ArticleFrontiers in medicine2026
Case Report: When infection mimics autonomic failure: postural hypotension secondary to skull base osteomyelitis.
Article in Frontiers in medicine, 2026. The graph could read no effect estimate from its abstract, so it casts no vote on the map. Not yet cited in PubMed.
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Abstract
Background: 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. Case: 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 months, 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 Conclusion: 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.
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