|Year : 2019 | Volume
| Issue : 3 | Page : 834-839
Clinical characteristics and complications of skull base osteomyelitis: A 12-year study in a teaching hospital in South India
Sohini Das1, Ramya Iyadurai1, Karthik Gunasekaran1, Reka Karuppusamy2, Zacharia Mathew1, Ebenezer Rajadurai1, Ajoy O John1, Sunithi Mani3, Tina George1
1 Department of Medicine, Christian Medical College, Vellore, Tamil Nadu, India
2 Department of Biostatistics, Christian Medical College, Vellore, Tamil Nadu, India
3 Department of Radiodiagnosis, Christian Medical College, Vellore, Tamil Nadu, India
|Date of Web Publication||27-Mar-2019|
Dr. Sohini Das
Department of Medicine, Christian Medical College and Hospital, Vellore, Tamil Nadu - 632 004
Source of Support: None, Conflict of Interest: None
Context: Skull base osteomyelitis (SBO) is an uncommon disease with substantial morbidity and mortality. Aims: The aim of this study is to characterize clinical features, outcomes, and complications of SBO. We also looked at differences in clinical profile in otogenic and non-otogenic SBO. Materials and Methods: This is a single-center retrospective observational study. Patients aged more than 15 years of age with clinical and radiological diagnosis of SBO admitted in general medicine department in a teaching hospital in South India from March 2006 to February 2018 were recruited. Results: A total of 41 patients with SBO were identified and included. Mean age was 56.9 ± 10.7 years. In all, 90% of patients (37/41) had diabetes mellitus and 29% (12/41) had recent head/neck surgery. Only 19% (8/41) needed ICU care, and mortality was 21% (9/41). Most common symptom was headache seen in 73% (30/41) of patients. Majority, 61% (25/41), had otogenic infections. Otogenic infections were associated with longer duration of diabetes mellitus (mean = 11.5 vs. 5 years, P = 0.01), higher creatinine levels (mean = 1.66 vs. 0.9 mg/dL, P = 0.014, odds ratio [OR] = 3.8), and higher incidence of cranial nerve palsy (92% vs. 56%; OR = 8.9) compared to non-otogenic SBO. Cranial nerve palsy (78%), meningitis (63%), and cerebral venous thrombosis (43%) were frequent complications of SBO in this study. The causative organisms for SBO in our cohort was bacterial in 60% (15/25) and fungal in 40% (10/25) of the patients. Surgical debridement for source control was done in 54% of patients (22/41) and was associated with survival at discharge (P = 0.001). Conclusions: Bacterial infections are the most common cause of SBO. Otogenic SBO is associated with longer duration of diabetes mellitus and higher incidence of cranial nerve palsy. Therapeutic surgical debridement plays an important role in treatment of SBO and is associated with improved survival.
Keywords: Non-otogenic skull base osteomyelitis, otogenic skull base osteomyelitis, skull base osteomyelitis
|How to cite this article:|
Das S, Iyadurai R, Gunasekaran K, Karuppusamy R, Mathew Z, Rajadurai E, John AO, Mani S, George T. Clinical characteristics and complications of skull base osteomyelitis: A 12-year study in a teaching hospital in South India. J Family Med Prim Care 2019;8:834-9
|How to cite this URL:|
Das S, Iyadurai R, Gunasekaran K, Karuppusamy R, Mathew Z, Rajadurai E, John AO, Mani S, George T. Clinical characteristics and complications of skull base osteomyelitis: A 12-year study in a teaching hospital in South India. J Family Med Prim Care [serial online] 2019 [cited 2019 Oct 20];8:834-9. Available from: http://www.jfmpc.com/text.asp?2019/8/3/834/254919
| Introduction|| |
Skull base osteomyelitis (SBO) is an uncommon disease with substantial morbidity and mortality. Necrotizing skull base infection can originate from the external auditory canal or paranasal sinuses. Rarely, dental infections, pharyngeal abscesses, and hematogenous spread of infection from another focus can lead to SBO. Otogenic SBO involves the temporal bone, and usually presents with symptoms of ear pain and discharge. Typical SBO, also known as “malignant otitis externa,” is a rapidly spreading infection with high lethality., Central or atypical SBO involves the sphenoid, occipital bone, and clivus. Paranasal sinus infection, dental infections, and hematogenous spread from a distant source can lead to central SBO.,,
Diabetes mellitus is the most important risk factor for development of SBO. Diabetics have increased interleukin-1β and macrophage inflammatory protein 2 secretion. This leads to persistence of macrophages in the pro-inflammatory phenotype rather than transformation to pro-healing forms, resulting in impaired phagocytic function., Diffuse microangiopathy and alkaline cerumen also predispose diabetics to SBO.,,
Presenting symptoms of early SBO (headache, fever, nasal congestion/discharge, ear pain/discharge) are non-specific. Diagnosis is often made when the disease is advanced and neurological deficits have occurred. Identification of causative organism is challenging in skull base infections. Biopsy of diseased bone is not feasible in some patients due to proximity to vital neurologic structures. Necrotic bone is avascular, resulting in reduced antibiotic delivery and necessitating long-treatment duration. Hence, SBO poses a diagnostic and therapeutic challenge to clinicians.
Despite advances in medical and surgical therapy, SBO has a mortality rate of 14.3%–22%., In a systematic review of 42 patients with central SBO, 31% had residual neurologic deficits after treatment.
Complications of SBO include cranial nerve palsies, meningitis, cerebritis, brain abscess, subdural effusions, and empyema. Arteritis and cerebral venous thrombosis secondary to infections can lead to infarcts in the brain.,
The aim of our study is to characterize clinical features, outcomes, and complications of SBO. We also looked at differences in clinical profile and incidence of complications in otogenic and non-otogenic SBO.
| Subjects and Methods|| |
This single center observational study was conducted in a teaching hospital in south India. Patient records with discharge diagnosis of “skull base osteomyelitis” or “malignant otitis externa” admitted under department of medicine over a 12-year period from 1 March 2006 to 28 February 2018 were screened. Patients aged more than 15 years of age with clinical and radiological diagnosis of SBO were included in this study. Institutional Review Board and Ethics Committee approval (IRB Min No. 11334) was obtained. Need for individual consent was waived owing to the retrospective nature of the study.
Demographic details, history and physical examination findings, risk factors, source of infection, laboratory and imaging reports, etiological organisms, outcomes, and presence of complications were obtained retrospectively from computerized inpatient medical records. Therapeutic surgical debridement and deep biopsies done were noted.
Based on clinical features and imaging reports, source of infection was categorized as
- Otogenic (otitis externa/otitis media/mastoiditis)
- Non-otogenic (paranasal sinuses/teeth and oral cavity/pharyngeal abscess/hematogenous spread from another focus).
Continuous data were reported with Mean ± Standard Deviation. Categorical data were reported with number and percentage. Parametric t test was used to find the difference between two groups. Pearson Chi-square test was used to find the association between two categorical variables. Simple logistic regression was used to find the association of factors on binary outcome. Statistical analysis was done using Statistical Package for Social Services (SPSS) software Version 21.0 (Armonk, NY: IBM Corp).
| Results|| |
Forty-one patients with SBO were included in this study. Among these, 68% (28/41) of patients were male. Mean age (Mean ± SD) of the study group was 56.9 ± 10.7 years (range = 37–81 years).
Diabetes mellitus was the most common co-morbidity, seen in 90% (37/41) of patients. Mean HbA1C was 9.06% ± 2.36%. Hypertension was seen in 66% (27/41) of patients. Nearly one-third, that is, 29% (12/41), had head/neck surgery in the last 1 year prior to the current presentation with SBO and 2% (1/41) had history of oral corticosteroid intake.
Source of infection
Source of infection was otogenic in 61% (25/41) and non-otogenic in 39% (16/41) of patients. Source of non-otogenic infections included paranasal sinus (19% [8/41]), oral cavity (9% [4/41]), pharynx/neck (7% [3/41]), and hematogenous spread (2% [1/41]). [Table 1] outlines the clinical profile and laboratory parameters of patients with otogenic and non-otogenic SBO.
|Table 1: Presenting symptoms, risk factors, and laboratory parameters in otogenic and non-otogenic skull base osteomyelitis|
Click here to view
In all, 73% (30/41) had headache at presentation (ear infection = 64% [16/25], paranasal sinus infection = 100% [8/8], dental/oral cavity infections = 3/4, pharyngeal infection = 2/3, hematogenous spread = 1/1). In the group with otogenic SBO, ear pain and ear discharge were present in 56% (14/25) and 68% (17/25) of patients, respectively.
Duration of diabetes mellitus was longer in otogenic SBO group as compared to non-otogenic group (11.5 vs. 5 years, P = 0.019, odds ratio [OR] = 1.1).
Three out of four patients with dental/oral cavity source had undergone surgical procedure prior to presentation (tooth extraction = 2, peritonsillar abscess drainage = 1). Infections arising from the pharynx/neck included retropharyngeal abscess (1), nasopharyngeal abscess (1), and left jugular fossa collection (1). One patient had sustained facial trauma in a road traffic accident followed by development of dental abscess.
Culture samples were obtained by deep biopsies of infective focus or therapeutic surgical debridement. Biopsies and surgical debridement were done in 83% (34/41) and 54% (22/41) of patients, respectively.
Pathogenic organism was identified in 61% (25/41) of patients with SBO. Among these patients, 60% (15/25) had bacterial infections (Staphylococcus aureus = 6, Pseudomonas aeruginosa = 4, Klebsiella = 3, non-hemolytic Streptococci = 1, Burkholderia pseudomallei = 1). Three out of eight gram-negative bacterial infections were resistant to ciprofloxacin. Of six patients with Staphylococcus aureus infection, four were methicillin resistant. In all, 40% (10/25) had fungal infection (Rhizopus = 8, Aspergillus flavus = 2).
Antibiotics were administered to 40 patients, and antifungals to 12 (amphotericin = 10, voriconazole = 2). Eleven patients were treated with both. A total of 46% (19/41) of patients received a single antibiotic/antifungal drug, and 54% (22/41) received combination therapy. The treating team had empirically started four patients on anti-tuberculous therapy along with antibiotics.
Otogenic infection group had higher creatinine levels compared to non-otogenic infection group (P = 0.014, OR = 3.8). There was a trend towards higher incidence of renal dysfunction in the otogenic group as compared to non-otogenic group (36% vs. 6.2%, P = 0.059).
Complications of SBO seen in this study were cranial nerve palsy (78% [32/41]), meningitis (63% [26/41]), cerebral venous thrombosis (44% [18/41]), cerebral infarcts due to arteritis (34% [14/41]), subdural abscesses (15% [6/41]), cerebritis (12% [5/41]), and brain (parenchymal) abscesses (5% [2/41]). Incidence of complications in otogenic and non-otogenic groups have been outlined in [Table 2].
|Table 2: Complications and outcomes of otogenic and non-otogenic skull base osteomyelitis|
Click here to view
In all, 78% (32/41) developed cranial nerve palsy. Seventh nerve and sixth nerve palsy were found most frequently (41% [17/41] and 36% [15/41], respectively). Using logistic regression, cranial nerve palsy was associated with otogenic SBO (P = 0.017, OR = 8.9). There was a trend towards association of subdural collections with non-otogenic SBO (P = 0.053). One patient had a temporal lobe abscess, which originated from an untreated dental infection. She underwent anterior temporal lobectomy and was treated with ceftriaxone for 12 weeks.
Mean duration of hospital stay was 21.9 ± 19 days. In all, 78% (32/41) of patients were alive at discharge and 22% (9/41) patients died during hospital stay, while 19% (8/41) required intensive care unit (ICU) care. Also, 54% (22/41) underwent therapeutic surgical debridement. Surgical debridement for source control was associated with improved survival at discharge (P = 0.001). Among 16 patients in whom pathogenic organism could not be identified, 75% (12) were alive at discharge and 25% (4) required ICU care.
| Discussion|| |
SBO is a life-threatening disease with significant morbidity. In all, 90% of patients in our study were diabetic, with 56% having poor glycemic control (HbA1c >8%). This is consistent with other studies, where diabetes mellitus is the most common risk factor mentioned.,,, This is similar to our study group, where 90% of patients had diabetes, but there was a longer duration of diabetes in the otogenic SBO group.
In our study, 61% of patients had otogenic infections and 19% had sinusogenic infections. In a European study, 75% and 25% patients had otogenic and sinusogenic SBO, respectively. In a review of 21 cases of SBO, Blyth et al. found that the source was otogenic in 47% (10/21 [8 = bacterial, 2 = fungal]) and sinusogenic in 42% (9/21 [9 = fungal]) of patients. Sinusogenic SBO was associated with fungal etiology in this study (P < 0.001). In a review of 84 cases of head and neck osteomyelitis from India by Prasad et al., sinusogenic, odontogenic, and otogenic infections accounted for 27%, 12%, and 5%, respectively. However, in contrast to our study, mandible was the most common bone involved in this study (38%). In our study, common bones involved were temporal bone and clivus part of occipital bone. The study by Prasad et al. also included a significant number of patients with malignancy and osteoradionecrosis of the jaw, which is different from our patient population. Rarely, cranial osteomyelitis can occur following head trauma (common in children) and after neurosurgical procedures.,, Our study group had only 1 patient with post-traumatic SBO.
Cranial nerve palsy, meningitis, and cerebral venous thrombosis were common complications of SBO in our study. Cranial nerve palsy was found in 78% of patients and was associated with ear infections (OR = 8.9), with the seventh nerve being most frequently involved. Otogenic infection originates in the external auditory canal and spreads sequentially to the temporal bone, fissure of Santorini, mastoid process, and skull base. Facial nerve is affected at stylomastoid foramen, and ninth, tenth, and eleventh nerves can be affected with infection at the skull base. Other studies have documented cranial nerve palsy in 15% to 56% of patients.,, Our study population may have had more patients with advanced disease as ours is a referral center.
We found that meningitis, cerebral venous thrombosis, and arterial infarcts are common complications of SBO. Pathogenesis of cerebral venous thrombosis in SBO involves spread of infection via diploic veins leading to sagittal sinus thrombophlebitis. In patients with central SBO, four out of six patients were noted to have cavernous sinus thrombosis in a study by Chang et al. Patients with SBO who develop cerebral venous thrombosis can be managed with therapeutic surgical debridement (source control) and antibiotic therapy. Serial brain imaging to monitor thrombus progression can be done. Among SBO patients with cerebral venous thrombosis, similar outcomes have been noted in those with and without anticoagulation., Clinicians managing patients with SBO should have a high index of suspicion for development of the above complications.
In patients with gram-negative infections, 37% (3/8) were noted to have ciprofloxacin resistance. Methicillin resistant Staphylococcal infection was seen in 66% (4/6). Resistant organisms have been associated with longer duration of treatment and hospital stay. In a study by Clerc et al. that included 31 patients with necrotizing external otitis from 2004 to 2011, 25% of Pseudomonas aeruginosa strains were ciprofloxacin resistant, and all had presented after 2007.
Prompt diagnosis, culture-guided antibiotic therapy, and early surgical debridement are essential components of management of SBO. Delay in treatment may lead to poor outcomes including development of complications and refractory cases.
In our study, 54% underwent therapeutic surgical debridement for source control. We found an association between therapeutic debridement and improved survival at discharge (P = 0.001). Surgical treatment in addition to antifungal therapy has been shown to increase survival rates in patients with fungal infections. Ridder et al. have advised early surgical debridement in conjunction with antibiotic therapy for central SBO. In his cohort, 80% (16/20) cases underwent surgical treatment and all patients were alive at follow-up.
Surgical debridement leads to source control, decreases infectious load, and provides an opportunity to obtain samples for culture to identify etiological organisms., If feasible, debridement for source control should be done in all patients with SBO.
Otitis externa, mastoiditis, and sinusitis are common problems that are often encountered by family physicians. In these patients, refractory otitis externa (poor response to antibiotic therapy), persistent headache, neurological deficits, and severe otalgia out of proportion to examination findings should raise suspicion for possible SBO. These patients should undergo imaging of the brain. If diagnosis of SBO is made, urgent referral to an otorhinolaryngologist is necessary for obtaining biopsy samples and surgical debridement.
Early diagnosis and prompt initiation of therapy has been associated with better prognosis and lower incidence of complications in SBO. As family physicians are the first point of contact for most patients, suspecting and diagnosing SBO at this level can prevent long-term neurological sequelae.
Hyperbaric oxygen therapy has been used as an adjunct to treatment in cranial osteomyelitis. Sandner et al. evaluated the role of hyperbaric oxygen therapy in cranial osteomyelitis. Management included antibiotics, surgical debridement, and adjuvant hyperbaric oxygen therapy. Six out of eight patients had complete recovery and two patients had residual cranial nerve palsies. In our hospital, we do not use hyperbaric oxygen therapy for the management of SBO.
Limitations of this study include inherent drawbacks owing to the retrospective nature of this study. Lack of follow-up data is another shortcoming that needs to be mentioned.
| Conclusion|| |
In this study, otogenic infections accounted for 61% of SBO, followed by paranasal sinus infections (19%). Cranial nerve palsy, meningitis, and cerebral venous thrombosis are frequent complications of SBO. Otogenic SBO is associated with longer duration of diabetes mellitus and higher incidence of cranial nerve palsy. Surgical debridement plays an important role in treatment of SBO and is associated with survival.
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Conflicts of interest
There are no conflicts of interest.
| References|| |
Chandler JR. Malignant external otitis. Laryngoscope 1968;78:1257-94.
Carlton DA, Perez EE, Smouha EE. Malignant external otitis: The shifting treatment paradigm. Am J Otolaryngol 2018;39:41-5.
Shama SA. Osteomyelitis of the central skull base: Otogenic and odontogenic sources. Multidetector CT study. Egypt J Radiol Nucl Med 2012;43:519-26.
Clark MPA, Pretorius PM, Byren I, Milford CA. Central or atypical skull base osteomyelitis: Diagnosis and treatment. Skull Base 2009;19:247-54.
Gupta R, Patadia D, Velayudhan V, Buchnea D. Orbital cellulitis, cavernous sinus thrombosis, internal jugular vein thrombus, and clival osteomyelitis secondary to acute sinusitis. Am J Respir Crit Care Med 2017;195:533-5.
Mirza RE, Fang MM, Ennis WJ, Koh TJ. Blocking interleukin-1β induces a healing-associated wound macrophage phenotype and improves healing in type 2 diabetes. Diabetes 2013;62:2579-87.
Schürmann C, Goren I, Linke A, Pfeilschifter J, Frank S. Deregulated unfolded protein response in chronic wounds of diabetic ob/ob mice: A potential connection to inflammatory and angiogenic disorders in diabetes-impaired wound healing. Biochem Biophys Res Commun 2014;446:195-200.
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.
Slattery WH, Brackmann DE. Skull base osteomyelitis. Malignant external otitis. Otolaryngol Clin North Am 1996;29:795-806.
Khan M, Quadri SQ, Kazmi A, Kwatra V, Ramachandran A, Gustin A, et al
. A comprehensive review of skull base osteomyelitis: Diagnostic and therapeutic challenges among various presentations. Asian J Neurosurg 2018;13:959-70.
] [Full text]
Choi PK, Chung JY, Kang HG. Central skull base osteomyelitis presenting only with a severe headache. Headache 2018;58:1236-7.
Johnson AK, Batra PS. Central skull base osteomyelitis: An emerging clinical entity. Laryngoscope 2014;124:1083-7.
Lee SK, Lee SA, Seon SW, Jung JH, Lee JD, Choi JY, et al
. Analysis of prognostic factors in malignant external otitis. Clin Exp Otorhinolaryngol 2017;10:228-35.
Blyth CC, Gomes L, Sorrell TC, da Cruz M, Sud A, Chen SCA. Skull-base osteomyelitis: Fungal vs. bacterial infection. Clin Microbiol Infect 2011;17:306-11.
Kilich E, Dwivedi R, Segal S, Jayawant S, Sadarangani M. Symptomatic stroke complicating central skull base osteomyelitis following otitis media in a 2-year old boy: Case report and review of the literature. Int J Pediatr Otorhinolaryngol 2016;89:140-4.
Severino M, Liyanage S, Novelli V, Cheesborough B, Saunders D, Gunny R, et al
. Skull base osteomyelitis and potential cerebrovascular complications in children. Pediatr Radiol 2012;42:867-74.
Le Clerc N, Verillaud B, Duet M, Guichard JP, Herman P, Kania R. Skull base osteomyelitis: Incidence of resistance, morbidity, and treatment strategy. Laryngoscope 2014;124:2013-6.
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.
] [Full text]
Sylvester MJ, Sanghvi S, Patel VM, Eloy JA, Ying YLM. Malignant otitis externa hospitalizations: Analysis of patient characteristics. Laryngoscope 2017;127:2328-36.
Ridder GJ, Breunig C, Kaminsky J, Pfeiffer J. Central skull base osteomyelitis: New insights and implications for diagnosis and treatment. Eur Arch Otorhinolaryngol 2015;272:1269-76.
Prasad KC, Prasad SC, Mouli N, Agarwal S. Osteomyelitis in the head and neck. Acta Otolaryngol (Stockh) 2007;127:194-205.
Mortazavi MM, Khan MA, Quadri SA, Suriya SS, Fahimdanesh KM, Fard SA, et al
. Cranial osteomyelitis: A comprehensive review of modern therapies. World Neurosurg 2018;111:142-53.
Sundar VI, Shekhawat J, Gupta A, Sinha VD. Post traumatic tubercular osteomyelitis of skull vault. J Neurosci Rural Pract 2013;4:138-41.
] [Full text]
Chang HY, Cheng KS, Liu YP, Hung HF, Fu HW. Neonatal infected subgaleal hematoma: An unusual complication of early-onset E. coli
sepsis. Pediatr Neonatol 2015;56:126-8.
Hatch JL, Bauschard MJ, Nguyen SA, Lambert PR, Meyer TA, McRackan TR. Malignant otitis externa outcomes: A study of the university health system consortium database. Ann Otol Rhinol Laryngol 2018;127:514-20.
Chang PC, Fischbein NJ, Holliday RA. Central skull base osteomyelitis in patients without otitis externa: Imaging findings. Am J Neuroradiol 2003;24:1310-6.
Bradley DT, Hashisaki GT, Mason JC. Otogenic sigmoid sinus thrombosis: What is the role of anticoagulation? Laryngoscope 2002;112:1726-9.
de Oliveira Penido N, Testa JRG, Inoue DP, Cruz OLM. Presentation, treatment, and clinical course of otogenic lateral sinus thrombosis. Acta Otolaryngol (Stockh) 2009;129:729-34.
Roden MM, Zaoutis TE, Buchanan WL, Knudsen TA, Sarkisova TA, Schaufele RL, et al
. Epidemiology and outcome of zygomycosis: A review of 929 reported cases. Clin Infect Dis 2005;41:634-53.
Sandner A, Henze D, Neumann K, Kösling S. Value of hyperbaric oxygen in the treatment of advanced skull base osteomyelitis. Laryngorhinootologie 2009;88:641-6.
[Table 1], [Table 2]