A Comprehensive Review of Skull Base Osteomyelitis: Diagnostic and Therapeutic Challenges among Various Presentations

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Abstract

Skull base osteomyelitis (SBO) is a complex and fatal clinical entity that is often misdiagnosed for malignancy. SBO is commonly a direct complication of otogenic, sinogenic, odontogenic, and rhinogenic infections and can present as central, atypical, or pediatric clival SBO. This review describes the clinical profile, investigational approach, and management techniques for these variants. A comprehensive literature review was performed in PubMed, MEDLINE, Research Gate, EMBASE, Wiley Online Library, and various Neurosurgical and Neurology journals with the keywords including: SBO, central or atypical SBO, fungal osteomyelitis, malignant otitis externa, temporal bone osteomyelitis, and clival osteomyelitis. Each manuscript's reference list was reviewed for potentially relevant articles. The search yielded a total of 153 articles. It was found that with early and aggressive culture guided long-term intravenous broad-spectrum antibiotic therapy decreases post-infection complications. In cases of widespread soft tissue involvement, an early aggressive surgical removal of infectious sequestra with preferentially Hyperbaric Oxygen (HBO) therapy is associated with better prognosis of disease, less neurologic sequelae and mortality rate. Complete resolution of the SBO cases may take several months. Since early treatment can improve mortality rates, it is paramount that the reporting radiologists and treating clinicians are aware of the cardinal diagnostic signs to improve clinical outcomes of the disease. It will decrease delayed diagnosis and under treatment of the condition. However, due to rarity of the condition, complete prognostic factors have not fully been analyzed and discussed in the literature.

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Most cited references 145

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Osteomyelitis.

Daniel Lew, Francis A Waldvogel (2004)

Bone and joint infections are painful for patients and frustrating for both them and their doctors. The high success rates of antimicrobial therapy in most infectious diseases have not yet been achieved in bone and joint infections owing to the physiological and anatomical characteristics of bone. The key to successful management is early diagnosis, including bone sampling for microbiological and pathological examination to allow targeted and long-lasting antimicrobial therapy. The various types of osteomyelitis require differing medical and surgical therapeutic strategies. These types include, in order of decreasing frequency: osteomyelitis secondary to a contiguous focus of infection (after trauma, surgery, or insertion of a joint prosthesis); that secondary to vascular insufficiency (in diabetic foot infections); or that of haematogenous origin. Chronic osteomyelitis is associated with avascular necrosis of bone and formation of sequestrum (dead bone), and surgical debridement is necessary for cure in addition to antibiotic therapy. By contrast, acute osteomyelitis can respond to antibiotics alone. Generally, a multidisciplinary approach is required for success, involving expertise in orthopaedic surgery, infectious diseases, and plastic surgery, as well as vascular surgery, particularly for complex cases with soft-tissue loss.

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Acute osteomyelitis in children.

Heikki Peltola, Markus Pääkkönen (2014)

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Postoperative central nervous system infection: incidence and associated factors in 2111 neurosurgical procedures.

Michael Hall, Shearwood McClelland (2007)

Postoperative central nervous system infection (PCNSI) in patients undergoing neurosurgical procedures represents a serious problem that requires immediate attention. PCNSI most commonly manifests as meningitis, subdural empyema, and/or brain abscess. Recent studies (which have included a minimum of 1000 operations) have reported that the incidence of PCNSI after neurosurgical procedures is 5%-7%, and many physicians believe that the true incidence is even higher. To address this issue, we examined the incidence of PCNSI in a sizeable patient population. The medical records and postoperative courses for patients involved in 2111 neurosurgical procedures at our institution during 1991-2005 were reviewed retrospectively to determine the incidence of PCNSI, the identity of offending organisms, and the factors associated with infection. The median age of patients at the time of surgery was 45 years. Of the 1587 cranial operations, 14 (0.8%) were complicated by PCNSI, whereas none of the 32 peripheral nerve operations resulted in PCNSI. The remaining 492 operative cases involved spinal surgery, of which 2 (0.4%) were complicated by PCNSI. The overall incidence of PCNSI was 0.8% (occurring after 16 of 2111 operations); the incidence of bacterial meningitis was 0.3% (occurring after 4 of 1587 operations), and the incidence of brain abscess was 0.2% (occurring after 3 of 1587 operations). The most common offending organism was Staphylococcus aureus (8 cases; 50% of infections), followed by Propionibacterium acnes (4 cases; 25% of infections). Cerebrospinal fluid leakage, diabetes mellitus, and male sex were not associated with PCNSI (P>.05). In one of the largest neurosurgical studies to have investigated PCNSI, the incidence of infection after neurosurgical procedures was <1%--more than 6 times lower than that reported in recent series of comparable numerical size. Cerebrospinal fluid leak, diabetes mellitus, and male sex were not associated with an increased incidence of PCNSI. The results from this study indicate that the true incidence of PCNSI after neurosurgical procedures may be greatly overestimated in the literature and that, in surgical procedures associated with a high risk of infection, prophylaxis for S. aureus and/or P. acnes infection should be of primary concern.

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Author and article information

Journal

Journal ID (nlm-ta): Asian J Neurosurg

Journal ID (iso-abbrev): Asian J Neurosurg

Journal ID (publisher-id): AJNS

Title: Asian Journal of Neurosurgery

Publisher: Medknow Publications & Media Pvt Ltd (India )

ISSN (Print): 1793-5482

ISSN (Electronic): 2248-9614

Publication date (Print): Oct-Dec 2018

Volume: 13

Issue: 4

Pages: 959-970

Affiliations

[1] Department of Neurosurgery, California Institute of Neuroscience, Thousand Oaks, CA, USA

[1 ] Department of Neurosurgery, Windsor University School of Medicine, Brighton's Estate, Cayon, St. Kitts, West Indies

[2 ] Department of Neurosurgery, College of Osteopathic Medicine of the Pacific, Western University of Health Sciences, Pomona, CA, USA

[3 ] Department of Neurosurgery, Advocate BroMenn Medical Center, Normal, IL, USA

[4 ] University of Oklahoma Health Sciences Center, Oklahoma City, OK, USA

[5 ] Department of Neurology, University of New Mexico, Albuquerque, NM, USA

Author notes

Address for correspondence: Dr. Muhammad Adnan Khan, California Institute of Neuroscience, 2100 Lynn Road, Suite 120 Thousand Oaks, CA 91360, USA. E-mail: adnan359@ 123456gmail.com

Article

Publisher ID: AJNS-13-959

DOI: 10.4103/ajns.AJNS_90_17

PMC ID: 6208218

PubMed ID: 30459850

SO-VID: a8c3c4e7-47fc-4e09-8d22-a040fad948b1

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A Comprehensive Review of Skull Base Osteomyelitis: Diagnostic and Therapeutic Challenges among Various Presentations

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Most cited references 145

Osteomyelitis.

Acute osteomyelitis in children.

Postoperative central nervous system infection: incidence and associated factors in 2111 neurosurgical procedures.

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