic patient, with persistent otologic symptoms as clinical onset and resistance to medical treatment. Fungal MOE has more subtle symptoms and is more aggressive than its bacterial counterpart. When MOE is resistant to antibacterial drugs, this should raise the suspicion of a fungal etiology of MOE. The current guidelines do not exhaustively describe the diagnosis, antifungal drugs of choice, and optimum duration of treatment. The description of these rare clinical cases should help with the multidisciplinary management of this disease in order to optimize the diagnosis and therapeutic protocol.
... This is particularly important because surgical biopsy is often not feasible due to the anatomical complexity of this region, as well as low patient tolerance. The positivity rates of microbial cultures are also low [7]. ...
... Finally, 13 articles were selected for the study. Of these, 9 reported fungal SBO [2,[11][12][13][14][15][16][17][18], 2 reported bacterial SBO [7,19], and another 2 had patients with both organisms [20,21]. The search methodology is detailed in Figure 1. ...
... Among all the studies reporting purely bacterial aetiology SBO, the presenting complaints were otogenic [7,19,21], while among the studies reporting purely fungal aetiology, complaints varied and included headache, nasal discharge/stuffiness, and ocular symptoms such as pain or ophthalmoplegia [2,11,12,[14][15][16][17][18]. One of the studies dealt only with orbital manifestations and therefore reported ocular complaints in 100% of patients [20]. ...
Introduction
To assess differentiating features between bacterial, Aspergillus, and Mucor skull base osteomyelitis (SBO) with regard to clinical presentation and imaging appearances.
Material and methods
A literature search was performed in April 2020 for studies on SBO with a minimum sample size of 10 patients. Studies that reported presenting symptoms, cross-sectional imaging findings, complications, and mortality were included in the analysis. The quality of included articles was tested using the Quality Assessment of Diagnostic Accuracy Studies 2 tool. A data extraction form was used to retrieve relevant parameters from each of the articles.
Results
Thirteen articles were included in the final analysis. Diabetes mellitus was the most common predisposing factor (12.5-91.0%). Presenting complaints in all bacterial SBO studies were otogenic, while fungal SBO patients had nasal/ocular complaints. Rates of mortality and surgical intervention in the fungal group were 50-100% and 50%, respectively, as compared to the bacterial group – 7-87% and 10%, respectively. On imaging, the site of initial infection in bacterial SBO was the external auditory canal, while in fungal SBO it was the paranasal sinus. The incidence of orbital extension was < 5% in bacterial and 44-70% in fungal SBO, among which Mucor had rates of 65-70%. Bone erosion was less extensive in bacterial SBO, and the patterns differed. The highest incidence of vascular involvement and non-enhancing lesions (23-36%) was seen in Mucor. Aspergillus showed highest sino-cranial extension (52-55%) and homogenous bright enhancement.
Conclusions
Systematic analysis of the clinico-radiological parameters in each of the studies revealed differences in presentation, clinical course, extension, bone erosion, and enhancement.
keywords:
skull base osteomyelitis, mucormycosis, aspergillosis, necrotising otitis externa, radiology, magnetic resonance imaging, X-ray computed tomography
... Radiological investigations play a pivotal role in diagnosing SBO and mapping its extension [18]. Various methods have been proposed in the literature, including contrast-enhanced CT and MRI, scintigraphy with 67-Gallium or 111-Indium, and bone scintigraphy with 99m-Technetium [5]. ...
Skull base osteomyelitis (SBO) is a potentially life-threatening inflammation of cranial base bony structures of variable origin. Criteria for diagnosis and treatment are still controversial. Demographics, predisposing factors, symptoms, imaging, and clinical, laboratory, histological, and microbiological data of patients managed for SBO at the University Hospital of Brescia (ASST Spedali Civili) between 2002 and 2017 were retrospectively reviewed. Patients were included in different etiological groups. The topographic distribution of magnetic resonance (MR) abnormalities was recorded on a bi-dimensional model of skull base, on which three different patterns of inflammatory changes (edematous, solid, or necrotic) were reported. In patients with a history of radiotherapy, the spatial distribution of SBO was compared with irradiation fields. The association between variables and etiological groups was verified with appropriate statistical tests. A classification tree analysis was performed with the aim of inferring a clinical-radiological diagnostic algorithm for SBO. The study included 47 patients, divided into 5 etiological groups: otogenic (n = 5), radio-induced (n = 16), fungal (n = 14), immune-mediated (n = 6), and idiopathic (n = 6). At MR, five types of topographical distribution were identified (central symmetric, central asymmetric, orbital apex, sinonasal, maxillary). In patients with a history of radiotherapy, the probability to develop SBO was significantly increased in areas receiving the highest radiation dosage. The analysis of patients allowed for design of a classification tree for the diagnosis of SBO. The integration of clinical and radiologic information is an efficient strategy to categorize SBO and potentially guide its complex management.
... Skull base osteomyelitis (SBO) is an infection of the temporal, sphenoid, or occipital bones that is typically caused by a complication of improperly treated otogenic or sinonasal infection in elderly patients with diabetes or immunocompromised patients. However, other diseases can cause the development of SBO without a preceding sinonasal or otogenic infection (1)(2)(3)(4). ...
... If the jugular foramen is affected, palsy can be present in cranial nerves IX, X, and XI and can cause a soft palate mobility disorder, unilateral vocal cord paralysis, and an inability to raise the arm above the horizontal plane, respectively. Similarly, hypoglossal canal involvement causes cranial nerve XII neuropathy, with tongue movement disorders (1,5,7,10). ...
... SBO can be classified as otogenic or nonotogenic in origin (8). SBO frequently has an otogenic origin, typically in patients with diabetes and recurrent otitis externa (1). Other causes of SBO include suppurative otitis media or mastoiditis. ...
Skull base osteomyelitis (SBO) is an infection of the temporal, sphenoid, or occipital bone that can be a challenge to diagnose because of its nonspecific symptoms, long clinical course, and radiologic findings that mimic those of other entities. The authors review this unusual infection on the basis of six proven cases. The diagnosis of SBO should be made according to four points: a high index of clinical suspicion, radiologic evidence of infection, repeated biopsies that are negative for malignancy, and positive results of microbiologic tests. SBO typically manifests clinically in patients with diabetes and recurrent otitis externa; the infection usually extends inferiorly to the compact bone of the infratemporal fossa, affecting the lower cranial nerve foramina. Several image-based techniques should be used to diagnose SBO. CT is the best option for evaluating bone erosion and demineralization, MRI can help delineate the anatomic location and extent of disease, and nuclear imaging is useful for confirming bone infection with high sensitivity. However, the standard diagnostic procedure for SBO is for patients to undergo repeated biopsies to rule out malignancy, with histopathologic signs of infection and detection of microorganisms in the biopsied bone or soft tissue indicating SBO. The ability to diagnose SBO can be increased by identifying patients at risk, recognizing the most important causes and routes of infection, describing the main radiologic findings, and always considering the differential diagnosis. ©RSNA, 2021.
