Annals of Nuclear Medicine and Molecular Imaging 2012:25:100-103 100 Annals of Nuclear Medicine and Molecular Imaging Journal webpage at worn sam.org7 ANMMI Case Report Osteomyelitis of Skull Base A case report and review of the literature Rong-Hsin Yang’, Lien-Xin Hu’, Cheng-Pei Chang'*, Yum-Kung Chu", Ren-Shyan Liu", ‘Shih-Jen Wang"? ‘Department of Nuclear Medicine, Taipel Veterans General Hospital, Taipei, Taiwan ‘National Yang-Ming University Collegeof Medicine, Taipei, Tarwan ARTICLE INFO ARSTRACT Anite history Background: Malignant extemal otis is @ severe infection of the external auditory Received November 7, 2011 canal and most often affects elderly patients with diabetes mellitus. in some patients, it ‘Accopled May 22,2012 may progress to skull base osteomyelitis. Early diagnosis and aggressive treatment are crucial to reduce risks of dissemination. Key words Case Report: We report a case of a 91-year-old patient with skull base osteomyelitis ren preceing th aovaeheadacre. Tete ws no vous ll elgn of econo te saan cnteoryate Pallente extemal sat" canal, Gonbined osteomyelis bone. can. (Te-99m ‘methylenediphosphonic acid bone scan and gallium scan) and magnetic resonance imaging revealed an active bone lesion in the skull base. The patient was treated with antibiotics for skull base osteomyelitis and the headache improved. Conclusions: The authors concluded that, in the elderly or immunacompromised patient, headache with active bone lesion on imaging should raise the possibilty of skull based osteomyelitis, even in the absence of an obvious infective source. The primary {goal should stil be to exclude an underlying malignant cause. Te-99m MDP bone sean Corresponding author CCheng-Pei Chang M.0., Department of Nuclear Medicine, Taipei Veterans General Hospital No.20%, Sec. 2, Shipai Rd, Betou District, Taipei City, Taiwan, 8.0.6. Tel 886-02-2875-7374 oxt.7301 4. Introduction Fax: 886- 02-28715849. E-mail address Speluraenettpe govt Malignant external otitis (MEO) is an infrequent but severe infection. The causative organism is usually Pseudomonas aeruginosa [1]. Among patients with MEO, skull base osteomyelitis (SBO) is a more serious, life-threatening condition, Usually it isa complication of repeated episodes of otitis externa which fail to resolve with topical medications and aural toilet, ‘SBO can affect the sphenoid and occipital bones, often centered on the clivus, and can be considered a variant of malignant otitis externa, It ean present with headache and a variety of cranial neuropathies, often a combination of cranial VI and lower cranial netve neuropathies. The imaging findings frequently mimic malignaney [2], making accurate histological diagnosis all the more important. It is important to differentiate $BO from other conditions that do not require such aggressive therapy and to evaluate the spread of the disease, in both the bone and soft tissue. Crucial is imaging data of the temporal bone, the skull base and foramina, the intratemporal fossa, the parapharyngeal space, the nasopharynx, the cranial nerves and the intracranial soft tissues, especially the meninges. The widely accepted standards include a scan with technetium - 99 m methylenediphosphonie acid (Te-99 m MDP) toID] ANMAEE + YoL25 + Nod + une 2012 Figure 1. The planar Gallium scan disclosed a hot spot is seen at the right aural region. eae reveal early osteocitis; gallium citrate (Ga-67) to obtain a baseline image to compare with later ones t monitor response to therapy; computed tomography (CT) to track bone involvement; and magnetic resonance imaging (MRI) ‘to evaluate the soft tissue [3,4]. Here we report the usefulness of Te-99 m MDP bone scan combined with MRI to evaluate a patient with SBO. The history of the case, the imaging findings and the correlation of bone scan and MRI scans are discussed. 2. Case report A 91-year-old woman presented with severe right-sided headache of one month duration, She gave a history ofa right, car infection treated three months earlier at an ENT clinic On clinical examination, the patient had a normal external auditory canal on both sides. A nasal endoscopic examination revealed a smooth roof of the nasopharynx with no evidence of ulceration or growth. Findings of the remainder of the ENT examination were normal except for tenderness in the right temporomandibular joint region, No obvious causes for her headache were noted and the patient was then referred to a neurologic outpatient department, Series studies (including head and CT and Brain MRI) showed no apparently abnormal findings. Meanwhile, the osteomyelitis scan (combined Te-99 m MDP and Ga-67 scintigraphy) revealed increased uptake over the right side skull base (Figures 1 and 2), We fused the SPECT images with the brain MRI. And found an active lesion located at the petrous region of the temporal bone (Figure 3). Tentative diagnosis was nasopharyngeal malignaney. Differential diagnosis included SBO, However, repeated biopsics from the nasopharynx revealed no evidence of malignancy. Based on radiologic and histologic findings, patient was diagnosed with right SBO secondary to MEO, ‘The patient was treated with intravenous ciprofloxacin for four weeks and the headache improved, Interestingly, the follow-up MRI showed a skull base lesion on the petrous. region of the right temporal bone, in the region of the previous gallium sean.3. Discussion Osteomyelitis of the central skull base is an uncommon condition that is potentially life threatening if not promptly recognized and properly treated [1]. It represents a diagnostic challenge in that it may present without any focus of infection in the ear, nose, or sinuses [5,6]. The clinician needs to review the symptoms, signs and history. In susceptible individuals, the following symptoms and signs should be considered to establish an carly diagnosis of recurrence: (1) unremitting/persistent headache in previously treated cases of MEO; (2) otitis media with effusion in the ipsilateral/contralateral ear in the absence of a nasopharyngeal lesion; and (3) the presence of lower cranial nerve/s deficits, especially in an elderly diabetic individual, Different imaging modalities may be helpful in assessing these patients. On diagnosis, CT findings may be Jacking initially but may later demonstrate clear bony ‘erosion. Seabold et al. found no CT evidence of bone erosion in 13 of 35 patients with biopsy-confirmed cranial ‘osteomyelitis [7]. He questioned the usefulness of CT for follow-up . MRI is a better soft tissue discriminator, offering, PBDICT fusion image ofhead and neck cancer 102 good imaging of soft tissue planes around the skull base and abnormalities of the medullary cavity of the bone, Malone et al. [8] indicate that typical SBO findings include non-specific marrow TI hypointensity and T2 hyperintensity, In terms of the differential diagnosis, the primary concer is the presence of a malignant process, be it primary or secondary. Squamous cell carcinoma, lymphoma, nasopharyngeal carcinoma and hematogenous metastases. may all_have similar MRI findings to SBO. Also similar on MRI are non- neoplastic conditions such as Wegener’s granulomatosis, tuberculosis, sarcoidosis, fibrous dysplasia and Paget's disease; the appearance on CT can help make the differentiation, particularly for the later two conditions, MRI may be used to detect postoperative osteomyelitis and may ‘be more useful in the follow-up of patients on antibiotics because marrow signal change may persist for up to 6 months afler successful treatment [9] Various nuclear medicine imaging techniques [7,10,11] have been advocated in suspected cases of SBO, including gallium-67 scintigraphy, indium-111 white blood eell scans, Te-99 m MDP bone scans and single-photon emission computed tomography, The last two techniques may be better olololelele elelseeleiela Figure 2. Due to the suspicious lesion in the right aural_region. SPECT was done - And it revealed an active bone lesion in the skull base region Probably over the nasophar- yns. However, the anatomic location is not well defined AAAAAAA103 ANMAE + YoL25 + Nod + une 2012 than CT and MRI at detecting postoperative osteomyelitis and may be more useful in the follow-up of patients on antibiotics because marrow signal change may persist for up to six months after successful treatment [7]. 4. Conclusion Headache in the elderly diabetic or immunocom- promized patient, with imaging findings of a lesion causing bony destruction to the central skull base, should raise the possibility of a diagnosis of central SBO as well as of malignancy, and both should be investigated concurrently. A past history of otitis externa, even if apparently resolved before the onsct of the presenting symptoms, should further raise suspicion of an underlying infective cause, Reference 1. Rubin J, Yur VL. Malignant external otitis: insights into pathogenesis, clinical manifestations, disgnosis, and therapy. Am J. Med 19RK5:391-8 2, Subburaman N, Chaurasia MK. Skull base ostomyelts interpreted ‘a malignancy Laryngol Otol 1999113:775-8 ‘ Figure 2. Thus, we fused the MRI and Te-99m MDP SPECT imagings, which disclosed a hot ‘spot at the right sided of naso- pharynx. The lesion is not in the surface of nasopharynx Besides, there is, no any abnormal gallium avid lesion in the right, EAC. It is a isolated lesion in the skull base. Parisor SC, Lucente FE, Som PM, Hirschman SZ, Armold LM, Roffmin JD. Nuclear scanning in necrotizing progzesive malignant extemal otis. Laryngoscope 1982:92:1016.9, Kohut RI, Lindsay JR” Necrtiing malignant extemal ot isopatboiogicproceses, Aan Otol Rhiol Laryngol 1979;88714 2, Marl J, Duclos JY, Darrouzst V, otal. Malignant or nosrtzing texte: experience in 22 caves, Ann Otolaryngol Chir Cervicotse 20005117291, (Chandler IR. Malignant otis extemal otis and osteomyelitis ofthe sl. AmJ Otol 1989;10:108-10, Seabold JE, Simonson TM, Weber PC, e al. Cranial ostomyelits iagnost and follow-op with Inei1t white blood call and Te99m methylene diphosphonate bone SPECT, CT, and MR. imaging Radiology 1995:196:779- 788 Malone DG, O'Boynick PL, Ziegler DK, Batizky S, Hubble JP, Holladay FP. Osteomyelitis of the skull base, 1992330426431 Seabold JE, Simonson TM, Weber PC, e al, Cranial osteomyelitis Aiagnosis and follow-up with In-I11 white blood cell and Te-99m methylene diphosphonate hone SPECT, CT, and MR. imaging. Radiology 1995;196-779- 78, Chang PC, Fischbein NJ, Holliday RA. Cental skull base ‘osteomyelitis paints without otis exera: imaging findings ‘AINR Am J Neuroradiol 2003 24:1310-1316 Singh A, Al Khabori M, Hyder MJ, Skull base osteomyelitis diagnostic and therapeutic challenges in atypical presentation ‘Otolaryngol Head Neck Surg 2068 :138:121-125,“Annals of Nuclear Medicine and Molecular Imaging 201228: 100-108 Annals of Nuclear Medicine and Molecular Imaging Journal webpage at worn sam.org7 Case Report UH AA BAIR MI GRIN REAM EHR BI ‘OCA PEE YC BRR ces BRU YN EY PR AY SS a a Ph a» ee Se ERR + AR AT AE SHE I MOLE PBS «TA ARABI + DU TR A» HE SCRE MBP PIER SS » LEMS ERE BP SENG LI ENR + SL OU LUI + A a teh hE 5B) 5S AY A e+ UAT A AMR 2k EY =A (active) Fa a + SK ie ae Bi a ME PRE + 2 RR P+ ARNT EZ RAIMI RAS Wear ELLA» PERRIS A RR EDT HE AE BSI A + MEE ~ ACRES +R A i BS SSM BE EL ASHORE RT = REAR + SE BLAH ASME RCE ERAT ETHE © WR is): A Se + PA >