Skull Base Osteomyelitis

SKULL BASE OSTEOMYELITIS (AS A
COMPLICATION OF MALIGNANT
OTITIS EXTERNA AND CHRONIC
SUPPURATIVE OTITIS MEDIA)
SUNDHARESHWARAN.C
PREETHI.B
3RD YEAR MBBS

SREE MOOKAMBIKA INSTITUTE OF
MEDICAL SCIENCES.
Guide :
Dr.SIVA SUBRAMANIYAM M.S M.Ch
Neurosurgery
PERSONAL INFORMATION :
A 64 year gentleman from Eethamozhi,
came to the Medicine OPD of SMIMS
on 21/08/2019
with the chief complaints of :
Headache x 4 days and

Double vision x 3days
 The patient was apparently normal 10 days ago.
 He developed headache which was sudden in onset,mild,
diffuse, relieved by taking rest and gradual in progression.
 He had difficulty in swallowing for 10 days before the
headache started.
 He started having double vision from the next day .
 He had intermittent fever.
 He also complained of aspiration of food.
 He also had h/o hearing difficulty for the past few months.
 There is intermittent ear discharge as he is a K/C/O
Diffuse otitis externa and chronic suppurative otitis
media for the past 10 months.
 No h/o vomiting, nausea, cough with expectoration,loss of
vision, loss of sensation of smell.
 He is a k/c/o CAD x 2 years ( CABG done
2 years ago) ,
 Diabetes Mellitus x 2years
 No regular treatment history
 No regular monitoring of blood sugar
levels,
 Hypertension x 2years.
 No Relevant data obtained from Family
History and Personal History.
 Conscious, Cooperative and Well Oriented to
time ,place and person.
 He was moderately nourished but he looked ill
built.
 No Pallor, No Icterus, No Cyanosis, No Clubbing,
No Generalized Lymphadenopathy, No Pedal
Edema.
• Pulse rate : 86 bpm

• Blood Pressure : 140/90 mmHg
• Respiratory Rate : 19 cycles/ minute
• Temperature : 97.8OF
 Cardio Vascular System : S1 S2
heard with normal intensity. No
murmurs.
 Respiratory System : Bilateral
Airway entry is normal. Normal
Vesicular breath sounds are heard on
both sides.
 Abdomen : Soft ,Non Tender, No
Organomegaly.
 Central Nervous System : Higher
Mental Functions are Normal.
CRANIAL NERVE EXAMINATION
 1)Olfactory Nerve : there is no abnormality
detected in the sensation of smell.
 2)Optic Nerve :
Visual acuity- 6/18 in both eyes.
Colour vision-normal
Field of vision-normal in all directions.
Pupil is fixed on the right side.
 3)Oculomotor Nerve 4)Trochlear Nerve 6)
Abducent Nerve :
Right eye movements restricted.
Partial Ptosis is present on the right eye.
 5) Trigeminal Nerve :
Absence of corneal and conjunctival reflexes.
Loss of sensations on the face.
 7) Facial Nerve :
Deviation of angle of mouth on the left side.
Taste sensation impaired on anterior 2/3rd of
tongue.
 8)Vestibulocochlear nerve : Rinne test positive on
the right side.Weber test lateralised to left ear.
(BC>AC). (Sensorineural type of hearing loss)
 9)Glossopharyngeal Nerve and 10)vagus nerve:
Uvula deviated to left.
Gag reflex is absent on both sides.
 Bulk of muscle-Right UL-25 cm,Left UL-
25CM
 Right LL-48CM,Left LL-48CM
 Tone is normal on both sides.
 Deep tendon reflexes –grade 2.
 Power is 5/5 in the upper and lower limbs
of both sides.
 Cerebellar function tests were normal.
 Right ear :
#congested external auditory canal with
discharge .
#Tympanic membrane cannot be seen on
inspection.
#Rinne test positive in the right ear.
#Weber test lateralised to left ear.
#(BC>AC ). (Sensorineural type of hearing loss
on the right side)
 Left ear is normal.

 Examination of Nose : Normal
 Examination of Oral Cavity and Throat :
Uvula is deviated to left.
 CBC : leukocytosis with predominant
neutrophilia
 Blood Sugar Level was elevated.
 Diagnostic Nasal Endoscopy showed
minimal watery secretion near right side
maxillary ostium.
 Lumbar puncture : CSF showed marked
rise in protein and decrease in glucose
level.CSF microscopy showed no WBCs.No
bacterial growth on culture of CSF.
MRI showed features of right
mastoiditis,pansinusitis with
features of skull base osteomyelitis
with edematous/inflammatory
changes of the adjacent soft tissue
of the neck spaces and intracranial
extension with abnormal meningeal
thickening enhancement along the
right middle cranial fossa.
Cerebral venous thrombosis
involving distal right transverse sinus
and sigmoid sinus.
 Skull Base Osteomyelitis with
Multiple Cranial Nerve involvement
on the right side due to
complicated malignant otitis
externa and chronic suppurative
otitis media.
•Inj PIPTAZ 4.5g (piperacillin plus
tazobactam) tds for 5days.
Inj.Meropenam 1g
Inj. Metrogyl 500mg
Inj. Dexamethasone 8mg iv
Nasogastric Tube for Feeding
SURGICAL INTERVENTION :
On 29/08/2019 ,cortical
mastoidectomy was done and biopsy
was sent for fungal culture which
showed no fungal growth.
Post Surgery , there was commendable
improvement in the patients health
condition .
Ptosis regressed , there was no

aspiration of food and hence the
patient was able to take food orally.
Ocular movements seemed to remain
the same as before .
This is an interesting
case of malignant
otitis externa and
CSOM complicated to
middle cranial fossa
extension and right
temporal bone
osteomyelitis (possibly
due to uncontrolled
diabetes mellitus)
which necessitated
surgical intervention.

Skull Base Osteomyelitis

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SKULL BASE OSTEOMYELITIS (AS A

3RD YEAR MBBS

A 64 year gentleman from Eethamozhi,

came to the Medicine OPD of SMIMS

with the chief complaints of :

Headache x 4 days and

• Pulse rate : 86 bpm

 Left ear is normal.

Ptosis regressed , there was no

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