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Year : 2017  |  Volume : 6  |  Issue : 3  |  Page : 200-201

Central or atypical skull base osteomyelitis

1 Department of Medicine, Guru Gobind Singh Medical College and Hospital, Baba Farid University of Health Sciences, Faridkot, Punjab, India
2 Department of Radiology, Guru Gobind Singh Medical College and Hospital, Baba Farid University of Health Sciences, Faridkot, Punjab, India

Date of Web Publication25-Sep-2017

Correspondence Address:
Paramdeep Singh
Department of Radiology, Guru Gobind Singh Medical College and Hospital, Baba Farid University of Health Sciences, Faridkot, Punjab
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/2277-8632.215528

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How to cite this article:
Kaur R, Singh P. Central or atypical skull base osteomyelitis. J NTR Univ Health Sci 2017;6:200-1

How to cite this URL:
Kaur R, Singh P. Central or atypical skull base osteomyelitis. J NTR Univ Health Sci [serial online] 2017 [cited 2022 Oct 2];6:200-1. Available from: https://www.jdrntruhs.org/text.asp?2017/6/3/200/215528


A 45-year-old diabetic female presented with increasing headache, drowsiness, and bilateral VII, X, and XII nerve palsies. She developed subsequent transient ischemic attacks and left Horner's syndrome. History of left acute otitis media was present, for which myringotomy was done few days earlier. Contrast-enhanced magnetic resonance imaging of the skull base and brain showed contrast enhancement in the clivus extending into the soft tissues surrounding the bilateral internal carotid arteries and jugular foramen. There was enhancement of the preclival soft tissue, in the prevertebral and carotid spaces, the basiocciput, occipital condyles, left middle ear cavity, left mastoid air cells, and petrous apices [Figure 1]a and [Figure 1]b. Contrast enhancing soft tissue was also seen to extend into the nasopharyngeal soft tissues. Left sigmoid sinus which was not adequately opacified with contrast was suggestive of thrombophlebilitis. No abnormal contrast enhancement was seen in the brain parenchyma. The direct tissue sampling by CT-guided fine-needle aspiration of preclival soft tissue was performed, and was sent for culture and histopathological analysis, which was indicative of infective etiology by Pseudomonas. Erythrocyte sedimentation rate (ESR) was raised. The patient was put on broad-spectrum antibiotics pending cultures and antibiotic susceptibility results. The patient was treated successfully with antibiotics, which were administered for 6 weeks.
Figure 1: Axial (a) postcontrast T1-weighted images showing extensive enhancement of the central skull base. Saggital (b) postcontrast T1-weighted image showing the enhancing clivus and preclival soft tissue

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Skull base osteomyelitis is an uncommon but grave, life-threatening disorder seen most frequently seen in elderly diabetic or immunocompromised patients. Usually the cases of skull base osteomyelitis have a history of ear infections (malignant otitis externa), with Pseudomonas aeruginosa as the most common pathogen. It initiates as a soft tissue infection of the external auditory canal and disperses via the fissures of Santorini and the tympanomastoid suture to involve the cranial base. The most common indicator of this ailment is constant deep otalgia that is characteristically worse at night and persists despite multiple courses of antibiotic therapy. On the contrary, atypical skull base osteomyelitis occurs much less often and does not start with otitis externa. It involves the sphenoid and occipital bones rather than the temporal bone. Patients at first may have headache as the lone symptom, with cranial neuropathies occurring afterward. Identification is typically based on a combination of imaging findings with biopsy and microbiology.[1] Magnetic resonance imaging (MRI) is a superior soft tissue resolution than computed tomography (CT), allowing better imaging of soft tissue planes near the skull base and abnormalities of the medullary cavity of bone. MR findings of osteomyelitis comprise marrow T1 hypointensity and T2 hyperintensity, which are not specific. The study of postcontrast images is necessary for accurate assessment of skull base enhancement.[2]

Previous reports from the Indian subcontinent have demonstrated similarities in clinical presentation, as was seen in our case.[3],[4] In a study conducted by Muranjan et al. among 5 patients of skull base osteomyelitis, all patients had headache followed by multiple cranial nerve paralysis. All were treated well with antibiotics.[3] In one of the reports published by Damle et al.,[5] the patient had low grade fever in addition to headache, earache, and dizziness. Because fever was not present in our case, it may be concluded that fever is an inconsistent finding in central skull base osteomyelitis, and may or may not be a presenting feature in this pathology. Unlike in our case, two of the previously published reports have also demonstrated orbital swelling and diminished vision due to orbital infection,[6],[7] while one of the reports mentioned temporoparietal abscess[8] in addition to abovementioned symptoms in skull base osteomyelitis. Therefore, diminished vision due to orbital infection or abscess might be one of the presenting symptoms of skull base osteomyelitis.

In the present case, the fairly young age of the patient, no past history of cancer, the presence of history of diabetes predisposing to infection, and signs of infection such as elevated ESR were very useful in raising the alarm for skull base osteomyelitis and signifying the necessity for prompt tissue sampling. It was noteworthy that elevated white blood cell count, fever, and abnormal blood cultures were strangely lacking in this patient, signifying that skull base infection should not be excluded in a patient without fever and normal total leucocyte counts.

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  References Top

Clark MP, Pretorius PM, Byren I, Milford CA. Central or atypical skull base osteomyelitis: Diagnosis and treatment. Skull Base 2009;19:247-54.  Back to cited text no. 1
Chang PC, Fischbein NJ, Holliday RA. Central skull base osteomyelitis in patients without otitis externa: Imaging findings. AJNR Am J Neuroradiol 2003;24:1310-6.  Back to cited text no. 2
Muranjan SN, Khadilkar SV, Wagle SC, Jaggi ST. Central Skull Base Osteomyelitis: Diagnostic Dilemmas and Management Issues. Indian J Otolaryngol Head Neck Surg 2016;68:149-56.  Back to cited text no. 3
Chakraborty D, Bhattacharya A, Gupta AK, Panda NK, Das A, Mittal BR. Skull base osteomyelitis in otitis externa: The utility of triphasic and single photon emission computed tomography/computed tomography bone scintigraphy. Indian J Nucl Med 2013;28:65-9.  Back to cited text no. 4
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Damle NA, Kumar R, Kumar P, Jaganathan S, Patnecha M, Bal C, et al. SPECT/CT in the Diagnosis of Skull Base Osteomyelitis. Nucl Med Mol Imaging 2011;45:212-6.  Back to cited text no. 5
Panda NK, Singhal SK, Mann SB. Osteomyelitis of the skull base due to mucormycosis. Indian J Otolaryngol Head Neck Surg 1999;51:47-50.  Back to cited text no. 6
Mittal K, Mittal A, Yadav S, Yadav J. Skull-base Osteomyelitis: A Dreaded Complication after Trivial Fall and Inadequate Management. Int J Pediatr 2015;3:933-6.  Back to cited text no. 7
Alva B, Prasad KC, Prasad SC, Pallavi S. Temporal bone osteomyelitis and temporoparietal abscess secondary to malignant otitis externa. J Laryngol Otol 2009;123:1288-91.  Back to cited text no. 8


  [Figure 1]

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