|Year : 2018 | Volume
| Issue : 2 | Page : 114-116
Osteomyelitis of temporal bone: A case report of a rare disease
Bigyan Raj Gyawali, Pabina Rayamajhi
Department of ENT-HNS, Institute of Medicine, Kathmandu, Nepal
|Date of Web Publication||4-Sep-2018|
Dr. Bigyan Raj Gyawali
Institute of Medicine, Kathmandu
Source of Support: None, Conflict of Interest: None
Osteomyelitis of temporal bone affecting the squamous portion is a very rare entity. We present here a case of osteomyelitis affecting the squamous portion of temporal bone following blunt trauma to the head.
Keywords: Osteomyelitis, squamous portion, temporal bone
|How to cite this article:|
Gyawali BR, Rayamajhi P. Osteomyelitis of temporal bone: A case report of a rare disease. Indian J Otol 2018;24:114-6
| Introduction|| |
Temporal bone is a complex bone of the human body. It is rarely involved by infection in the form of osteitis or osteomyelitis. Toulmouche  described the first case of progressive osteomyelitis of the temporal bone in 1838. In 1959, Meltzer and Kellemen  described a case of progressive Pseudomonas osteomyelitis of the temporal bone and skull base. Chandler is credited with the clinical description of what he termed malignant otitis externa in 1968 and thereafter.
Osteomyelitis is basically defined as the inflammation of marrow cavity and later progresses to involve the overlying periosteum. It usually involves the long bones of the human body. Osteomyelitis in temporal bone may involve its various portions such as mastoid, middle ear cleft, otic capsule, petrous apex, and clivus. The most common form, which is often described as acute necrotizing otitis externa or malignant otitis externa, involves the bony external auditory canal.
Here, we present a rare case report of temporal bone osteomyelitis involving the squamous portion of temporal bone.
| Case Report|| |
A 66-year-old female presented to our outpatient department with a history of headache for 9 months. Headache was preceded by trivial blunt trauma to the right temporal region following fall. There was no history of loss of consciousness; however, the headache persisted. Headache was confined to the right temporal region, dull in nature, continuous with intermittent exacerbations, and relieved to some extent with analgesics, but there were no known aggravating factors. It was not associated with vomiting, blurring of vision, seizure, and fever. There was no history of ear discharge, decreased hearing, vertigo, and tinnitus.
She did not have any significant past medical illness such as hypertension, diabetes, tuberculosis, hormonal disorders such as hyperparathyroidism, and any significant treatment history.
On examining the patient, general examination revealed no significant findings. Local examination showed tenderness over the right temporal region. However, there was no local rise of temperature, erythema, swelling, and fluctuation. Examination of ears bilaterally yielded normal findings with intact tympanic membrane, positive Rinne result, and centralized Weber test result. Vestibular examination was normal. Nose-and-throat examination findings were normal. There were no palpable lymph nodes. Her central nervous system examination showed normal motor power and sensory functions of all the four limbs. All cranial nerves were intact. There were no other focal areas of tenderness in rest of the body parts.
She was advised for a thorough hematological, biochemical, and hormonal analyses. All reports were within normal range. Her blood and serum tests are mentioned in [Table 1].
The patient was advised for high-resolution computed tomography (HRCT) temporal bone and magnetic resonance imaging of head. Imaging [Figure 1] and [Figure 2] revealed bony defect in squamous portion of the right temporal bone, with features suggestive of osteomyelitis.
|Figure 1: Computed tomography scan showing defect in squamous portion of the right temporal bone|
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|Figure 2: Magnetic resonance imaging showing high-signal intensity in the right temporal region|
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Based on the clinical findings and imaging reports, a diagnosis of the right temporal bone osteomyelitis was made. The patient was planned to start on a 6-week course of capsule ampicillin/cloxacillin (1 g) 6 hourly a day and tablet diclofenac (50 mg) 8 hourly a day for 2 weeks along with a proton pump inhibitor. She was followed up after 6 weeks. The patient was completely asymptomatic with no localized tenderness at the end of the treatment course and was considered cured. However, no imaging was done to confirm our conclusion.
| Discussion|| |
Osteomyelitis of the temporal bone is not a common entity. Resulting from infection of the marrow cavity, the process can be triggered by various factors, primarily by the pathogenic organism itself or secondarily by the superimposed infection following trauma to the bone. Not much has been mentioned in the literatures about the osteomyelitis of temporal bone affecting the squamous portion following trauma.
Diagnosis of a temporal bone osteomyelitis requires a high index of suspicion, especially when a patient presents with otalgia, headache, or multiple cranial nerve palsies. Imaging to prove the extension of infection to bony structures is generally necessary to establish the diagnosis of osteomyelitis. Imaging modalities include HRCT, technetium 99m-medronate methylene diphosphonate bone scanning, and gallium citrate Ga-67 scintigraphy. CT defines the location and the extent of the disease at initial evaluation.
Treatment includes broad-spectrum antibiotics for not <6 weeks. Surgical debridement should be considered if there is no response to medical therapy. Literatures have shown efficacy of various groups of antibiotics such as aminoglycosides, third-generation cephalosporins such as ceftazidime, and quinolones such as ciprofloxacin. These groups of antibiotics primarily target Pseudomonas aeruginosa and are appropriate in cases with malignant otitis externa. However, our case was different. Since in our patient, osteomyelitis was triggered by trauma and the culture sensitivity could not be established, we planned to start antibiotic empirically covering both Gram-positive and Gram-negative organisms. Ampicillin/cloxacillin was the drug chosen for a duration of 6 weeks. Furthermore, repeat imaging should have been done for the confirmation of diagnosis, but considering the cost and patient's affordability, it was restrained.
| Conclusion|| |
Posttraumatic osteomyelitis of temporal bone may present with persistent headache with a preceding history of trauma. A high index of suspicion is required and imaging will help in concluding the diagnosis. Pus for culture/sensitivity has to be taken whenever accessible. The first line of management should always be a long course of antibiotics for at least 6 weeks, with surgery being reserved for those cases with extensive disease and those not responding to antibiotics.
Declaration of patient consent
The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.
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Conflicts of interest
There are no conflicts of interest.
| References|| |
Toulmouche MA. Observations on cerebral otorrhea: Latest considerations (in French). Gautte Med Paris 1838;6:422-6.
Meltzer PE, Kellemen G. Pyocyaneus osteomyelitis of the temporal bone. Mandible and zygoma. Laryngoscope 1959;60:1300-16.
Chandler JR. Malignant external otitis. Laryngoscope 1968;78:1257-94.
Fitzgerald RH Jr., Brewer NS, Dahlin DC. Squamous-cell carcinoma complicating chronic osteomyelitis. J Bone Joint Surg Am 1976;58:1146-8.
Amorosa L, Modugno GC, Pirodda A. Malignant external otitis: Review and personal experience. Acta Otolaryngol Suppl 1996;521:3-16.
Prasad SC, Prasad KC, Kumar A, Thada ND, Rao P, Chalasani S, et al.
Osteomyelitis of the temporal bone: Terminology, diagnosis, and management. J Neurol Surg B Skull Base 2014;75:324-31.
[Figure 1], [Figure 2]