A rare presentation of central skull base Osteomyelitis in a case of severe headache

Abstract

A 75-year-old fit and well patient with an old mastoid cavity presented to the ENT outpatient clinic with a four-week history of right-sided hemicranial pain with neuralgic characteristics. Head and neck examinations via otoscopy and flexible nasoendoscopy were essentially unremarkable without evident cause for the patient’s symptoms. Hence an urgent computed tomography (CT) neck with contrast was arranged, revealing an abnormal appearance of the petrous apex and nasopharynx. A subsequent magnetic resonance image (MRI) of the skull base including a cholesteatoma diffusion-weighted imaging (DWI) protocol confirmed abnormal appearances of the central skull base, with a differential diagnosis between osteomyelitis and an invasive nasopharyngeal neoplasia invading the petrous apex. The patient was referred to a tertiary multi-disciplinary skull base team, and a consensus diagnosis of central petroclival skull base osteomyelitis was made. Treatment with oral antibiotics was commenced promptly with guidance from the microbiology team, and sequential follow-up MRI scans documented progressive improvement in the osteomyelitis with corresponding gradual resolution of the headache.