Skull Base Osteomyelitis: Contemporary Concepts in Diagnosis and Management with a Neurosurgical Perspective

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Abstract Skull base osteomyelitis (SBO) is an uncommon but potentially fatal infection of elderly, diabetic, or otherwise immunocompromised patients that poses major diagnostic and therapeutic challenges. Typical SBO arises as an extension of necrotizing external otitis involving the temporal bone, whereas atypical or central SBO involves the clivus and central skull base in the absence of overt otologic disease and frequently mimics malignancy. This systematic review synthesizes contemporary evidence on SBO, with particular emphasis on central disease and on issues relevant to Asian neurosurgical practice, where the burden of diabetes, tuberculosis, and invasive fungal infection is substantial. PubMed/MEDLINE, EMBASE, Scopus, and the Cochrane Library were searched from inception to October 2025 for case reports, case series, observational studies, and clinical trials reporting clinical, microbiological, imaging, management, or outcome data in radiologically or histologically confirmed SBO; a narrative synthesis was undertaken because of heterogeneity in study design, definitions, and outcome reporting. SBO predominantly affects older males in the fifth to eighth decades, with diabetes mellitus and other conditions impairing microvascular perfusion and immune function as major risk factors. Typical SBO remains largely Pseudomonas aeruginosa–driven, whereas central SBO shows a broader spectrum dominated by Staphylococcus aureus, Pseudomonas, and an increasing proportion of mucormycosis and Aspergillus infection, with culture–negative disease in up to one–third of cases. High–resolution CT and contrast–enhanced MRI are complementary for early detection and disease mapping, while fluorodeoxyglucose positron emission tomography (PET)/CT or PET/MRI, documented in only a subset of predominantly recent series, has emerged as a sensitive tool for diagnosis and treatment monitoring. Long–course, high–dose antimicrobial therapy (6–20 weeks, including at least 6–8 weeks of parenteral therapy) is the cornerstone of treatment; surgery is mainly reserved for diagnostic biopsy, drainage, and debridement, and extensive debridement has not consistently improved cure rates. Mortality has fallen but remains up to 20 to 30% in some cohorts, and many survivors have persistent cranial neuropathies. Early multidisciplinary assessment, protocol–driven imaging, culture–directed prolonged therapy, and PET–guided decisions on treatment cessation are likely to reduce relapse and improve long–term outcomes.