{"status":"ok","message-type":"work","message-version":"1.0.0","message":{"indexed":{"date-parts":[[2026,5,19]],"date-time":"2026-05-19T06:09:14Z","timestamp":1779170954864,"version":"3.51.4"},"reference-count":14,"publisher":"Frontiers Media SA","license":[{"start":{"date-parts":[[2026,5,19]],"date-time":"2026-05-19T00:00:00Z","timestamp":1779148800000},"content-version":"vor","delay-in-days":0,"URL":"https:\/\/creativecommons.org\/licenses\/by\/4.0\/"}],"content-domain":{"domain":["frontiersin.org"],"crossmark-restriction":true},"short-container-title":["Front. Med."],"abstract":"<jats:sec>\n                    <jats:title>Background<\/jats:title>\n                    <jats:p>Skull base osteomyelitis (SBO) is an uncommon but life-threatening complication of necrotising otitis externa, typically affecting older adults with diabetes. Presentation is often non-specific, and diagnosis is frequently delayed.<\/jats:p>\n                  <\/jats:sec>\n                  <jats:sec>\n                    <jats:title>Case<\/jats:title>\n                    <jats:p>\n                      An 84-year-old man with type 1 diabetes, vascular comorbidity and advanced frailty presented with a fall preceded by dizziness on standing. He reported a 6-month history of recurrent falls and severe postural light-headedness; persistent right-sided otalgia and offensive otorrhoea had been present for the preceding 3\u202fmonths, indicating that the ear symptoms followed the orthostatic symptoms. On admission, he had marked postural hypotension despite withdrawal of potentially contributory medication and initiation of fludrocortisone. Initial CT brain imaging was normal, and the sepsis screen was inconclusive. Ten days after admission, he developed a new right-sided facial palsy. Repeat CT head was again unremarkable. Shortly afterwards, he had profuse bleeding from the right ear. Otoscopy, performed for the first time in hospital by an otorhinolaryngology specialist, showed florid otitis externa with a polypoid lesion in the external auditory canal. MRI with skull base sequences revealed extensive necrotising otitis externa with right skull base osteomyelitis extending towards the carotid canal, while CT venography later showed adjacent inflammatory change around the petrous internal carotid artery. Ear swab culture grew\n                      <jats:italic>Pseudomonas aeruginosa<\/jats:italic>\n                      sensitive to gentamicin and intermediately sensitive to ceftazidime. High-dose intravenous ceftazidime (2\u202fg three times daily) was started shortly after diagnostic MRI, microbiological sampling, and infectious diseases review, approximately 10\u202fdays after admission, and was continued for approximately 7\u202fweeks. Inflammatory markers normalised, and repeat swab cultures were negative. However, follow-up MRI demonstrated partial resolution of the primary osteomyelitis focus with extension into the temporomandibular fossa. Severe postural hypotension persisted despite withdrawal of potentially contributory medication, together with non-pharmacological measures and fludrocortisone. The patient became increasingly deconditioned and bed-bound, developed prolonged delirium and stage 3 acute kidney injury, and died in hospital.\n                    <\/jats:p>\n                  <\/jats:sec>\n                  <jats:sec>\n                    <jats:title>Conclusion<\/jats:title>\n                    <jats:p>This case highlights skull base osteomyelitis as an important differential diagnosis in older, frail patients with diabetes who present with chronic ear disease, cranial neuropathy and otherwise unexplained refractory orthostatic hypotension. In this patient, inflammation adjacent to the carotid canal\/carotid sinus region may have contributed, although causality could not be proven, and alternative contributors to autonomic dysfunction remained possible.<\/jats:p>\n                  <\/jats:sec>","DOI":"10.3389\/fmed.2026.1795309","type":"journal-article","created":{"date-parts":[[2026,5,19]],"date-time":"2026-05-19T05:40:45Z","timestamp":1779169245000},"update-policy":"https:\/\/doi.org\/10.3389\/crossmark-policy","source":"Crossref","is-referenced-by-count":0,"title":["Case Report: When infection mimics autonomic failure: postural hypotension secondary to skull base osteomyelitis"],"prefix":"10.3389","volume":"13","author":[{"given":"Avik","family":"Roy","sequence":"first","affiliation":[{"name":"Department of Medicine for the Elderly, Hull University Teaching Hospitals NHS Trust","place":["Hull, United Kingdom"]}],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"Ayuni Zahirah","family":"Zahar","sequence":"additional","affiliation":[{"name":"Department of Medicine for the Elderly, Hull University Teaching Hospitals NHS Trust","place":["Hull, United Kingdom"]}],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"Zin","family":"Lin Tun","sequence":"additional","affiliation":[{"name":"Department of Medicine for the Elderly, Hull University Teaching Hospitals NHS Trust","place":["Hull, United Kingdom"]}],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"Saikat","family":"Mandal","sequence":"additional","affiliation":[{"name":"School of Medicine, University of Nottingham","place":["Nottingham, United Kingdom"]},{"name":"NIHR Nottingham Biomedical Research Centre, Nottingham University Hospitals NHS Trust and the University of Nottingham","place":["Nottingham, United Kingdom"]}],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"Arkadeep","family":"Dhali","sequence":"additional","affiliation":[{"name":"Sheffield Teaching Hospitals NHS Foundation Trust","place":["Sheffield, United Kingdom"]},{"name":"Faculty of Health, Imperial College London","place":["London, United Kingdom"]}],"role":[{"role":"author","vocabulary":"crossref"}]}],"member":"1965","published-online":{"date-parts":[[2026,5,19]]},"reference":[{"key":"ref1","doi-asserted-by":"publisher","first-page":"156","DOI":"10.1148\/rg.2021200046","article-title":"Diagnosis of skull base osteomyelitis","volume":"41","author":"\u00c1lvarez J\u00e1\u00f1ez","year":"2021","journal-title":"Radiographics"},{"key":"ref2","doi-asserted-by":"publisher","first-page":"rjae282","DOI":"10.1093\/jscr\/rjae282","article-title":"Navigating the complexity of skull base osteomyelitis: a case study and comprehensive review","volume":"2024","author":"Horache","year":"2024","journal-title":"J Surg Case Rep"},{"key":"ref3","doi-asserted-by":"publisher","first-page":"342","DOI":"10.1097\/MOO.0000000000000745","article-title":"Current management of skull base osteomyelitis","volume":"29","author":"Auinger","year":"2021","journal-title":"Curr Opin Otolaryngol Head Neck Surg"},{"key":"ref4","doi-asserted-by":"publisher","first-page":"bcr0620103109","DOI":"10.1136\/bcr.06.2010.3109","article-title":"Recurrent syncope and chronic ear pain","volume":"2010","author":"Clegg","year":"2010","journal-title":"BMJ Case Rep"},{"key":"ref5","doi-asserted-by":"publisher","first-page":"381","DOI":"10.1111\/coa.14041","article-title":"Systematic review of the diagnosis and management of necrotising otitis externa: highlighting the need for high-quality research","volume":"48","author":"Takata","year":"2023","journal-title":"Clin Otolaryngol"},{"key":"ref6","doi-asserted-by":"publisher","first-page":"987","DOI":"10.1016\/j.otc.2023.06.004","article-title":"Skull Base osteomyelitis: historical perspective, diagnosis and management update","volume":"56","author":"Hamiter","year":"2023","journal-title":"Otolaryngol Clin N Am"},{"key":"ref7","doi-asserted-by":"publisher","first-page":"538","DOI":"10.1002\/lio2.1035","article-title":"Cranial nerve palsy prevalence and associated factors in patients with malignant otitis externa","volume":"8","author":"Zonnour","year":"2023","journal-title":"Laryngoscope Investig Otolaryngol"},{"key":"ref8","doi-asserted-by":"publisher","first-page":"575","DOI":"10.1002\/ar.23829","article-title":"The carotid sinus nerve-structure, function, and clinical implications","volume":"302","author":"Porzionato","year":"2019","journal-title":"Anat Rec (Hoboken)"},{"key":"ref9","doi-asserted-by":"publisher","first-page":"102792","DOI":"10.1016\/j.autneu.2021.102792","article-title":"Recommendations for tilt table testing and other provocative cardiovascular autonomic tests in conditions that may cause transient loss of consciousness: consensus statement of the European Federation of Autonomic Societies (EFAS) endorsed by the American autonomic society (AAS) and the European academy of neurology (EAN)","volume":"233","author":"Thijs","year":"2021","journal-title":"Auton Neurosci"},{"key":"ref10","doi-asserted-by":"publisher","first-page":"431","DOI":"10.1007\/s13760-019-01110-w","article-title":"Skull base osteomyelitis: factors implicating clinical outcome","volume":"119","author":"Soko\u0142owski","year":"2019","journal-title":"Acta Neurol Belg"},{"key":"ref11","doi-asserted-by":"publisher","first-page":"340","DOI":"10.53854\/liim-3203-8","article-title":"Microbial spectrum, management challenges, and outcome in patients with otogenic skull base osteomyelitis","volume":"32","author":"AlSharhan","year":"2024","journal-title":"Infez Med"},{"key":"ref12","doi-asserted-by":"publisher","first-page":"589","DOI":"10.1097\/MNM.0000000000001847","article-title":"18F-FDG PET imaging for treatment response assessment and management guidance in patients with skull base osteomyelitis","volume":"45","author":"Saxena","year":"2024","journal-title":"Nucl Med Commun"},{"key":"ref13","doi-asserted-by":"publisher","first-page":"576","DOI":"10.1258\/0022215041615100","article-title":"Use of magnetic resonance imaging as the primary imaging modality in the diagnosis and follow-up of malignant external otitis","volume":"118","author":"Ismail","year":"2004","journal-title":"J Laryngol Otol"},{"key":"ref14","doi-asserted-by":"publisher","first-page":"514","DOI":"10.1177\/0003489418778056","article-title":"Malignant otitis externa outcomes: a study of the university HealthSystem consortium database","volume":"127","author":"Hatch","year":"2018","journal-title":"Ann Otol Rhinol Laryngol"}],"container-title":["Frontiers in Medicine"],"original-title":[],"link":[{"URL":"https:\/\/www.frontiersin.org\/articles\/10.3389\/fmed.2026.1795309\/full","content-type":"unspecified","content-version":"vor","intended-application":"similarity-checking"}],"deposited":{"date-parts":[[2026,5,19]],"date-time":"2026-05-19T05:41:08Z","timestamp":1779169268000},"score":1,"resource":{"primary":{"URL":"https:\/\/www.frontiersin.org\/articles\/10.3389\/fmed.2026.1795309\/full"}},"subtitle":[],"short-title":[],"issued":{"date-parts":[[2026,5,19]]},"references-count":14,"alternative-id":["10.3389\/fmed.2026.1795309"],"URL":"https:\/\/doi.org\/10.3389\/fmed.2026.1795309","relation":{},"ISSN":["2296-858X"],"issn-type":[{"value":"2296-858X","type":"electronic"}],"subject":[],"published":{"date-parts":[[2026,5,19]]},"article-number":"1795309"}}