Skull base osteomyelitis secondary to malignant otitis externa

Focal and entrapment neuropathies

Of the many patterns of peripheral nerve disorders in diabetes mellitus (DM), isolated clinical involvement of single nerves, though less common than distal symmetric polyneuropathy and perhaps polyradiculoneuropathy, constitute an important collection of characteristic syndromes. These fall into four anatomical regions of the body: cranial, upper limb, truncal, and lower limb territories. Each of these groups of mononeuropathies has its own ensemble of epidemiologic patterns, clinical presentations, laboratory and radiologic findings, differential diagnosis, management principles and prognosis.

Temporomandibular joint involvement as a positive clinical prognostic factor in necrotising external otitis

Objective:

Necrotising otitis externa is associated with high morbidity and mortality rates. This study investigated whether temporomandibular joint involvement had any prognostic effect on the course of necrotising otitis externa in patients who had undergone hyperbaric oxygen therapy after failed medical and sometimes surgical therapy.

Methods:

A retrospective case series was conducted of patients in whom antibiotic treatment and surgery had failed, who had been hospitalised for further treatment and hyperbaric oxygen therapy.

Results:

Twenty-three patients with necrotising otitis externa were identified. The temporomandibular joint was involved in four patients (17 per cent); these patients showed a constant gradual improvement in C-reactive protein and were eventually discharged free of disease, except one patient who was lost to follow up. Four patients (16 per cent) without temporomandibular joint involvement died within 90 days of discharge, while all patients with temporomandibular joint involvement were alive. Three patients (13 per cent) without temporomandibular joint involvement needed recurrent hospitalisation including further hyperbaric oxygen therapy; no patients with temporomandibular joint involvement required such treatment.

Conclusion:

Patients with temporomandibular joint involvement had lower rates of recurrent disease and no mortality. Therefore, we suggest considering temporomandibular joint involvement as a positive prognostic factor in necrotising otitis externa management.

Skull base osteomyelitis missed in mastoidectomy for cholesteatoma

Conclusions A high suspicion of skull base involvement should be warranted, even if radiological findings are not atypical, in cases of chronic otitis media (COM) with cholesteatoma. Objective To investigate some clues indicating the development of skull base osteomyelitis (SBO) in patients who received mastoidectomy, through reviewing pre-operative temporal bone computed tomography (TBCT). Method Retrospective review of patients with SBO after mastoidectomy for COM. A total of five patients with SBO after mastoidectomy with available pre-operative TBCTs were enrolled in this study. Results All patients were diagnosed as COM with cholesteatoma and open cavity mastoidectomy was performed. After surgery, SBO were occurred. The recovery in these five patients was complicated by lower cranial nerve palsy, and one patient had a stroke due to lateral thrombophlebitis. Through re-interpretation of pre-operative TBCT, the bony destruction around the skull base missed at the initial diagnosis was observed in all cases.

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 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.

Skull base osteomyelitis in otitis externa: The utility of triphasic and single photon emission computed tomography/computed tomography bone scintigraphy

Background:

Skull base osteomyelitis (SBO) refers to infection that has spread beyond the external auditory canal to the base of the skull in advanced stages of otitis externa. Clinically, it may be difficult to differentiate SBO from severe otitis externa without bony involvement. This study was performed to determine the role of three phase bone scintigraphy (TPBS) and single photon emission tomography/computed tomography (SPECT/CT) in detecting SBO.

Materials and Methods:

We retrospectively analyzed records of 20 patients (14 M, 6 F) with otitis externa and suspected SBO. TPBS and SPECT/CT of the skull were performed. Findings were correlated with clinical, laboratory and diagnostic CT scan findings.

Results:

All patients were diabetic with elevated erythrocyte sedimentation rate. A total of 18 patients had bilateral and two unilateral symptoms. Cranial nerves were involved in eight patients and microbiological culture of ear discharge fluid positive in seven. Early images showed increased temporal vascularity in nine patients and increased soft-tissue uptake in 10, while delayed images showed increased bone uptake in 19/20 patients. Localized abnormal tracer uptake was shown by SPECT/CT in the mastoid temporal (15), petrous (11), sphenoid (3) and zygomatic (1) and showed destructive changes in five. Thus, TPBS was found positive for SBO in 10/20 patients and changed the management in four.

Conclusion:

Our study suggests that TPBS with SPECT/CT is a useful non-invasive investigation for detection of SBO in otitis externa.

Malignant Otitis Externa

Objective

Malignant otitis externa (MOE) is a severe disease with varying outcomes. Despite advances in antibiotic treatment, a significant proportion still succumbs to this disease. We aimed to analyze the effect of clinical factors on prognosis and to review treatment outcomes in our institution.

Study Design

Case series with retrospective chart review of MOE cases from 2006 to 2011.

Setting

Department of Otolaryngology–Head and Neck Surgery, National University Hospital, Singapore, a tertiary referral center.

Subjects and Methods

Patients with MOE admitted for treatment were studied and divided into 2 outcome groups depending on response to a 6-week course of intravenous antibiotics. Demographic and disease factors were analyzed with regard to outcome.

Results

Nineteen cases were analyzed. Disease resolved in 63.2% after 6 weeks of antibiotics. Mortality was 21.1%. Age, diabetic control, duration of diagnostic delay, cranial nerve involvement, and inflammatory markers were not found to predict prognosis. Erythrocyte sedimentation rate and C-reactive protein levels correlated with disease activity and can be used to monitor progress. Clival involvement was associated with persistent disease ( P = .002). Only 63.2% of cases had positive cultures. Pseudomonas aeruginosa was the main organism, and 33.3% of isolates were multidrug resistant. Outcome was not different in cases where culture-directed therapy was employed vs those where empirical ceftazidime and fluoroquinolone were used ( P = .650).

Conclusion

Malignant otitis externa remains an insidious disease with significant mortality. Involvement of the clivus portends a poorer prognosis. Combination therapy with intravenous ceftazidime and oral fluoroquinolone remains relevant despite concerns of culture-negative cases and multidrug-resistant Pseudomonas.

Single photon emission computed tomography/computed tomography for malignant otitis externa: lesion not shown on planar image

Malignant otitis externa is a severe and rare infection of the external acoustic meatus. Triphasic bone and (67)Ga scintigraphies are used to initial detect and follow-up the response of therapy. With single photon emission computed tomography/computed tomography images, the diagnostic sensitivity is higher. We presented a case with malignant otitis externa with initial negative planar scintigraphic finding. The lesion was detected by photon emission computed tomography/computed tomography images. We concluded that the photon emission computed tomography/computed tomography should be performed routinely for patients with suspected malignant otitis externa, even without evidence of lesion on planar images.

Skull base osteomyelitis following a mastoidectomy

Skull base osteomyelitis is a rare but life-threatening condition that is characterized by osteitis of the temporal bone and skull base. Although skull base osteomyelitis is recognized as a rare complication of malignant external otitis or middle ear infection, it may also occur following a mastoidectomy. We present a case of an 81-year-old woman who suffered severe otalgia with normal-looking EAC and tympanic membrane that developed six weeks following a canal wall up mastoidectomy. Otalgia was the only abnormal feature to suspect occurrence of skull base osteomyelitis.

Utility of (99m)Tc-MDP hybrid SPECT-CT for diagnosis of skull base osteomyelitis: comparison with planar bone scintigraphy, SPECT, and CT

PURPOSE

To evaluate single photon emission tomography-computed tomography (SPECT-CT) for diagnosis of skull base osteomyelitis (SBO) and to compare this technique with planar bone scintigraphy (BS), SPECT, and CT.

METHODS

Data from 13 patients with known/suspected SBO were retrospectively analysed. Planar BS and SPECT images were evaluated by an experienced nuclear medicine physician, CT by and experienced radiologist, and SPECT-CT by the nuclear medicine physician and radiologist in consensus. On the basis of diagnostic confidence a score of 1-5 was given, with 1 being definitely osteomyelitis, 2 being probably osteomyelitis, 3 being equivocal, 4 being probably normal, and 5 being definitely normal. ROC analysis areas under the curves (AUC) were calculated. For diagnostic values a score of ≤2 was taken as positive. Clinical/imaging follow-up/microbiology was taken as reference standard.

RESULTS

AUC was largest for SPECT-CT (0.977) followed by SPECT (0.909), CT (0.886), and planar BS (0.614). However, no significant difference was found between the techniques except for borderline significance between planar BS with SPECT-CT (P = 0.071) and CT (P = 0.072). Accuracy was 46% for planar BS, 85% for SPECT, 77% for CT and 92% for SPECT-CT.

CONCLUSION

SPECT-CT seems to be useful, but not superior to planar BS, SPECT, or CT, for diagnosis of SBO.

A diagnostic dilemma of central skull base osteomyelitis mimicking neoplasia in a diabetic patient

We present a case which illustrates the diagnostic difficulty in distinguishing between osteomyelitis of the central skull base and base of skull tumours. A woman in her early forties presented with seizures and multiple cranial nerve palsies. She also had a background of chronic otalgia and poorly controlled diabetes mellitus. The clinical diagnosis of skull base osteomyelitis (SBO) was made, but both MRI and bone scans were unable to distinguish this from a skull base malignancy on imaging criteria. Eventually biopsies were required to exclude the diagnosis of malignancy and the patient was treated for central SBO.

Skull base osteomyelitis and potential cerebrovascular complications in children

Skull base osteomyelitis is an aggressive, life-threatening infection that can be challenging to diagnose and treat. It occurs predominantly in elderly immunocompromised patients, but it has also been reported in children with normal immunological status. Typical skul base osteomyelitis arises as a complication to ear infection mainly involving the temporal bone and is usually caused by Pseudomonas aeruginosa. Atypical or central skul base osteomyelitis originates from paranasal infections, is primarily centred on the clivus and is usually caused by Aspergillus, Pseudomonas, Salmonella or Staphylococcus species. Potential complications include retropharyngeal abscesses, cranial neuropathies, meningitis, intracranial abscesses, sinovenous thrombosis, and carotid artery involvement with or without ischemic infarcts. The purpose of this pictorial essay is to illustrate the spectrum of imaging findings and potential complications of skul base osteomyelitis.

SPECT/CT in the Diagnosis of Skull Base Osteomyelitis

Skull base osteomyelitis is a potentially fatal disease. We demonstrate here the utility of SPECT/CT in diagnosing this entity, which was not obvious on a planar bone scan. A (99m)Tc MDP bone scan with SPECT/CT was carried out on a patient with clinically suspected skull base osteomyelitis. Findings were correlated with contrast-enhanced CT (CECT) and MRI. Planar images were equivocal, but SPECT/CT showed intense uptake in the body of sphenoid and petrous temporal bone as well as the atlas corresponding to irregular bone destruction on CT and MRI. These findings indicate that SPECT/CT may have an additional role beyond planar imaging in the detection of skull base osteomyelitis.

Spectrum of radiological appearances of necrotising external otitis: a pictorial review

Necrotising external otitis, also known as malignant otitis externa, is an aggressive, resorptive osteomyelitis of the temporal bone. Although rare, necrotising external otitis is a potentially fatal disease, with complications which include temporomandibular joint osteomyelitis, sigmoid sinus thrombosis and meningitis. Imaging findings may be subtle, particularly in the early stages. We present a broad range of imaging findings which may occur in necrotising external otitis cases.

A rare case of bilateral malignant otitis externa and osteomyelitis with lower cranial nerve sequelae

The authors present the case of a 76-year-old male who presented with right-sided recurrent malignant otitis externa (MOE) and skull-base osteomyelitis. His management involved aggressive antimicrobial therapy and multiple hyperbaric oxygen treatments. After resolution of his right-sided infection, the patient returned a short time later with symptoms and findings consistent with new, left-sided MOE with involvement of the left skull-base. With repeat treatment, the patient is now cured of his infection but poses a challenge to the treating team about future management.

Skull-base osteomyelitis: fungal vs. bacterial infection

Skull-base osteomyelitis (SBO) occurs secondary to invasive bacterial and fungal infection. Distinguishing between fungal and bacterial aetiologies of SBO has significant therapeutic implications. An 18-year (1990-2007) retrospective review of patients with SBO presenting to Westmead Hospital was performed. Epidemiological, clinical, laboratory and radiology data were collated. Twenty-one patients (median age 58 years) with SBO were identified: ten (48%) had bacterial and 11 (52%) had fungal SBO. Diabetes mellitus (57%) and chronic otitis externa (33%) were the most frequent co-morbidities; immunosuppression was present in five cases (24%). Cranial nerve deficits occurred in ten (48%) patients. The commonest pathogens were Pseudomonas aeruginosa (50% bacterial SBO) and a zygomycete (55% fungal SBO). Compared to bacterial SBO, fungal SBO was more frequently associated with underlying chronic sinusitis, sinonasal pain, facial/periorbital swelling and nasal stuffiness or discharge and the absence of purulent ear discharge (all p <0.05). Bacterial SBO was more frequently associated with deafness, ear pain or ear discharge (all p <0.05). Median time to presentation was longer in patients with bacterial SBO (26.3 weeks vs. 8.1 weeks, p 0.08). Overall 6-month survival was 88% (14/18 patients). All four deaths occurred in patients with fungal SBO. Immunosuppression was a risk factor for death (p <0.05). Early diagnostic sampling is recommended in patients at increased risk of fungal SBO to enable optimal antimicrobial and surgical management.

Recurrent syncope and chronic ear pain

An elderly gentleman presented to hospital with recurrent blackout episodes consistent with syncope and a 3-month history of right ear pain. Significant postural hypotension was recorded. White cell count and C reactive protein were elevated. MRI of the head and neck revealed a soft tissue abnormality in the right nasopharynx and base of skull. Tissue biopsies were obtained and microbiology specimens revealed a mixed growth of pseudomonas and diphtheroids. There was no histological evidence of malignancy. A diagnosis of skull base infection was made. Infective involvement of the carotid sinus was considered to be the cause of the recurrent syncope and postural hypotension. The patient responded well to a 12-week course of intravenous meropenem. Inflammatory markers returned to normal and a repeat MRI after 3 months of treatment showed significant resolution of infection. The syncopal episodes and orthostatic hypotension resolved in parallel with treatment of infection.

Diffusion MR imaging features of skull base osteomyelitis compared with skull base malignancy

BACKGROUND AND PURPOSE

SBO is a life-threatening infection that may have radiologic features similar to those of the neoplastic processes. The purpose of this study was to evaluate the DWI findings in SBO to facilitate the differential diagnosis.

MATERIALS AND METHODS

The MR imaging findings of 9 patients with SBO were retrospectively evaluated and compared with MR imaging studies from 9 patients with NPC, 9 with lymphoma, and 9 with metastatic disease of the skull base. ADC measurements were performed from the ADC(ST) and the ADC(NST) in all 4 groups.

RESULTS

The mean ADC(ST) values were 1.26 ± 0.19 × 10(-3) mm(2)/s for SBO, 0.74 ± 0.18 × 10(-3) mm(2)/s for NPC, 0.59 ± 0.11 × 10(-3) mm(2)/s for lymphoma, and 0.99 ± 0.34 × 10(-3) mm(2)/s for metastatic disease, respectively. The mean ADC value of SBO was significantly higher than those of NPC and lymphoma (P < .0001). There was no significant difference for the comparison of SBO and metastatic lesions. When an ADC value equal to or higher than 1.08 × 10(-3) mm(2)/s was used to rule out lymphoma and NPC, the accuracy was 96%.

CONCLUSIONS

Although SBO is a relatively rare condition, its differential diagnosis from neoplastic processes of the skull base is essential to start appropriate treatment promptly. ADC values may help to distinguish patients with SBO from those with malignant lesions.

Acute abducens nerve palsy and weight loss due to skull base osteomyelitis

A 90-year-old man presented to the emergency department with multiple symptoms including double vision, reduced mobility, dysphagia, recent rapid weight loss, ear discharge and deafness. He had diabetes and other chronic medical problems, including otitis media with mastoiditis. This case highlights the difficulty of investigating weight loss in older people, who may not show the usual clinical features of infection, and of distinguishing between infection and malignancy when radiological findings are inconclusive. His eventual diagnosis was osteomyelitis of the skull base with cranial nerve involvement.

Atypical presentations of malignant otitis externa

INTRODUCTION

Malignant otitis externa is a life-threatening infection of the skull base. Its presentation is not always typical.

CASE REPORTS

We report three cases of malignant otitis externa which illustrate the diversity of its clinical manifestations and the difficulties in its diagnosis.

DISCUSSION

The perception of malignant otitis externa as an infection caused by Pseudomonas aeruginosa in diabetic patients is not always correct. The adoption of diagnostic criteria could be helpful in identifying atypical cases.

Imaging of inflammatory and infectious diseases in the temporal bone

Inflammatory and infectious diseases of the temporal bone are a major indication to perform high-resolution CT and MR imaging studies. Such studies allow one to evaluate the extent of the disease in the soft tissues and in the bony structures of the temporal bone. On these same imaging studies the possible extension of the infection to surrounding regions is visualized. In this article a segmental approach is used, focusing on four structures in the temporal bone: the external ear, the otomastoid and petrous apex, the inner ear, and the facial nerve. For each of the four sections imaging findings are described and illustrated, and if relevant a differential diagnostic approach is highlighted.

Antifungal therapy of Aspergillus invasive otitis externa: efficacy of voriconazole and review

Invasive otitis externa (IOE) due to Aspergillus is a rare, potentially life-threatening, invasive fungal infection affecting immunocompromised patients. The invasive process may lead to skull base osteomyelitis with progressive cranial nerve palsies and can result in irreversible hearing and neurological impairment. We report two cases of Aspergillus IOE treated with voriconazole alone and a literature review of antifungal therapy of Aspergillus IOE. Twenty-five patients, including the two described in the present report, were analyzed. Eighteen patients were treated with amphotericin B, and nine of them received itraconazole as an additional agent. Three patients received initial therapy with itraconazole, and one patient was treated with both voriconazole and caspofungin therapy. The two patients in the present report received voriconazole therapy alone with good clinical and biological tolerance despite prolonged treatment. The last patient did not receive antifungal therapy, as the diagnosis was made postmortem. Eighteen patients underwent an initial extensive surgical debridement. The majority of the patients had a favorable outcome, 17 patients experienced a complete recovery, and 6 showed a partial improvement. Both of the patients reported on here had favorable outcomes, and no aggressive surgical debridement was required. Although voriconazole has been shown to be effective for the treatment of invasive aspergillosis, its precise role in the management of Aspergillus IOE had not been documented. These observations demonstrate that voriconazole could be an effective and well-tolerated therapeutic option for the management of Aspergillus IOE.

Malignant otitis externa

Malignant otitis externa is an invasive, potentially life-threatening infection of the external ear and skull base that requires urgent diagnosis and treatment. It affects immunocompromised individuals, particularly those who have diabetes. The most common causative agent remains Pseudomonas aeruginosa. Definitive diagnosis is frequently elusive, requiring a high index of suspicion, various laboratory and imaging modalities, and histologic exclusion of malignancy. Long-term oral antipseudomonal agents have proven effective; however, pseudomonal antibiotic resistance patterns have emerged and therefore other bacterial and fungal causative agents must be considered. Adjunctive therapies, such as aggressive debridement and hyperbaric oxygen therapy, are reserved for extensive or unresponsive cases.

MRSA with progression from otitis media and sphenoid sinusitis to clival osteomyelitis, pachymeningitis and abducens nerve palsy in an immunocompetent 10-year-old patient

A previously healthy 10-year-old patient with headache, otalgia, and hearing loss was diagnosed with pachymeningitis and methicillin-resistant Staphylococcus aureus otitis media and bacteremia. Despite antimicrobial therapy, intracranial extension progressed, including clival osteomyelitis, sphenoid sinusitis, cavernous sinus inflammation and cranial nerve palsies, until the sphenoid sinus was drained. This case exemplifies an aggressive MRSA intracranial infection that advanced despite antibiotic therapy.

Usefulness of CT scans in malignant external otitis: effective tool for the diagnosis, but of limited value in predicting outcome

Computerized tomography (CT) scanning is a well recognised tool for the diagnosis of malignant external otitis. To investigate the degree of correlation between CT findings scan and the patients clinical status focusing on a subgroup of patients with cranial nerve palsies. Diagnosis of malignant external otitis was confirmed in 23 patients (average age 71 years, age range 39-87) based on criteria of severe pain, otitis externa refractory to conventional treatments and possibly diabetes mellitus and pseudomonas detection. CT was performed on 23 of these patients. Results from these scans were analysed and correlated with patient clinical status. Retrospective analysis of CT images and medical notes were used for data analysis.The CT scans of all 23 patients showed evidence of involvement of disease outside the external auditory canal, confirming the diagnosis. Sixteen out of 23 patients (70%) demonstrated evidence of bone erosion. Four of the 16 showed involvement of the petrous apex. From our subset of ten patients with cranial nerve involvement, eight demonstrated evidence of bone erosion and two showed mastoid and middle ear involvement without bone erosion. All four patients with petrous apical involvement presented with cranial nerve palsies (two lower cranial nerve palsies, one seventh nerve palsy and one combined lower and seventh nerve palsy). CT scanning was found to be a fast and economical tool in the initial assessment of patients with malignant external otitis. Petrous apex involvement was constantly associated with cranial nerve palsies, usually the lower cranial nerves. CT findings of temporal bone in itself however, were not closely correlated to the clinical outcome of the patients.

Cranial Nerve Involvement in Malignant External Otitis: Implications for Clinical Outcome

BACKGROUND

Malignant external otitis is an uncommon, potentially lethal infection of the temporal bone primarily affecting elderly diabetic patients.

OBJECTIVE

To determine whether cranial nerve involvement in malignant external otitis affects or predicts the clinical outcome in terms of morbidity and mortality.

METHODS

Diagnosis of malignant external otitis was established in 23 patients (average age, 71 yr; range, 39-87) based on inclusion criteria of severe pain, otitis externa refractory to conventional treatments, diabetes mellitus, and Pseudomonas aeruginosa detection. Computed tomography confirmed temporal bone involvement extending outside the external auditory canal.

DATA ANALYSIS

Retrospective analysis of hospital records.

RESULTS

Ten of 23 (43.5%) patients showed cranial nerve involvement. The following cranial nerves were affected: facial nerve (6/10), lower cranial nerves (combination of IX, X, XI, XII) (3/10), and extended nerve palsy (VI, VII, IX, X, XI) (1/10). Thirteen of 23 (56.5%) patients displayed no cranial nerve involvement. All patients were treated with long-term, high-dose antibiotic treatment dependent on the microbiological findings.

CONCLUSIONS

All patients with lower cranial nerve palsy recovered normal function; however, the facial nerve palsy was significantly less likely to improve by medical treatment. Cranial nerve involvement did not affect the patient survival rate under an optimized medical treatment in our series.

Ostéomyélite de la base du crâne d'origine otosinusienne. Étude d'une série de cinq cas récents

INTRODUCTION

Skull base osteomyelitis is an uncommon but severe condition generally secondary to necrotizing otitis externa. The aim of this study was to determine the patients demographics, clinical and radiological findings, and outcomes of this condition.

MATERIAL AND METHODS

We prospectively follow 5 patients with a diagnosis of skull base osteomyelitis between 2004 and 2005. Clinical, biologic and imaging data were collected, and also follow-up during treatment.

RESULTS

The five patients were men and the average age at presentation was 75 years (63-89). All except one had a previous diabetes mellitus, with a more or less recent clinical story of otitis externa. All of them suffered of headaches and cranial nerve(s) deficits, particularly facial nerve. Diagnosis was made on MRI with gadolinium injection and fat saturation, and Pseudomonas aeruginosa identified as pathogen in all cases. One patient deceased of cranial nerves palsy complication. In 4 cases we found previously a too short or non adapted treatment of necrotizing otitis externa.

CONCLUSIONS

In the setting of headache, cranial nerves deficit and abnormal skull base imaging on MRI with Fat sat, osteomyelitis should be consider as the likely diagnosis. This complication should be avoided by optimal management of necrotizing otitis externa.

Circumferential Petrosectomy for Petrous Apicitis and Cranial Base Osteomyelitis

OBJECTIVE

Petrous apicitis and cranial base osteomyelitis are life-threatening conditions. A surgical management may be necessary in cases that progress, in conditions that fail to improve with medical treatment, or in cases with impending complications. In this study, we describe a technique to remove the maximum amount of infected temporal bone while preserving the integrity of the peripheral auditory pathway and facial nerve.

STUDY DESIGN

Retrospective study.

SETTING

Tertiary referral hospital.

PATIENTS

Five patients with impending complications, whose disease progressed or whose conditions failed to improve while on culture-directed antibiotics underwent circumferential petrosectomy.

INTERVENTIONS

The circumferential petrosectomy removes most of the temporal bone around the external, middle, and inner ear. A combined retrolabyrinthine-apical petrosectomy is performed in conjunction with the fallopian bridge technique using a transmastoid and middle cranial fossa approach. A split temporalis muscle flap is used to bring vascularized tissue to the mastoid, jugular foramen, and petrous apex.

MAIN OUTCOME MEASURES

Disease resolution, change in hearing or facial nerve function, complications.

RESULTS

Each of the five patients had modifications to the procedure tailored to their disease extent: three had disease primarily involving the petrous apex and two had disease adjacent to the jugular foramen. Additional cultures of the infected bone were obtained during surgery. A culture-directed antibiotic therapy (duration, 6-10 weeks) was administered after surgery, which resulted in the complete resolution of the disease and the associated symptoms in all five patients. No patient experienced hearing loss or facial nerve dysfunction as a result of the surgery within at least 1 year of follow-up in four of the five patients in this series.

CONCLUSION

The circumferential petrosectomy is a potential treatment option when medical treatment fails in patients with petrositis or cranial base osteomyelitis. It permits maximal temporal bone debridement while preserving hearing and facial nerve integrity in these life-threatening disease processes.

Otogenic skull base osteomyelitis caused by invasive fungal infection

Otogenic skull base osteomyelitis (SBO) of fungal etiology is a very rare but life-threatening complication of inflammatory processes of the ear. The authors present a case of otogenic SBO caused by Aspergillus flavus in a 65-year-old man with a fatal course. Because of the encountered difficulties with the proper diagnosis and treatment, the authors reviewed the literature on the subject.

Value of hyperbaric oxygen in bacterial and fungal malignant external otitis treatment

Malignant external otitis (MEO) is an invasive, morbidity, even mortality, mainly pseudomonal infection of the external auditory canal, frequently involving the base of the skull, multiple cranial nerve and the meninges. In many cases conventional therapy has been prolonged, intensive and relatively ineffective, especially in infections other than bacterial (mainly fungal). We presented theoretical principles of hyperbaric oxygen (HBO) treatment in MEO, our own experience and others' experience in applying this treatment method. We treated eight patients with MEO applying pharmacotherapy, topical management, surgery in one case and also adjunct HBO. In six patients, infection was caused by Pseudomonas aeruginosa, in one by Staphylococcus sp. and in one by Aspergillus sp. Complete recovery was achieved in seven patients. In the patient with MEO caused by Aspergillus sp., intracranial complications developed and the patient died. Our experiences in employing HBO in bacterial-caused MEO have confirmed the role of HBO as a valuable, beneficial, supporting classical treatment method. Small number of patients with MEO, especially with non-bacterial infection, and unforeseen clinical course of disease make our experience difficult to objectivize.

Ostéomyélite de l’étage moyen de la base du crâne d’origine sinusienne

OBJECTIVES

The study goals were to determine the patient demographics, identify predisposing factors, and determine efficacy of treatment for nonotologic osteomyelitis of the middle skull base.

MATERIAL AND METHODS

Symptoms and treatment of five patients (sex ratio: 3/1; mean age: 57,1 ans) with osteomyelitis of the middle skull base treated from 1991 to 2005 are analyzed. All patients with a biopsy-proven diagnosis of osteomyelitis of the skull base were retrospectively evaluated.

RESULTS

Four patients presented with asthenia, weight loss, headache, and fever. No patient presented with neurologic deficits associated with a destructive lesion of the osseous skull base. Three patients had an underlying immunocompromising condition (diabetes mellitus, steroid and immunosuppressor use). CT scan and MRI demonstrated central skull base abnormality, mainly at the level of the clivus. Systemic antibacterial/antifungal therapy, aggressive debridement of involved bone, and medical optimization remain important in the treatment of this group of patients.

CONCLUSION

The interpretation of the results is performed after an analysis of the literature.