Prasad KC, et al. Osteomyelitis in Head & Neck 1
OSTEOMYELITIS IN THE HEAD AND NECK
DR. KISHORE CHANDRA PRASAD H. M.S., D.L.O.
PROFESSOR & HEAD OF THE DEPARTMENT OF OTOLARYNGOLOGY – HEAD &
KASTURBA MEDICAL COLLEGE MANGALORE,
KARNATAKA STATE, INDIA.
HONORARY MEDICAL OFFICER, DISTRICT GOVERNMENT WENLOCK HOSPITAL,
MANGALORE, KARNATAKA STATE, INDIA.
DR. SAMPATH CHANDRA PRASAD H. M.B.B.S.
RESIDENT, DEPARTMENT OF OTOLARYNGOLOGY – HEAD & NECK SURGERY,
KASTURBA MEDICAL COLLEGE, MANGALORE,
KARNATAKA STATE, INDIA
DR. NEELA MOULI D. M.S.
RESIDENT, DEPARTMENT OF OTOLARYNGOLOGY – HEAD & NECK SURGERY,
KASTURBA MEDICAL COLLEGE, MANGALORE,
KARNATAKA STATE, INDIA
DR. SALIL AGARWAL M.S.
RESIDENT, DEPARTMENT OF OTOLARYNGOLOGY – HEAD & NECK SURGERY,
KASTURBA MEDICAL COLLEGE, MANGALORE,
KARNATAKA STATE, INDIA
AUTHOR FOR CORRESPONDENCE AND REPRINTS:
DR. H. KISHORE CHANDRA PRASAD M.S, D.L.O,
FIRST FLOOR, NETHRAVATHI BUILDING,
BALMATTA, MANGALORE - 575001
DAKSHINA KANNADA, KARNATAKA STATE, INDIA.
TEL: 91-824-09448488883, 91-824 - 2447394; 91-824-2492085
E-mail – firstname.lastname@example.org
Prasad KC, et al. Osteomyelitis in Head & Neck 2
OSTEOMYELITIS IN THE HEAD AND NECK
Purpose: In today’s antibiotic era, osteomyelitis in the head & neck is a rare occurrence. Dealing
with osteomyelitis in head & neck bones is not the same as in other bones of the body due to the
nature of the bones, complex anatomy of the region & esthetics. Our purpose is to analyze the
behavior of osteomyelitis in the head & neck bones and its management.
Materials and methods: 82 cases of osteomyelitis in head & neck in a 10-year period were
reviewed. Pus for culture, antibiotic sensitivity & radiology were the main investigations.
Medical line of treatment was effective in acute cases. Surgery was opted in chronic cases.
Results: Mandible, frontal bone, cervical spine, maxilla, temporal bones and nasal bones were
involved. The mandible was the most common bone affected. Contagious infection and radiation
were most common predisposing factors.
Conclusion: The Head and Neck surgeon should process a high degree of suspicion to promptly
diagnose osteomyelitis of various bones in head and neck, to initiate an early treatment, which
includes long-term appropriate antibiotics & surgery.
Osteomyelitis (OM), head & neck, mandible, osteoradionecrosis (ORN), cervical spine, nasal
bone, temporal bone
Prasad KC, et al. Osteomyelitis in Head & Neck 3
Although it has been suggested that osteomyelitis is a disappearing disease, it is still commonly
encountered in areas of poor socioeconomic condition1 and is a major problem in the developing
countries. The general lack of awareness of the prevalence of the disease and its features often
leads to a misdiagnosis and delay in treatment. Early detection of this condition and prompt
attention will pre-empt the need for a surgical intervention in an otherwise protracted course of
illness. In the head & neck, osteomyelitis is more difficult to treat because of the anatomical
region and also due to esthetic considerations. The incidence of osteomyelitis in the head & neck,
its etiology, clinical features, management and results, have not been studied in detail, though
there is literature available on the diseases affecting individual bones. Osteomyelitis can be
defined as an inflammatory condition of the bone, which begins as an infection of the medullary
cavity, rapidly involves the haversian systems and extends to involve the periosteum of the
affected area.2 Infection occurs as a result of a bacteremia, an inoculation during aseptic or bone
surgery or a contiguous infectious focus. Conditions altering the vascularity of the bone like
radiation, malignancy, osteoporosis, osteopetrosis & Pagets disease predispose to osteomyelitis.
Systemic diseases like diabetes, anaemia and malnutrition that cause concomitant alteration in
host defenses profoundly influences the course of osteomyelitis.2 The consequences of this
infection range from the minor nuisance of a draining tract, to a pathologic fracture at the
infected site, to the possible malignant transformation to carcinoma.3 The bones reported to be
involved by osteomyelitis in the head and neck are mandible, frontal bone, cervical spine,
maxilla, nasal bone, the temporal bone and the skull base. The diagnosis is mainly made by
clinical presentations like discharging sinus, periosteal thickening and tenderness, confirmed by
Prasad KC, et al. Osteomyelitis in Head & Neck 4
the presence of sequestrum or bony destruction with or without pathological fractures on
radiography. Imaging with radionuclide scans, computerized tomography and magnetic resonance
imaging are used for early detection, when the diagnosis of osteomyelitis is equivocal or to help
gauge the extent of bone and soft tissue infection. Surgical treatment involves debridement of
necrotic bone and tissue, obtaining appropriate cultures, managing dead space, and when
necessary, obtaining bone stability. Acute cases respond very well to medical line of treatment.
Others require surgical intervention with long-term broad-spectrum antibiotic therapy for four to
six weeks. Here we present our experience in managing 82 patients with osteomyelitis of various
bones in the head and neck.
Prasad KC, et al. Osteomyelitis in Head & Neck 5
MATERIALS AND METHODS
Ours is a retrospective & prospective study of 82 cases of osteomyelitis (OM) in head and neck
done over a period of 10 years from 1994 to 2004. This included osteomyelitis of the mandible,
frontal bone, cervical spine, maxilla, nasal bone and the temporal bone. The age, gender and
medical history of these patients were recorded. All patients underwent a thorough clinical
examination. Typical clinical findings included localized bone pain, erythema, draining sinus
tracts, fluctuating abscesses, deformity, instability and local signs of impaired vascularity, range
of motion, presence of a previous open wound and ear discharge. In addition to local signs of
inflammation and infection, signs of systemic illness, including fever, irritability and lethargy
were used to diagnose osteomyelitis. Once clinically diagnosed as osteomyelitis, the following
relevant investigations were used depending on the site.
1. Radiological investigations like orthopantomogram, plain x-ray skull bones, X-ray neck
antero-posterior & lateral view
2. Computed Tomography Scan
3. Pus from the discharging sinus for culture and sensitivity
4. Wide bore needle aspiration cytology in cases of ambiguous diagnosis
5. Biopsies from the granulation tissues for histopathological examination
6. Routine blood examination, blood sugar analysis and ELISA for HIV
Once the diagnosis and the extent of disease was confirmed, patients were treated either
medically, surgically or both depending on the site, chronicity and severity of the lesion. Patients
with acute OM (abrupt onset of symptoms) were empirically treated with a combination of
intravenous Inj. Crystalline Penicillin 10-20 lakh units 6th hourly, Inj. Gentamycin 80 mg 8th
Prasad KC, et al. Osteomyelitis in Head & Neck 6
hourly & Inj. Metrogyl 500 mg 8th hourly for 15 days followed by oral antibiotics for not less
than four weeks and sometimes up to six weeks.
In cases of chronic OM (where the symptoms were more long-standing and the patients had
already received prior courses of antibiotics), surgical intervention was made with peri-operative
antibiotic cover. Surgical procedure depended on the site of the lesion. In all cases, the pus was
sent for microbiological study. The granulation tissues, if any, were sent for histopathological
study. All patients were supplemented with a high protein, multivitamin diet and general nursing
care. Antituberculous therapy and anti-retroviral therapy were initiated in cases of tuberculosis &
Surgeries on the mandible
In chronic OM, a wound debridement, sequestrectomy and saucerization was done with
intermedullary wiring and fixation with bone grafts, plates & screws wherever possible. In cases
of ORN, a radical sequestrectomy or hemimandibulectomy was done.
Surgeries on the frontal bone
Limited OM due to acute sinusitis was dealt with Functional Endoscopic Sinus Surgery (FESS)
for drainage of pus. More destructive disease processes were dealt with an external Lynch
Howarth operation. In all cases, the pus in the frontal sinus and the subperiosteal abscess was
evacuated and the diseased bone was debrided. The diseased sinus mucosa was removed.
Surgeries on the cervical spine
Wide bore needle aspiration was done two to three times as and when there was collection of pus
that gave rise to symptoms while the patients were put on i.v antibiotics. When aspirations failed,
patients were taken up for external surgical approach. An incision was given along the anterior
border of sternocleidomastoid. The sternocleidomastoid and carotid sheath were retracted
Prasad KC, et al. Osteomyelitis in Head & Neck 7
laterally. The abscess in the retropharyngeal space was drained. The body of the vertebrae was
inspected, debrided and granulations and pus were sent for histopathological analysis.
Surgeries on the maxilla
Most of the cases presented with considerable bony destruction. In such cases, sequestrectomy or
total maxillectomy (in cases of osteoradionecrosis) was done.
Surgeries on the nasal bone
An external incision was applied at the naso-labial fold and flap elevated to reach the affected
area. The diseased bone was then excised.
Surgeries on the temporal bone
A post aural incision was given under GA. The skin with the periosteum was elevated over the
mastoid & along the external auditory canal (EAC). The necrosed cartilage and the osteomyelitic
bone segment of the EAC & the mastoid bone were excised in both cases without opening up the
whole of the mastoid. A wide meatoplasty was done. Antibiotic pack was placed and changed
every two days till the wound healed. One of the patients received hyperbaric oxygen therapy.
All patients were kept on regular follow up.
Prasad KC, et al. Osteomyelitis in Head & Neck 8
RESULTS AND OBSERVATIONS
Age & sex predilection for patients with OM – Of the 82 patients with osteomyelitis (OM) in
our study, the age, sex and site predilection are shown in Table No.1. Males predominated. Age
ranged from 15 yrs (nasal OM) to 70 yrs (mandiblular OM). In our study the bones involved by
osteomyelitis in decreasing order of frequency are mandible, frontal bone, cervical spine,
maxilla, nasal bones and the temporal bone.
Predisposing factors in patients with OM – Some patients had more than one predisposing
factors. The mandible was found to be most susceptible for osteoradionecrosis (ORN) (41%)
followed by maxilla (40%) and cervical spine (1 case) (Table 2). Malignancy (28%) and
odontogenic (22%) causes were other main predisposing factors in mandible. Odontogenic
infections & chronic sinusitis each gave rise to osteomyelitis in 30% of the patients with OM of
the maxilla. Chronic sinusitis was the main cause of frontal bone osteomyelitis (100%).
Tuberculosis (67%) and malignancy (33.33%) were the main predisposing factors in cervical
spine osteomyelitis. Trauma predisposed to osteomyelitis of the nasal bones in two cases while a
long-standing ulcer was the cause in another case. Diabetes mellitus with malignant otitis externa
were the main predisposing factors in two cases of temporal bone OM.
Contiguous infections were an underlying condition in 28 of the 82 cases (34%) of OM of the
bones in the head & neck. Contiguous infections include chronic sinusitis in most cases,
rhinosporidiosis in one of the cases of OM of the maxilla, malignant otitis externa in the OM of
the temporal bone and other nonspecific infections in cases of OM of the mandible. Radiation
was an underlying condition in 18 of the 82 cases (22%); malignancy in 14 (17%); diabetes
Prasad KC, et al. Osteomyelitis in Head & Neck 9
mellitus in 12 (15%); tuberculosis in 11 (13%); odontogenic infections in 10 (12%) and trauma in
5 (6%) cases.
Clinical features in patients with OM – Nine patients were diagnosed to have acute OM
including five cases of OM of mandible, two of OM of maxilla and two cases of OM of the
frontal bone based on abrupt onset of symptoms. 73 were diagnosed to have chronic OM.
Clinical features of patients with OM of the mandible included pain (32 cases), tenderness (32),
swelling (30), discharging sinus with sequestra (28) (Figure 1), periosteal thickening (23),
lymphadenopathy (12), trismus (11), bony irregularity (11), loosening of tooth (10) and
pathological fractures (5).
Patients with OM of the frontal bone had headache (20), sinus tenderness (20) swelling over the
floor of the sinus (14) and pus in the middle meatus (15).
Patients with OM of the cervical spine had tenderness over the cervical spine (13), neck rigidity
(12), torticollis (10), bulge over the posterior pharyngeal wall (14), stridor (5) and neurological
Patients with OM of the maxilla had pain (10), swelling over the maxilla (10), tenderness (8),
bony irregularity (8), discharging sinus with sequestra (7), loosening of tooth (5),
lymphadenopathy (5) and trismus (1) (Figure 2).
Patients with OM of the nasal bones had swelling (3), discharging sinus (3) & tenderness (3)
Patients with OM of the temporal bone had severe pain (2), tragal tenderness (2), ear discharge
(2), facial nerve palsy (1) and extradural abscess (1).
Investigations in OM – A preliminary X-ray was done in all cases. In OM of the mandible,
orthopantomogram revealed bony destruction, sequestra and altered contours of mandible in 27
Prasad KC, et al. Osteomyelitis in Head & Neck 10
of the 32 cases and pathological fractures in the remaining five cases. In frontal sinus OM, X-ray
PNS showed bony destruction, sequestra, periosteal or extradural abscess and haziness of the
sinus in 14 of the 20 cases and loss of scalloping in six. In maxillary sinus OM, X-ray PNS
showed haziness of maxillary sinus in 9 of the 10 cases along with bony destruction of the
anterior wall in seven cases. In all 15 cases of cervical vertebral OM, X-ray soft tissue of the
neck revealed widening of pre-vertebral space with destruction of one or more vertebral bodies
and inter-vertebral discs. CT scan done in eight cases showed destruction of body of vertebra,
pre-vertebral abscess in all cases and compression of spinal cord due to abscess in two cases
(Figure 4). CT-guided biopsy was done in two cases.
Pus from the diseased area was sent for culture and sensitivity in 75 of the 82 cases. The
organisms cultured were Staphylococcus aureus in 38 cases (51%), Streptococci in 22 cases
(29%), Pneumococci in 12 cases (16%), Mycobacterium Tuberculosis in 11 cases (15%),
Klebsiella and Pseudomonas in three (4%) and Bacteroids in one case (1.33%). ELISA for HIV
was positive in one of our patients who had osteomyelitis of both mandible and maxilla. Biopsy
was taken in 74 cases from granulations in and around the discharging sinuses from mandible,
frontal bone, vertebral bodies, maxilla, nasal bone and the external auditory canal.
Histopathological studies from the 75 biopsies done in chronic OM revealed chronic
inflammation in 49 patients (60%), malignancy in 14 cases (23%), tuberculosis in 11 cases (15%)
and rhinosporidiosis in one case of maxillary OM (1.33%).
Treatment modalities in OM – Five patients with acute mandibular OM were managed
medically with intravenous antibiotics and analgesics followed by dental extraction. In chronic
OM, most of the patients had received prior courses of antibiotics that failed to resolve the
condition. Hence, surgical treatment that was opted essentially involved removal of the diseased
Prasad KC, et al. Osteomyelitis in Head & Neck 11
segment of bone along with antibiotics for six weeks. This included sequestrectomy with
saucerization in 13 patients. Intermedullary wiring and fixation with plates & screws was done in
seven cases where a segment of the mandible had to be excised (figure 5). In cases of ORN, a
radical sequestrectomy was done in seven patients and hemimandibulectomy in six patients
(figure 6). One patient refused surgery and was put on broad-spectrum antibiotics and the patient
was lost for follow up. There was no recurrence of OM in any of the other cases.
Six patients with limited frontal bone OM underwent FESS for drainage of pus. Two of these
were OM secondary to acute frontal sinusitis and were cured completely. Four cases of OM due
to chronic sinusitis did not respond and had to undergo Lynch Howarth operation. 14 patients
primarily underwent a Lynch Howarth operation. All the patients received a course of antibiotics
for six weeks. All the patients were cured completely of the disease.
Of the 10 patients with cervical spine OM due to tuberculosis, two underwent wide bore needle
aspiration and eight underwent external surgical approach for drainage of the abscess and
sequestrectomy of the body of the cervical vertebrae, followed by anti-tuberculous therapy. All
the patients received a course of antibiotics for six weeks in cases. All patients had a cervical
collar for a minimum period of one year along with physiotherapy. All patients responded well to
this treatment. Five patients had secondary metastatic deposits in the spine leading to OM and
abscess. Of the five, one patient had undergone radiation six months earlier and he was subjected
to wide bore aspiration and antibiotics. Two other patients underwent external drainage following
failure of wide bore needle aspiration. All the three subsequently succumbed to the disease. One
patient also had lung metastasis and died within a few days of admission.
Two patients with acute OM of the maxilla due to chronic sinusitis who were managed medically
responded well to the treatment. Four patients with chronic OM underwent sequestrectomy and
Prasad KC, et al. Osteomyelitis in Head & Neck 12
had no recurrence on follow up. Total maxillectomy was done in four cases of ORN. All of them
subsequently succumbed to the disease.
All the three cases of nasal bone OM were managed by sequestrectomy followed by broad-
spectrum antibiotics for six weeks.
Both the patients with temporal bone OM underwent debridement followed by wide meatoplasty
along with antibiotics for six weeks. One of the patients did not respond to debridement and
developed facial nerve palsy and meningitis. He then received hyperbaric oxygen therapy and
debridement once after this following which the disease showed complete regression.
Prasad KC, et al. Osteomyelitis in Head & Neck 13
The term ‘osteomyelitis’ which was introduced by Nelaton4 in 1844, implies an infection of the
bone and marrow. Osteomyelitis most commonly results from bacterial infections, although
fungi, parasites and viruses can affect the bone and marrow. Though osteomyelitis in long bones
of the body can be comparable to the flat and irregular bones of the head & neck in ways of
etiopathology, their management varies in the head & neck due to anatomical & cosmetic
considerations. Various classifications of OM are proposed,5,6,7,8 the most useful being acute,
subacute & chronic OM. Abrupt onset of symptoms and signs during the initial stage of infection
indicates an acute OM. If this phase passes without complete elimination of infection, subacute
or chronic OM can become apparent9. Chronicity of osteomyelitis is multifactorial. The relative
avascular and ischemic nature of the infected region and sequestrum produces an area of lowered
oxygen tension as well as an area that antibiotics cannot penetrate. The lowered oxygen tension
effectively reduces the bacteriocidal activities of polymorpholeukocytes10 and also favors the
conversion of a previously aerobic infection to one that is anaerobic. The diffusion rate of
antibiotics into dead bone is so low that frequently it is impossible to reach the organisms
regardless of the external concentration.11 This may lead to ineffective antibiotic concentrations
at the site of infection despite serum levels indicating therapeutic concentrations. The increased
frequency of antibiotic usage as well as the wider variety of antibiotics has resulted in the
emergence of resistant organisms, often to multiple antibiotics. In addition, chronic osteomyelitis
tends to be polymicrobial both in terms of aerobic and anaerobic microorganisms10. An open
wound or sinus tract is always a potential source of superinfection. In instances where proper
antibiotic therapy was started to treat the organisms initially recovered from the infected site,
Prasad KC, et al. Osteomyelitis in Head & Neck 14
there is the potential for successive infections with more virulent, more resistant, or opportunistic
Osteomyelitis of the mandible – This is the most common bone involved by OM in the head
and neck. Inflammatory lesions are by far the most common pathologic condition of the jaws.
The jaws are unique from other bones of the body in that the presence of teeth creates a direct
pathway for infectious and inflammatory agents to invade bone by means of caries and
periodontal disease.12 The predisposing factors for OM include dental infection, trauma,
especially compound fractures, surgery, infections of oral cavity leading to periosteites, infections
from furuncles or lacerations. In some cases no causes can be identified and hematogenous
spread is presumed to be the origin. Conditions leading to decreased bone vascularity like
malignancy, tuberculosis and radiation can also predispose to OM. There have been reports
describing OM due to infection from decubitus ulcers. Dental infections are the most frequent
cause of acute OM of the jaws.13 In a study by Teher AAY14 of 88 cases of OM of the mandible,
he found trauma to be the most common predisposing cause for OM attributing it to the geo-
political difficulties. In our series we found that radiotherapy followed by malignancy preceded
odontogenic infections & trauma as a predisposing cause for chronic OM. Doses above 50 Gy
usually are required to cause osteoradionecrosis and mandible is the most commonly involved
bone. In both acute & chronic forms, the most common sites of the mandible are the posterior
bodies of the mandible.12 Clinical features are same for both the acute & chronic variants except
that in chronic OM these symptoms are milder. Clinical features are deep intense pain, high
intermittent fever, parasthesia or anaesthesia of the lip due to involvement of the mental nerve,
pus and sequestra exudates through fistulae, trismus, regional lymphadenopathy, induration of
Prasad KC, et al. Osteomyelitis in Head & Neck 15
soft tissue, wooden character of bone with pain and tenderness on palpation. The associated teeth
may be mobile and sensitive to percussion.12
Culture and sensitivity of the discharge usually reveals staphylococcus, streptococcus,
pneumococcus and anaerobes like bacteroides. Orthopantomogram shows scattered areas of bone
destruction, sequestra / involucrum, alteration in the contour of the mandible and occasionally
pathological fractures. CT scan is a superior tool especially in cases with dense sclerotic bone. To
detect early OM, a two-phase Technetium bone scan followed by a gallium citrate scan may help
to confirm diagnosis.12 Histopathological examination of the surgical specimen or granulation
tissues helps us in accurate diagnosis of the predisposing factors like malignancy, tuberculosis or
other granulomatous conditions, while ELISA test helps in the diagnosis of HIV infection. The
treatment protocol consists of a combination of surgery and antimicrobial treatment. The aim of
surgery is elimination of all infected, necrotic tissue and to facilitate drainage. The type of
surgery depended on the extension of osteomyelitic process, which includes sequestrectomy &
radical sequestrectomy. In cases of ORN, Hao, et al.,15 and Shaha, et al.,16 have advocated the
necessity of radical debridement and resection of dead bone, though how much bone needs to be
removed is a matter of debate.
Osteomyelitis of the frontal bone – Osteomyelitis of the diploic frontal bone is most often the
result of infections of the frontal sinus. It can also be due to trauma or surgery on the anterior
wall of the sinus & be aggravated by swimming. The thin compact bony floor is the first to be
involved. Osteomyelitis may be fulminating type (Figure 7), spreading type, localized type or
sclerosing type. The fulminating type develops after surgery or virulent sinusitis and is
characterized by massive tissue death and gross sequestration. High fever, headache and swelling
over the forehead are seen. The disease can localize to form subperiostial abscess or spread to
Prasad KC, et al. Osteomyelitis in Head & Neck 16
cause intracranial extension. The spreading type is less dramatic than fulminant, presenting as
high fever, headache and cellulites of orbit and forehead. Sequestra and multiple puffy tumours
(Potts) form over the frontal bone, which can later spread to the parietal and occipital bones, and
even to the whole calvarium if untreated (necrotising calvarium). The localizing type is usually
due to chronic sinusitis causing local necrosis of the bone and a subperiostial abscess.
Sequestrum does not occur. Sclerosing osteitis is a form of localized disease due to longstanding
abscess leading to sclerosis of frontal sinus. According to Zielnik-Jurkiewicz B et al.,17 teenagers
are the most frequently affected. In our series, we found that the 20-40 and 40-60 yr age group
were the most commonly affected. X-ray of the paranasal sinuses shows subperiosteal and
extradural abscess, moth eaten appearance of the bone and sequestra. The imaging modality of
choice for detection of complications is CT scan. Bone scanning will detect osteomyelitis but
cannot define soft tissue suppuration.18 Acute cases can be managed by long-term broad-
spectrum antibiotics for 4-6 weeks. Surgical treatment consists of drainage of subperiostial
abscess and removal of sequestra by an external Lynch Howarth operation. Functional
endoscopic sinus surgery can be used to drain the sinus in less severe lesions. Bondar' VP et al.,19
recommend three therapeutic approaches: closed healing of the wound after dissecting the fistula
and removal of osteomyelitic bone lesions, drainage of frontal sinuses via the frontonasal
anastomosis, and tamponade of the cavity, that developed after the resection of the pathological
focus, with the host muscle tissue. He suggests that small osteomyelitic lesions of the frontal
bone can be removed by dissecting the fistula, 3-4 day draining and suturing the wound. We
advocate endoscopic approach for drainage of pus in limited OM secondary to acute sinusitis and
external approach for all cases of OM due to chronic sinusitis along with aggressive antibiotic
therapy in all cases. In advanced osteomyelitis of the frontal sinus walls, preference should be
Prasad KC, et al. Osteomyelitis in Head & Neck 17
given to the neurosurgical approach with a wide revision of the pathological focus, removal of
the mucosa, suppurative epidural layers and further formation of an enlarged frontonasal
anastomosis and prolonged drainage of the cavity for 24 to 30 days. When treating osteomyelitis
of frontal squama with its significant enlargement, the most efficient method is tamponade of the
cavity formed by the hard membrane, skin and bone with the host muscle. Another condition that
needs to be noted is chronic recurrent multifocal osteomyelitis (CRMO) in which the frontal and
sphenoid bones can be involved.20 Characterized by a prolonged and fluctuating course of
osteomyelitis at different sites, CRMO is self-limited, although sequelae can occur. The
diagnosis is one of exclusion. Recognition of CRMO can prevent aggressive surgical treatment.
Osteomyelitis of the cervical spine – It is very uncommon because of the relatively small
amount of spongy tissue in the vertebral body. Cervical vertebral osteomyelitis (CVO) is usually
hematogenous in origin21. The majority of patients have medical risk factors and comorbidities
that include diabetes, trauma, drug abuse and infectious processes in extraspinal areas.22 It can
also be secondary to tuberculosis, malignancy and radiotherapy. Tuberculosis was the most
common cause of CVO in our series. Alan et al23 reports & discusses osteoradionecrosis of
cervical vertebra and occipital bone in patients treated by radiotherapy for malignancies of the
head and neck. Lumbar and dorsolumbar spine is most commonly affected by tuberculosis while
cervical and upper dorsal spine is rarely involved. It presents commonly as a pre or paravertebral
cold abscess but presenting anteriorly causing airway obstruction is very rare. The patients
present with varying symptoms like restricted and painful neck mobility, torticollis, trismus,
posterior pharyngeal wall bulge, fluctuant neck swelling and stridor. Patients can also have
neurological deficits due to the pressure effect of cold abscess over the spinal cord, this being the
case in some of our patients. The diagnosis of CVO can be accomplished in most cases by using
Prasad KC, et al. Osteomyelitis in Head & Neck 18
plain x-ray films and computerized tomography scans. Nevertheless, preferential use of magnetic
resonance imaging in cases in which there is a neurological deficit is helpful in identifying
epidural compressive processes.22 Treatment is evacuation of the cold abscess either by a wide
bore needle aspiration or by an external surgical approach followed by antimicrobial therapy for
4-6 weeks or longer. Antituberculous therapy is initiated in case of co-existing tuberculosis. In
addition to abscess drainage, neurologic decompression or stabilization may be necessary. In
patients with secondaries in the spine with OM, drainage of pus is done along with antibiotics for
6 weeks and chemotherapy.
Osteomyelitis of the maxilla – Though OM of maxilla is rare, it is more frequently seen in
infants and children, as more bone is available in the maxilla during infancy. During the
preantibiotic era, phossy jaw and other forms of chemical OM resulted from medicines like
mercury, arsenic, bismuth and environmental pollutants like lead, phosphorus used in safety
matches. The predisposing factors for OM of maxilla include dental infections, maxillary
sinusitis, trauma, or conditions which compromise the blood supply of the bone like radiotherapy
and malignancy. Cassatly MG et al.,24 reported an iatrogenic thermal LASER injury that lead to
bone necrosis and OM of maxilla. Liu CJ et al.,25 reported actinomycosis in a patient treated for
osteoradionecrosis of maxilla while receiving radiotherapy for nasopharyngeal carcinoma.
Likewise, in our series, we also had a case of osteoradionecrosis of maxilla secondary to
radiotherapy and super infection with rhinosporidiosis. OM can occur in infants secondary to
hematogenous spread from umbilical cord or boils, or from contaminated feeding bottles or
unclean nipples. Clinical features are fever, rigors, pain and tenderness over the maxilla,
halitosis, loosening of teeth, discharging sinuses, numbness of cheek, cellulitis of face, occular
symptoms like epiphora, proptosis, impaired eyeball movements occasionally blindness and
Prasad KC, et al. Osteomyelitis in Head & Neck 19
lymphadenopathy. Radiograph shows multiple small radiolucent patches with sequestrum after
10 days. In acute OM medical therapy is effective which includes parenteral broad-spectrum
antibiotics, high protein and multivitamin diet for 4-6 weeks. Chronic cases require
sequestrectomy. In advanced osteoradionecrosis, total maxillectomy may be necessary.
Osteomyelitis of nasal bone – This is a very rare entity. It is usually associated with
osteomyelitis of neighboring bones like maxilla. We had one case of osteomyelitis of maxilla and
nasal bone due to a long-standing ulcer and two cases following trauma. Wadhera R et al., 26 have
reported OM of the nasal bones due to tuberculosis. Nasal OM can be clinically diagnosed by the
discharging sinus, periosteal thickening and bony tenderness. X-ray of nasal bones may show a
hypodense area and no special investigation is required. Local debridement along with a course
of broad-spectrum antibiotics for a period of one month gives good results.
Osteomyelitis of temporal bone – Osteomyelitis of temporal bone is a rare disease that occurs
secondary to malignant otitis externa (MEO) or chronic suppurative otitis media. Chandler27 in
1968 was credited with coining the term malignant otitis externa. The term malignant is used to
emphasize the serious nature of this infection, as in the original historical report six of the 13
patients died. The disease occurs predominantly in elderly diabetics and the causative agent is
almost uniformly Psuedomonas aerugenosa. The other predisposing factors include
immunocompromised individual, radiotherapy, malignancy and trauma. Schweitzer, et al.,28
listed warning signs of temporal bone osteomyelitis as 1) deep pain (temporal, parietal, post
auricular, retroorbital); 2) intermittent, foul otorrhea and spiking fever; 3) preauricular cellulites;
4) woody induration of pinna; 5) chronic mastoid cutaneous-fistula; 6) fibrotic mastoid
granulation tissue; 7) intermittent facial twitching suggestive of facial canal dehiscence and 8)
persistent leukocytosis and an elevated sedimentation rate. Plain radiograph in temporal bone
Prasad KC, et al. Osteomyelitis in Head & Neck 20
OM shows sequestra. CT scan is helpful in accurate diagnosis and may show sclerosis of
temporal bone. Other modalities include Technetium Tc 99m medronate methylene
diphosphonate bone scanning, and gallium citrate Ga 67 scintigraphy. Treatment consists of
broad-spectrum antibiotics for not less than three months along with surgical debridement and a
wide meatoplasty. Local treatment of the auditory canal includes meticulous cleaning and
debridement plus topical application of antimicrobial agents. Strict diabetic control is necessary.
Despite the reported efficacy of prolonged systemic antibiotic therapy, treatment failure do occur
due to tissue hypoperfusion and hypoxia where the use of hyperbaric oxygen (HBO) increases
wound PO2 levels, enhances phagocytic oxidative killing of aerobic micro-organisms, promotes
angioneogenesis and osteoneogenesis. Treatment consists of 100% O2 given for 90 minutes at 2.5
atm absolute pressure five days a week, 20 times as an adjuvant therapy 29. Dudkiewicz M et
al.,30 describes osteomyelitis of the temporal bone beyond the mastoid framework as an unusual
complication of acute mastoiditis. The disorder is characterized by a failure to respond both
locally and systemically to accepted medical and surgical therapy, persistent fever and high levels
of inflammatory markers and computerized tomography findings of temporal bone destruction.
He advocates antibiotics and at least a cortical mastoidectomy, which provides good prognosis.
Osteomyelitis of the skull base – Skull Base Osteomyelitis (SBO) is an aggressive, invasive,
indolent infection with potentially significant morbidity and mortality. The most common form
of SBO is MEO. The course of antibiotic therapy varies from a short 2 to 3 weeks for MEO in
children to 6 months for SBO in adults. Baseline CT and radionucleide scans will attempt to
differentiate Necrotizing Otitis Externa (NOE) from MEO and SBO. Noyek et al.,31 conclude
that radionuclide bone and gallium scanning can make a significant physiologic imaging
Prasad KC, et al. Osteomyelitis in Head & Neck 21
contribution to the more effective management of patients with OM of the temporal bone, skull
base, paranasal sinuses and mandible. The role of surgery is not very well defined except taking
biopsy and local debridement of necrotic tissue and drianage of abscess or formal
tympanomastoid procedures like MRM or radical mastoidectomy with partial petrous apicectomy
and embolectomy for jugular vein thrombosis. Concern exists that surgery may enhance MEO
and SBO by opening up facial spaces and new tissue plane with spreading infection. Prolonged
antibiotic therapy with third generation cephalosporins or oral fluro-quinolones has been the
principal means of therapy.
Prasad KC, et al. Osteomyelitis in Head & Neck 22
Osteomyelitis in the head & neck is a difficult disease to treat. OM can affect the most important
bones in the face and the skull base. The treating Otolaryngologist must harbor a high index of
suspicion in patients with predisposing conditions to effectively diagnose OM early when it can
be treated completely. Simple investigations like X-rays and CT scans generally suffice for
diagnosis but bone scans will detect early disease. Long-term appropriate antimicrobial therapy
suffices in acute cases. Surgical intervention with adequate debridement of diseased bone along
with antibiotics gives the best result in chronic OM. Regular follow-up examinations and
radiology of the affected region are part of the standard therapy. As yet, in some areas of the
Asia-Pacific region, the incidence of OM is still relatively high, and statistics emphasize the need
to prepare for a resurgence of bone and joint infections due to the spread of the human
immunodeficiency virus & other acquired immune suppression diseases.
Prasad KC, et al. Osteomyelitis in Head & Neck 23
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19. Bondar' VP, Nekhlopochin SN. Surgical treatment of osteomyelitis of the frontal bone and
the walls of the frontal sinus. Vestn Otorinolaringol. 1989 Jan-Feb;(1):42-5.
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Prasad KC, et al. Osteomyelitis in Head & Neck 27
FIGURES AND TABLES
Figure 1 – Osteoradionecrosis of the mandible with discharging sinus
Figure 2 – Osteoradionecrosis of the maxilla
Figure 3 – OM of the nasal bone involving the maxilla
Figure 4 – CT scan of OM of the cervical spine showing erosion of the vertebral body with
compression of the trachea and spinal cord
Figure 5 – Intermedullary wiring and fixation with plates & screws
Figure 6 – Operative specimen of osteoradinecrosis of the mandible
Figure 7 – Frontal bone OM; fulminating type
Table No. 1 – Age and sex predilection for patients with OM
Site 0 – 20 yrs 20 – 40 yrs 40 – 60 yrs > 60 yrs
M F M F M F M F
2 2 3 14 6 3 2 32
1 2 5 3 4 4 1 20
2 1 8 2 2 15
1 2 1 4 1 1 10
1 1 1 3
4 3 11 9 31 15 6 3 82
Table No. 2 – Predisposing factors in patients with OM
Prasad KC, et al. Osteomyelitis in Head & Neck 28 Download full-text
2 20 3 1 2 28
Radiation 13 1 4 18
Malignancy 9 5 14
Diabetes 4 3 2 1 2 12
Tuberculosis 1 10 11
Odontogenic 7 3 10
Trauma 2 1 2 5