Osteomyelitis Associated with Acute Sinusitis in the Setting of an Extensively Pneumatized Skull Base

Introduction: Pneumatization patterns within the skull base and paranasal sinuses can vary between individuals. Due to the reduced thickness present in an extensively pneumatized skull base, infections can easily develop, either through the extension of paranasal sinus disease through emissary veins or direct mucosal extension. We describe an otherwise healthy patient with extensive pneumatization of the petrous apex, clivus, and occipital condyles who presented with acute sinusitis that, ultimately, progressed to an acute infectious process of the clivus and skull base. Given this rare case in a healthy patient and the unique pneumatization pattern, we aim to present our experience with diagnosis and management as well as summarize the present literature on clinical complications associated with hyperpneumatization of the skull-base.

Case Presentation: A 41-year-old female with history of headaches presented to the emergency department with 6 days of headache, right ear pressure, bilateral facial pain, and posterior neck pain. There was no antecedent event or prior history of sinonasal infections. She denied visual disturbances, ophthalmoplegia, or dysphagia. Physical exam showed intact cranial nerves and unremarkable vital signs. In initial computed tomography (CT) scan of the head was performed, demonstrating acute sinusitis with air-fluid levels in the skull base. Intravenous (IV. ceftriaxone, vancomycin and systemic steroids were administered in the emergency department and dedicated skull base imaging was performed. CT and magnetic resonance imaging demonstrated acute sinusitis involving the bilateral maxillary, ethmoid, and sphenoid sinuses with air-fluid levels in extensively pneumatized right petrous apex, clivus, and occipital condyles. There was evidence of bony dehiscence along the posterior cortex of the clivus just anterior to the basilar artery. Given risks for possible intracranial spread, she underwent urgent endoscopic endonasal drainage of the clivus, temporal bone, and paranasal sinuses with right sided tympanostomy. Surgical cultures were positive for Cutibacterium acnes; the patient was treated with long-term IV ceftriaxone without complications. At her 3-month follow-up, the patient was stable and asymptomatic.

Discussion and Conclusions: Literature on this pattern of pneumatization and subsequent development of infection, especially in a healthy patient, is scarce and limited to case reports. In a similar report, Hoistad et al described a similar presentation that developed due to longstanding sphenoid sinusitis progressing to osteomyelitis of the clivus, anterior basioccipital bone, and petrous apices bilaterally. Successful recovery occurred after transoral drainage of clivus and IV antibiotics. Similar cases are described in the literature detailing rapid progression of nearby infections into the surrounding bone due to mastoiditis in the setting of pneumatized zygomatic processes. Regardless of the location, the most common treatment is surgical intervention with drainage of the infection and IV antibiotics. The present and literature review suggest that “hyperpneumatization” is a risk factor for skull base extension of common otolaryngologic infections. While these cases are rare, they may present in previously healthy patients and can potentially lead to life-threatening infections from acute bacterial sinusitis or otitis media. More research is necessary in this area to develop a more comprehensive understanding of complications due to hyperpneumatization.

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Artikel online veröffentlicht:
05. Februar 2024