Osteomyelitis in the head and neck.
ABSTRACT All bones of the facial skeleton and spine are susceptible to osteomyelitis due to various predisposing conditions. Current radiological tools are sufficient to provide adequate diagnosis. Treatment can be conservative resection of the diseased bone with adequate clearance in all cases except in cases of osteomyelitis due to osteoradionecrosis (ORN) where resection has to be more radical.
In today's antibiotic era, osteomyelitis in the head and neck is a rare occurrence. Dealing with osteomyelitis in head and 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, and esthetics. Our purpose was to analyze the behavior of osteomyelitis in the head and neck bones and its management.
A total of 84 cases of osteomyelitis in head and neck were reviewed in a 10-year period. Pus for culture, antibiotic sensitivity, and radiology were the main investigations. A medical line of treatment was effective in acute cases. Surgery was opted for in chronic cases.
Mandible, frontal bone, cervical spine, maxilla, temporal bones, and nasal bones were involved, in descending order of frequency, i.e. the mandible was the most common bone affected. Nine patients were diagnosed as having acute osteomyelitis (11%); 75 were diagnosed as having chronic osteomyelitis (89%). Radiation-induced ORN leading to osteomyelitis was the most common cause of osteomyelitis of the mandible (13 of the 32 cases; 41%). Odontogenic infections and chronic sinusitis each gave rise to osteomyelitis in 3 of 10 cases (30%) of the patients with osteomyelitis of the maxilla. Chronic sinusitis was the main cause of frontal bone osteomyelitis in all 20 cases (100%). Tuberculosis (10 of 15 cases; 67%) and malignancy (5 of 15 cases; 33%) were the main predisposing factors in cervical spine osteomyelitis. Malignant external otitis (MEO) with diabetes mellitus was an underlying factor in all four cases of osteomyelitis of the temporal bone. Of the 18 patients with a diagnosis of ORN, the mandible was found to be the most susceptible bone (13 cases; 72%), followed by the maxilla (four cases; 22%) and cervical spine (1 case). Acute osteomyelitis responded to antibiotics. Sequestrectomy was carried out in all chronic cases but in cases of ORN more radical surgery was performed.
- [Show abstract] [Hide abstract]
ABSTRACT: A reliable imaging technique is needed for follow-up of patients with temporal and facial osteomyelitis. Clinical outcome in 20 patients with suspected osteomyelitis of the temporal/mastoid, calvarium, and mandible facial bones was evaluated with 30 combined In-WBC/Tc-99m MDP bone single photon emission computed tomographic (SPECT) scans and 27 computed tomographic scans. Simultaneous dual-tracer 25-minute SPECT scans were acquired 18 to 20 hours after radiotracer injection by use of a three-detector system. Diagnosis of the 20 patients (age range, 3 to 74 years) included 8 with facial osteomyelitis, 6 with malignant otitis externa, 3 with mandibular osteomyelitis, and 3 with calvarial osteomyelitis. Diagnosis was confirmed by biopsy/culture results in 18 patients and by endoscopic and clinical evaluation in 2 patients with initial negative scans. Of the 30 In-WBC/MDP scans, 15 were true-positive, 13 true-negative, 1 false-negative, and 1 equivocal. Of a total of 27 CT scans, 9 were true-positive, 5 false-negative, and 1 equivocal in patients with biopsy-proven osteomyelitis. Three computed tomographic scans were false-positive and 1 was equivocal in patients without osteomyelitis, because of concurrent postoperative bone abnormalities. Additionally, 8 computed tomographic scans were true-negative. These results suggest that dual In-WBC/Tc-99m MDP bone SPECT scintigraphy provides an accurate imaging modality for diagnosis and follow-up of temporal and facial osteomyelitis when existing clinical or postoperative bone changes make it difficult to detect active osteomyelitis by computed tomographic scan.Otolaryngology Head and Neck Surgery 08/1995; 113(1):36-41. · 1.73 Impact Factor
Article: Topische Immunmodulation[Show abstract] [Hide abstract]
ABSTRACT: HintergrundRezidivierende Exazerbationen bei chronischer Otitis externa stellen für den Behandler eine besondere Herausforderung dar. Untersucht werden sollte die therapeutische Wirksamkeit einer neuen Klasse von lokal applizierbaren Immunmodulatoren mit antiinflammatorischem, nichtsteroidalem Wirkmechanismus. Patienten und MethodenIn einer prospektiven Studie an 33 Patienten erfolgte alle 2 (–3) Tage eine Streifeneinlage mit Tacrolimus-Salbe (Protopic® 0,1%), insgesamt 3-mal ein Streifenwechsel. Der Behandlungserfolg wurde durch Nachuntersuchungen, anhand einer Videodokumentation und eines standardisierten Befundbogens beurteilt. Ergebnisse28 Patienten zeigten eine signifikante Verbesserung der klinischen Symptomatik, 13 von ihnen eine komplette Heilung (Follow-up: 10–22 Monate). Bei Rezidiven (15 Fälle) waren die symptomfreien Intervalle signifikant verlängert und die Anzahl weiterer Episoden verringert. SchlussfolgerungDank ihrer sicheren und erfolgreichen antientzündlichen Wirkung stellen topische Immunmodulatoren eine neue Alternative bei chronisch therapieresistenter Otitis externa dar. BackgroundRecurrent exacerbation of chronic external otitis represents a special challenge for the attending physician. The goal of our study was to evaluate the effectiveness of novel topical immunomodulators acting through an anti-inflammatory, nonsteroidal mechanism. Patients and MethodsIn a prospective study, in 33 patients an ear wick containing tacrolimus ointment (Protopic 0.1%) was inserted every 2–3 days. Altogether, the wick was changed three times. Therapeutic outcomes were assessed by reexaminations, video-otoscopy, and a standardized findings sheet. ResultsTwenty-eight patients showed significant improvement of clinical symptoms, with 13 of them showing complete healing (follow-up 10–22 months). Relapses (15 cases) were associated with significantly extended symptom-free intervals and reduced numbers of further recurrent episodes. ConclusionsBecause of the safe and successful anti-inflammatory effects, topical immunomodulators represent a new alternative in chronic inflammatory stages of otherwise therapy-resistant external otitis.HNO 01/2008; 56(5):530-537. · 0.42 Impact Factor
- International journal of odontostomatology. 09/2010; 4(2):197-202.
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