Current Indications for Surgical Intervention with Lateral Skull Base Osteomyelitis

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BACKGROUND

Lateral skull base osteomyelitis (SBO), also called malignant otitis externa or necrotizing otitis externa, is a subacute yet relentless infection of the external auditory canal and skull base most often found in elderly males and diabetics. When SBO was first described in the 1950s, the first-line therapy was surgical intervention. Over the past few decades, a transition toward culture-directed antibiotics has shifted the treatment paradigm of SBO toward primary medical management, with mortality rates now decreasing to 10-20% compared to 50% initially.

Today, the treatment of SBO involves multidisciplinary coordination between otolaryngology and infectious disease. Although the introduction of quinolone antibiotics has significantly decreased the mortality rate, the rate of surgical intervention has not drastically changed over time. The rarity of this condition leads to significant variability in practice styles among individuals and institutions, and there is no consensus on the specific indications for surgical intervention. The purpose of this best practice review was to interpret the available evidence to better define contemporary indications for surgery.

BEST PRACTICE

Key management principles of SBO include aggressive diabetes control, reversal of immunocompromised states, and prolonged antibiotics with anti-pseudomonal coverage. When it comes to contemporary indications for surgical intervention, failure of medical management has the strongest justification; however, the definition of “medical failure” and the types of surgery indicated in these circumstances are not well defined. Surgical cultures do not typically yield pathogen data that leads to a change in antibiotic regime; therefore the utility of surgery solely to obtain deeper cultures may be limited. There may be a role for surgery in the setting of aggressive features such as facial palsy and fungal involvement; however, the benefits have not been clearly demonstrated based on currently available data.