1. SKULL BASE OSTEOMYELITIS: Fungal vs
Bacterial infection ( C.C Blyth et al, Clin
Microbiol Infect 2011;17:306-311
DR KAMLESH K DUBEY
Deptt. Of Otorhinolaryngology
AIIMS, New Delhi

2. INTRODUCTION
 First described in 1959 by Meltzer and Kelemen
 Skull-base osteomyelitis (SBO) is an uncommon condition
 Associated with significant morbidity and mortality
 Described most often as a complication of malignant otitis
externa secondary to Pseudomonas aeruginosa infection
 May also occur in the absence of malignant otitis externa and
with pathogens other than Pseudomonas
aeruginosa, including fungi.
 Fungal SBO : Aspergillus, Scedosporium spp.

3. INTRODUCTION
 RISK FACTORS:
a) Increasing age
b) Diabetes mellitus
c) Microvascular disease
d) Immunodeficiencies: primary / acquired
 Fungal SBO has also occurred in the absence of these
traditional risk factors

4. INTRODUCTION
 ESSENTIALS OF MANAGEMENT OF SBO:
I. Early diagnosis
II. Identification of the causative pathogens
III. Prompt initiation of appropriate antimicrobial or surgical
therapies
IV. Continuation of therapy for an adequate period

5. AIMS & OBJECTIVES
 Compare the epidemiology and clinical characteristics of
bacterial and fungal SBO
 Aiming to identify unique risk factors and clinical associations

6. Material and Methods
 Study design: retrospective study over 18 years(1990-2007).
 Cases identified following interrogation of medical records
using International Statistical Classification of Diseases and
related Health Problems definitions
 Otorhinolaryngology, Histopathology and Microbiology data
bases were also queried for cases of SBO.
 Approval for the study was obtained from Sydney West Area
Health Service Human Research Ethics Committee

7. Material & Methods
 For each patient clinical information was recorded on a
standardized form and included:
a) Patient demographics
b) Comorbidities & predisposing factors within 90 days
c) Likely source of infection : ear, sinuses, other
d) Clinical features
e) Results of microbiological and histopathological investigations
f) Treatment
g) Hospital length of stay
h) Clinical outcomes

8. Materials & Methods
Results of computed tomography(CT), magnetic resonance
imaging (MRI) and bone scan Technitium-99m/gallium citrate
(Ga)-67 were assessed by radiologist who was blinded to other
results.

9. Materials & Methods
 Definitions :
A. Definite : skull base infection in patients with localizing
symptoms/signs at presentation who had:
i. Radiological or scintigraphic features indicative of bone
erosion and/or infection.
ii. Isolation and/or visualization of pathogen from affected
bone(s) and surrounding tissue.

10. Materials & Methods
Probable SBO:
Infection in patients with localizing symptoms/signs with
evidence of SBO on imaging studies, but from whom a
pathogen was recovered from clinical specimens other than
bone or tissue (e.g. ear swabs) or in whom a definitive
response to antimicrobial therapy was evident.
Primary source of pathogen:
Assigned according to patient clinical features in context of
accompanying microbiological and radiological results.

11. Materials & Methods
Statistical analysis :
I. Clinical data analyzed using SPSS, version 15.0.0 ( SPSS
Inc., Chicago, IL USA).
II. Variables associated with SBO caused by bacteria were
compared with those associated with fungal SBO
III. Analyses were also performed to examine risk
factors, presenting symptoms, causative pathogen, and
treatments administered associated with survival at 6
months.
IV. Univariate analyses were performed using a Student’s t-test
(for continuous variables) or Chi-square or Fisher’s exact
tests( for categorical variables)
V. p<0.05 was considered statistically significant

12. RESULTS
 DEMOGRAPY:
i. -From over 500 patients identified through search, 21
patients met the case definition of SBO.
ii. 15 had proven SBO and six had probable infection.
iii. Mean patient age was 58 years (range 26-80 years)
iv. 66.7% -male

13. RESULTS
Predisposing factors:
i. Diabetes mellitus was most frequent predisposing factor---
-12 patients ; 57%
ii. Chronic otitis externa 33%
iii. chronic sinusitis 29%
iv. Immunosuppression 10%
v. Trauma or surgery 30%

14. RESULTS
 Median time to presentation:
i. Bacterial - 26.3 weeks (4.2-28.5)
ii. Fungal - 8.1 weeks (0.6-15.5)

15. CLINICAL BACTERIAL FUNGAL SIGNIFICANCE
FEATURES
FEVER 3 (30.0%) 6 (54.5%) NS
HEADACHE 4 (40.0%) 8 (72.7%) NS
RESULTS
DEAFNESS 7 (70.0%) 2 (18.2%) p 0.03
EAR PAIN 8 ((80.0%) 2 (18.2%) p<0.009
EAR DISCHARGE 8 (80.0%) 1 (9.1%) p<0.002
SINONASAL PAIN 1 (10.0%) 8 (72.7%) p<0.008
FACIAL OR 1 (10.0%) 7 (63.6%) P 0.024
PERIORBITAL
SWELLING
NASAL 3 (30.0%) 9 (81.8%) p 0.03
STUFFINES OR
DISCHARGE
CRANIAL NERVE 5 (50.0%) 5 (45.5%) NS
INVOLVEMENT
EYE/ORBIT 0 2 (18%) -
INFECTION

16. RESULTS
SITE OF INFN BACTERIAL FUNGAL SIGNIFICANCE
EAR DISEASE 8 (80.0%) 2 (18.2%) p<0.02
SINUS 0 9 (81.8%) p<0.04
DISEASE
TRAUMATIC/U 2 (20.0%) 0 NS
NCERTAIN

17. THERAPY BACTERIAL FUNGAL SIGNIFICANCE
RECEIVED
SURGERY 5 (50.0%) 11 (100%) p<0.02
RESULTS
ANTIBACTERI 10 (100%) 6 (54.5%) P<0.04
AL THERAPY
ANTIFUNGAL 0 11 (100%) p<0.001
THERAPY
HYPERBARIC 0 2 (18.2%) NS
O2 THERAPY

18. RESULTS
OUTCOME BACTERIAL FUNGAL SIGNIFICANCE
SURVIVAL(6 7/7 (100%) 7/11 (63.7%) NS
MONTHS)

19. DISCUSSION
 SBO is uncommon infection
 Complication of uncontrolled otogenic, odontogenic or sinus
infection
 Large adequately powered epidemiological studies have not
been published
 Present study, using strict case definitions for SBO, reveals
that fungi accounted for a significant proportion : approx.
50% of SBO
 Significant morbidity of SBO in the present study is
consistent with previous reports

20. DISCUSSION
 Almost half (48%) of patients had persistent cranial nerve
abnormalities, other reports 21-43%.
 Extension into brain uncommon.
 Cerebral involvement has been associated with high mortality
in reported cases despite surgical intervention.
 As reported in other studies, diabetes mellitus and chronic
ear disease.
 Confirmation of underlying chronic sinusitis as a risk factor
for SBO is required.

21. DISCUSSION
 Otogenic Pseudomonas aeruginosa infection accounted for
50% of bacterial SBO.
 SBO complicating malignant otitis externa is almost uniformly
caused by this bacterium
 Other bacteria and fungi are also important causes of SBO
 Fungal SBO is increasingly reported in literature
 Apparent rise reflect apparent rise in use of
immunosuppressive therapy
 Importantly however fungal SBO may also occur in
immunocompetent individuals

22. DISCUSSION
 Most cases of fungal SBO has been due to Aspergillus or
Scedosporium spp., reportedly arising from contiguous
spread of ear infection
 Authors observed that fungal SBO occurred primarily as a
result :
i. Underlying sinus infection
ii. Zygomycetes were most frequent pathogen
 Reasons fro relative prevalence Zygomycetes not readily
apparent but are of interest
 Zygomycetes are well known pathogens of invasive fungal
sinus

23. DISCUSSION
 Although not statistically significant, majority >70% fungal
SBO patients had diabetes (known risk factor for
zygomycetes)
 There may be differences in clinical risk factors and
associations for bacterial and fungal SBO

24. DISCUSSION
Fungal SBO features:
 More likely to have underlying chronic sinus disease
 Symptoms attributable to invasive sinus infection
a. Sino-facial pain
b. Periorbital swelling
c. Nasal stuffiness/discharge
 Absence of purulent ear discharge was a sensitive (91%)
predicator of underlying fungal SBO
 Clinical failure with antibacterial therapy should also promt
similar considerations

25. DISCUSSION
TREATMENT OPTIONS:
 Antimicrobial therapy
i. Because P. aeruginosa infection predominates in most
case series of bacterial SBO
ii. Initiation of antibiotics with activity against P. aeruginosa is
appropriate pending microbiological diagnosis
iii. Because zygomycetes were responsible for >50% of
fungal SBO use of regimens including high-dose
amphotericin B formulations is advised pending definitive
diagnosis

26. DISCUSSION
TREATMENT OPTIONS:
ROLE OF SURGERY:
I. Likely influenced by pathogen
II. Early surgery is associated with improved survival in
patients with improved survival in patients with
zygomycosis
III. Aggressive surgical debridement is recommended in
fungal SBO
IV. Probably unnecessary in patients with bacterial SBO

27. Skull base osteomyelitis: diagnostic and
therapeutic challenges in atypical presentation( A.
Singh et al. Otolaryngology head and neck surgery
volume 133, Issue 1, july 2005;121-125
 Objectives :
To document diagnostic and management difficulties in
masked skull base osteomyelitis secondary to malignant otitis
externa, emphasis on establishing diagnostic criteria in
recurrence.
 Study design:
Retrospective analysis of 3 cases of inadequately treated
malignant otitis externa in elderly diabetic individuals leading to
recurrence and atypical manifestations of skull base
osteomyelitis on contralateral side with or without multiple
cranial nerve involvement.

28.  Result :
i. Two of 3 cases died despite aggressive treatment
ii. One case treated successfully with combination of
antipseudomonal microbial drugs for 8-12 weeks and
hyperbaric oxygen therapy
iii. Major complications observed were:
a. thrombosis of lateral sinus and IJV thrombosis
b. Meningitis
c. Ophthalmoplegia
d. Blindness
e. Cervical spine erosion
f. Paralysis of all cranial nerve except 1st C.N

29. Management of osteomyelitis of anterior skull
base and craniovertebral junction
(Yadranko Ducic. Otolaryngology Head Neck Surg
2003;128:39-42)
 Objectives :
To determine patient demographics, identify predisposing
factors and determine efficacy of treatment for nonotologic
osteomyelitis of skull base and craniovertebral junction
 Study design:
All patients with biopsy proven diagnosis of osteomyelitis of
skull base treated by author from 1997 through 2001 were
retrospectively evaluated

30.  Results :
i. Six patients were identified on review
ii. Average age of presentation was 56.7 years (38-70 yrs.)
iii. All except one had immunocompromising condition (DM, HIV, Steroid use)
iv. Most presented with neurologic deficits associated with a destructive lesion of
osseous skull base
v. Aggressive debridement of involved bone enabled through use of broad field
standard skull base approaches were associated with clinical resolution in each
case
vi. Systemic antibacterial/antifungal therapy and medical optimization remain important
adjuncts in treatment of this group of patients
vii. In the absence of any persistent neurologic deficit and in the presence of a normal
ESR, reasonable to discontinue systemic therapy after 6 weeks
viii. Persistent elevation of ESR or a return of symptoms would mandate repeat
imaging, including gallium scanning

31.  Conclusion:
i. Nonotologic osteomyelitis of skull base and
craniovertebral junction is a locally aggressive disorder
causing lytic destruction of skull base bone often with
underlying dural enhancement
ii. Systemic immunocompromise i.e. is usually noted
iii. Aggressive surgical debridement of all affected bone
achieved through broad field exposure afforded by
modern skull base approaches
iv. Culture guided antifungal or antibiotic therapy

32. Cranial nerve involvement in malignant external
otitis: implication for clinical outcome
(Mani N et.al. Laryngoscope.2007
May;117(5):907-10)
 Objective :
To determine whether cranial nerve involvement in malignant
external otitis affects or predicts clinical outcome in terms of
morbidity and mortality
Methods:
Diagnosis of malignant otitis externa established in 23 patients
based on inclusive criteria:
i. Severe pain
ii. Otitis externa refractory to conventional treatments
iii. Diabetes mellitus
iv. Pseudomonas aeruginosa infection detection

33.  Data analysis:
Retrospective analysis of hospital records

34.  Results :
i. Ten of 23(43.5%) patients showed cranial nerve
involvement
ii. Cranial nerve affected were:
a. facial nerve (6/10)
b. Lower cranial nerves (combination of IX,X,XI,XII)
c. Extended nerve palsy(VI,VII,IX,X,XI)(1/10)
d. 13/23(56.5%) patients displayed no cranial nerve
involvement
e. All patients treated with long term, high dose antibiotic
treatment dependent on the microbiological findings

35.  Conclusions:
i. All patients with lower cranial nerve palsy recovered
normal function
ii. Facial nerve palsy was significantly less likely to improve
by medical treatment
iii. Cranial nerve involvement did not affect patient survival
rate under an optimized medical treatment

36. Otogenic cranial base osteomyelitis: a proposed
prognosis-based system for disease classification
(Lee S. et.al. Otol Neurotol.2008 Aug;29(5):666-72
 Objectives:
To review presentation , microbiology, and long term results of treating otogenic cranial
base osteomyelitis to develop a prognosis based classification system
 Patients & Method:
i. 38 patients with otogenic cranial base osteomyelitis treated between 1989-2002
ii. Patient demographics, presentation, pathogens, details of therapy, and disease
specific survival were recorded
iii. Patients stratified using Tc-99 single photon emission computerized
tomography(SPECT) at presentation in to 4 grades:
grade I- mild uptake,
grade II- focal mastoid/temporal bone uptake not reaching midline
grade III- petrous temporal bone uptake reaching midline
grade IV- uptake crossing midline, involving contralateral temporal bone

37.  Results :
i. 27/38 men
ii. Average age at presentation 65+/- 16 yrs
iii. Mean adjusted charlson comorbidity score was 5 & 63% of
patients were diabetic
iv. Most common presenting symptoms: pain, otorrhea
v. 8 patients had cranial nerve neuropathy
vi. Antibiotics were administered for 161 days, 6 patients had
concomitant surgery
vii. Avg. f/u was 33 months
viii. 3 year disease-specific survival was 76%

38. Results :
-Univariate predictors of survival were:
i. SPECT grade
ii. Fungal/mixed infections
iii. Charlson score
iv. Immune compromise
v. Cranial nerve neuropathy
-only independent predictor of survival on multivariate Cox regression was
SPECT stage at presentation
Conclusion :
Cranial base osteomyelitis is associated with significant
morbidity, mortality and requires prolonged treatment
Long term outcome can be predicted from initial SPECT scan

39. Outcomes of malignant external otitis: survival vs
mortality
(Chen CN. Acta Otolaryngol.2010;130(1):89-94)
 Objectives :
To analyze factors that affect survival of patients with MEO in
todays era of advanced antibiotics
 Patients & Methods:
Patients with a diagnosis of MEO from 1993-2005 were collected
 Results:
i. 26 patients with mean age 63.7±10.2 years were included
ii. All had history of diabetes mellitus
iii. Most frequent pathogens:
Pseudomonas aeruginosa 26.9%
Klebsiella pneumoniae 19.2%
Fungus 15.4%

40.  Results
cranial nerves were involved in 11 patients
Facial nerve was most frequently(38.46%) involved
Complications such as intracranial involvement were noted
Mastoidectomy performed in 12 patients
Total of five patients died
 Conclusion:
i. Mortality was not related to age , sex , degree of glucose
intolerance, duration of diabetes mellitus, microorganism, comorbid
disease or involvement of a single cranial nerve
ii. Intracranial involvement and multiple cranial nerves involvement
were correlated with mortality

41. Malignant otitis externa
(Matthew J. Carfrae. Et.al. Otolaryngol Clin N
Am.41;(2008):537-549
 Results :
i. With current cranial nerve involvement does not preclude
cure
ii. Patient may have incomplete recover of facial nerve function
iii. Lower cranial nerves exhibited good recovery
 Conclusion :
Poor prognostic factor include
i. Fungal infection
ii. MRI finding of middle cranial fossa and foramen magnum
dural inhancement

42. Final Discussion
 Skull base osteomyelitis: infection spread to skull base beyond
external auditory canal
 Diabetes mellitus remains most important associated condition:
Because of associated:
i. Endarteritis
ii. Microangiopathy
iii. Small vessel obliteration
Pathophysiology: Pseudomonas aeruginosa has ability to invade
vessel walls and cause a vasculitis with thrombosis and
coagulation necrosis of surrounding tissue
Cellulitis->chondritis->osteitis->osteomyelitis

43.  Pathophysiology:
i. Infection from EAC spreads to skull base through fissures of santorini,
small perforations in cartilaginous portion of EAC along floor of canal
ii. Compact bone of skull base becomes replaced with granulation tissue
leading to bone destruction
iii. Progressive spread of infection to skull base foramina causes cranial
neuropathies
iv. Most common nerve involved Facial nerve because of proximity of
stylomastoid foramen to EAC
v. Nerves of jugular foramen next to get affected
vi. More medial spread to petrous apex can affect abducens and trigeminal
nerves & further medial optic nerve
vii. Spread of infection to sigmoid sinus can lead to septic thrombosis of
sigmoid and internal jugular vein
viii. Intracranial complication: meningitis , cerebral abscess

44.  Levenson’s criteria:
i. Refractory otitis externa
ii. Severe nocturnal otalgia
iii. Purulent otorrhea
iv. Granulation tissue in external canal
v. Growth of pseudomonas aeruginosa from EAC
vi. Presence of diabetes and other immunocompromised
state
vii. Positive bone scan

45. Cohen D, Fredman P. The diagnostic criteria of
malignant external otitis. J Laryngol Otol
1987;101:216-21
A. Obligatory :
i. Pain
ii. Edema
iii. Exudates
iv. Granulations
v. Microabscess(when operated)
vi. Positive bone scan
vii. Failure of local treatment after >1week treatment
viii. Possibly pseudomonas in culture

46.  Cohen’s diagnostic criteria:
B. Occasional :
i. Diabetes mellitus
ii. Cranial nerve involvement
iii. Positive radiograph
iv. Debilitating condition
v. Old age

47. Staging system
 Corey (1985)
i. Stage I: infection
ii. Stage II: involving cranial nerves
iii. Stage III: intradural spread
 Benecke (1989):
i. Stage I: Necrotizing otitis externa: soft tissue infection
ii. Stage II: limited skull base osteomyelitis
iii. Stage III: extensive skull base osteomyelitis with involvement
of occipital bones, facial bones, and contralateral extension

48. Staging System
 Levenson’s
 Davis’s staging system(1992)
 Dr A. Thakar, D. A. Tandon, S. Bahadur, S. K. Kacker (1996)

49.  Scott-Brown’s Otorhinolaryngology Head n Neck Surgery
staging (by combining three staging system published between
1985-1991)
Stage 1: clinical evidence of malignant otitis externa with soft
tissue infection beyond external auditory meatus, but
negative 99mTc bone scan
Stage 2: soft tissue infection beyond external auditory meatus
with positive 99mTc bone scan
Stage 3: as stage 2 but with cranial neuropathy
3a: single
3b: multiple
Stage 4: as stage 2/3 with intracranial complications
(meningitis, empyema, sinus thrombosis, brain abscess)

50.  Microbiology :
A. Bacterial : P. aeruginosa, S. aureus, S. epidermis, P.
mirabilis, K. oxytoca, P. cepacia
Features of pseudomonas: gram negative obligate aerobe
contain mucoid surface layer protecting against phagocytosis
Produce: lytic enzymes- collagenase, elastase, also endotoxin
B. Fungal :
Aspergillus fumigatus, A. flavus, A. niger, Scedosporium
apiospermum,

51. ETIOLG AGE DIABET IMMUN GRANU ME/MA HISTOL
Y ES OSUPP LATION STPID OGY
RESSIO TISSUE INVOLV
N EMENT
BACTE older common common Gm-rod
RIA + -
(pseudo
mona)
FUNGA younger Less More - + Branchin
L common common g
(aspergil septated
lus) hyphae,
calcium
oxalate
crystal

52. Diagnosis :
A. History
B. Clinical examination
C. Laboratory studies: CRP , ESR
D. Imaging studies

53.  Clinical examination:
i. Tympanic membrane usually normal
ii. EAC skin soggy , edematous
iii. Scanty and foul smelling discharge
iv. Foul smelling discharge the onset of osteomyelitis
v. Patients usually dose not have fever or other
constitutional symptoms
vi. Cranial nerve palsies

54.  Imaging :
CT
MRI
NUCLEAR IMAGING

55.  CT:
i. Sensitive to bone erosion and decreased skull base density
ii. Sensitive in diagnosing:
abscess formation, involvement of
mastoid, temporomandibular joint, infratemporal fossa, petrous
apex, carotid canal
iii. Demineralization of skull base of ≥30% is identifiable on CT
scan
iv. These changes persist despite resolution of disease, therefore
poor choice for measuring treatment response
v. Inadequate for showing intracranial extension and bone marrow
involvement

56.  MRI:
i. Shows changes in soft tissue (particularly dural
enhancement and involvement of medullary spaces)
ii. Persistence of these changes despite resolution makes
MRI poor study for determining disease resolution

57.  Nuclear imaging:
Technetium Tc99m methylene diphosphonate (MDP)
scintigraphy:
i.Concentrate in areas with osteoblastic activity
ii. Allows earlier diagnosis of osteomyelitis than CT
iii.Not specific for infection

58.  Gallium Ga67 citrate :
Concentrates in areas of active inflammation through attaching
to lactoferrin (present in large quantities in leukocytes
-Binding to transferrin
-Binding to bacteria directly
-Positive for soft tissue and bone infections
-Uptake returns to normal after infection has cleared
 Several studies have suggested repeating gallium studies
every 4 weeks -to assess treatment response
-as reliable test to stop treatment if negative

59.  Indium scan:
i. Type of white blood cell scintigraphy
ii. More reliable than CT in detection
iii. Can be used to monitor response to treatment
iv. Further work needs to be performed on this modality to
elucidate its role in skull base osteomyelitis

60. CONDITION GALLIUM TECHNETIUM CT
OTITIS EXTERNA + - -
MOE + + MAY BE(-)
SBO + + +
RECURRENT (-) AFTER + + IF SBO
MOE TREATMENT
THEN +
RESOLVED MOE - + + IF SBO

61. treatment
 Long process
 Meticulous aural toilet
 Antibiotic or antifungal agents: length of treatment dictated by
patients clinical picture and inflammatory markers
 Hyperbaric oxygen:
a. For cases of intracranial spread
b. When disease is recurrent or refractory to antibiotics
c. Not enough data to provide recommendations

62. Role of surgery
 Central or atypical skull base osteomyelitis: diagnosis and
treatment( Matthew P.A et.al. Skull Base 2009;19:247-254)
a. Providing tissue that helps exclude a neoplastic pathology
b. Allowing reliable culture of microorganism responsible

63. Anti pseudomonal antibiotics
 Aminoglycosides: gentamicin , amikacin, tobramycin
 Quinolones: ciprofloxacin, levofloxacin
 Cephalosporin:
ceftazidim, cefepime, cefoperazone, cefpirome, ceftobiprole
 Antipseudomonal penicillins:
i. Carboxypenicillins: carbenicillin, ticarcillin
ii. Ureidopenicillins: piperacillin, azlocillin, mezlocillin
iii. Carbapenems: meropenem, imipenem, doripenem
iv. Polymyxins: plymyxinB, colistin
v. Monobactams: aztreonam
Route : all I.V except
Oral : fluroquinolones
Aerosolized: tobramycin, aztreonam

64. Role of surgery
 Malignant otitis externa with skull base osteomyelitis
(E. Illing et.al. JSCR.2011;5:6)
a. Surgical resection of diseased bone not recommended
due to disease spread through fascial and vascular planes
b. Biopsies can be obtained
c. Any abscess can drained
d. In the presence of facial nerve palsy, decompression is not
indicated

65. Final Conclusion
 Cranial nerve palsies in elderly diabetic or immunocompromised patient
imaging finding of a lesion causing bony destruction in skull base should
raise concern of a diagnosis of SBO
 Past history of otitis externa even if resolved before onset of presenting
symptoms should raise suspicion of an underlying infective cause
 Prompt diagnosis with nuclear and CT imaging, biopsy to rule out
malignancy and culture (aerobic, anaerobic, and fungal) is essential
 High dose oral quinolones can be started in established pseudomonal
infection
 Early diagnostic sampling recommended in patients at increased risk of
fungal SBO to enable optimal antimicrobial and surgical management
 The length of time of therapy continued guided by clinical findings,
normalization of inflammatory markers, resolution on MRI, gallium scan
findings
 Intracranial extension and multiple cranial nerves can be correlated with
mortality

66. Monitoring progress in infection
Clinical features in monitoring Severe otalgia, exudates,
granulations
Serial inflammatory markers CRP, ESR
Monitoring glycaemic control Capillary blood glucose
Monitoring imaging Gallium citrate scan/SPECT
MRI
CT
Complications Facial +/- other cranial
neuropathy, dural sinus
thrombosis, meningitis, cerebral
abscess, other