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Necrotizing Base of Skull Ostiomylitis

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by

hanan saleh

on 31 October 2013

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Transcript of Necrotizing Base of Skull Ostiomylitis

Osteomyelitis of the Base of Skull
Definition
Is an aggressive and potentially fatal infection originating commonly in the external auditary canal in Diabatic pts, with progressive spread along the soft tissues and bone of the skull base via santorini’s fissures, ultimately involving intracranial structures
Namingل
OUT LINES
Definition
Naming
Epidemiology
Microbiology
Risk Factors
Clinical features
Diagnostic Criteria
Stages
Examination
Investigations
Treatment
Complications
Malignant otitis externa (in 1959, meltzer & Kelemen presented the first case )
In 1974, chandler report 13 cases (from 1968 to 1974)
Necrotizing external otits
Osteomylitis of the base of the skull
Epidemiology
65-70 years old
Male: female, 1.8:1
Immunocompromised patients (DM, HIV, On immunosuppression) WHY???
Microbiology
P.aeruginosa >90% >>
gram -ve aerobe not normally found in the EAC.
contain a mucoid surface layer that protect it from phagocytosis
produce lytic enzymes causing necrotizing vasculitis
will colonize in a moist environment and in the absence of effictive host defenes
Risk Factor
Aural water exposure
Clinical Feature
Examination
Granulation tissue in the inferior portion of the external auditory canal at the bone-cartilage junction ( santorini’s fissures )
Lab:
ESR
CRP
Culture of ear secretion and Tissue biopsy
Radiology:
CT scan
MRI
Technetium 99m scan (diagnostic)
Gallium citrate Ga 67 scintigraphy (follow up)
Investigation
Ciprofloxacin 750 mg PO BID
+ Rifampcin 600mg BID
for 6 to 12 weeks
Treatment of Resistant P. aeruginosa
hospitalization for biopsy, debridement and parenteral antibiotics >> Amphotericin B (>12 week)

Study on February 2006
6-week course of:
IV ceftazidime
topical aminoglycoside steroid drops
Treatment of Culture-Negative Skull Base Osteomyelitis
Complications
CNS:
Meningitis
Brain abscess
Dural sinus thrombophlebitis
References
Done By: Hanan Saleh Abu AL-faraj
Supervised By: Dr.Adel Lotfy

Otalgia >90% (throbbing pain, nocturnal)
Purulent otorrhea >90%
Fever :rare
Cervical lymphadenopathy
Trismus (temporomandibular joint)
facial nerve palsy 20% >>> why
Diagnostic Criteria
Obligatory criteria (major):
pain, edema, exudate, granulations,
positive Technetium 99 scan or
failure of local treatment often more
than 1 week,pseudomonas in culture.
Occasional criteria (minor):
diabetes, cranial nerve involvement,
positive radiograph, old age.
2012
Two-drug combination therapy
antipseudomonal with an aminoglycoside for 4-8 weeks, depending on the extent of involvement.
Antipseudomonas aminoglycosides:
Gentamicin ,Tobramycin , Amikacin
Antipseudomonas :
penicillin : Ticarcillin ,Timentin,Piperacillin ,....
quinolones : Ciprofloxacin , levofloxacin,.....
3rd/ 4th generation cephalosporins : Ceftazidime , cefepime, ..
Diagnostic criteria
Image
Stages
Stage 1
– purulent otorrhoea, otalgia (out of proportion), granulation tissue on otoscopy.
Stage 2
– disease extends to soft tissues and skull base with or without involvement of CN .
Stage 3
– intracranial extension.
Atypical presentation
Otitis media not responing to usual ttt
Nasopharyngeal mass
Parapharyngeal fullness
My
In 1989 >>>
Feb. 2006
Treatment
Thanks for inspiring me...
Hanan :)
Control the DM
Hyperbaric oxygen
Aspergillus ,staphylococcus aureus,
proteus mirabilis, klebsiella oxytoca,
candida parapsilosis

Other organiam
Radiologica Grading
Full transcript