What is the best course of action for a patient with tenderness along the lateral left skull base, considering their age, medical history, and other symptoms?

Evaluation and Management of Tenderness Along Lateral Left Skull Base

Obtain MRI of the brain and skull base with gadolinium contrast to evaluate for skull base pathology, cranial nerve involvement, or infectious/inflammatory processes, particularly if red flag symptoms are present. 1, 2

Initial Clinical Assessment

The presence of tenderness along the lateral skull base requires systematic evaluation for serious underlying pathology:

• Assess for red flag symptoms including fever, neurological deficits (cranial nerve palsies, motor weakness), severe or persistent headache, visual changes, hearing loss, facial weakness, or constitutional symptoms (weight loss, night sweats) 1, 2
• Examine for cranial nerve dysfunction, particularly cranial nerves VII-XII which traverse the skull base, including facial nerve function, hearing assessment, and evaluation for lower cranial nerve palsies 1
• Palpate for point tenderness over the mastoid, temporal bone, and skull base regions to localize the area of maximal tenderness 1, 3
• Evaluate for signs of infection including otorrhea, mastoid swelling, or external auditory canal inflammation that could indicate complicated otitis externa progressing to skull base osteomyelitis 1

Diagnostic Imaging Strategy

When Imaging is Indicated

MRI of the brain and skull base with gadolinium is the preferred initial imaging modality when red flags are present or skull base pathology is suspected 1, 2:

• MRI provides superior soft tissue contrast for evaluating skull base lesions, cranial nerve pathways, and early marrow involvement in infectious or inflammatory processes 1, 4
• Gadolinium enhancement helps distinguish vascular lesions, identify inflammatory processes, and evaluate the extent of skull base involvement 1
• Include imaging from skull base to thoracic inlet if cranial nerve palsy is present to evaluate the entire course of affected nerves 1

CT Temporal Bone Considerations

CT temporal bone with IV contrast should be obtained if skull base osteomyelitis is suspected or to evaluate bony erosion 1:

• CT excels at demonstrating bone erosion and is particularly useful for evaluating complicated otitis externa progressing to necrotizing otitis externa/skull base osteomyelitis 1
• High-resolution CT (HRCT) is preferred for defining anatomical extension of osteomyelitis 1

When Imaging May Not Be Required

No immediate imaging is needed for acute mechanical neck pain without red flags, radiculopathy, or skull base-specific symptoms 1, 2

Differential Diagnosis to Consider

The location of tenderness along the lateral skull base suggests several important diagnostic possibilities:

• Skull base osteomyelitis/necrotizing otitis externa in patients with diabetes or immunosuppression, which carries high morbidity and mortality 1
• Inflammatory pseudotumor of the lateral skull base, which commonly involves the mastoid bone (61.5% of cases) and presents with nonspecific symptoms 5
• Skull base neoplasms including leiomyomas, angioleiomyomas, or metastatic lesions, which may present with local tenderness and cranial nerve deficits 1, 6
• Glossopharyngeal neuralgia presenting as jolting pain behind the ear radiating down the neck 2
• Temporomandibular joint syndrome with referred otalgia to the periauricular area 2

Management Algorithm Based on Clinical Presentation

If Red Flags Present (Fever, Cranial Nerve Deficits, Immunosuppression)

1. Obtain MRI brain and skull base with gadolinium immediately 1, 2
2. Add CT temporal bone with IV contrast if skull base osteomyelitis suspected 1
3. Check inflammatory markers (ESR, CRP) and complete blood count 1
4. Initiate empiric antibiotics if skull base osteomyelitis suspected, as this condition requires long-term antimicrobial therapy 1
5. Urgent ENT and neurosurgery consultation for potential biopsy or surgical intervention 1, 5

If No Red Flags Present

1. Trial of conservative management with NSAIDs for pain control 2
2. Re-evaluate within 2-4 weeks if symptoms persist 2
3. Obtain MRI if symptoms worsen or fail to improve with conservative management 1, 2

Critical Pitfalls to Avoid

• Do not delay imaging in diabetic or immunocompromised patients with skull base tenderness, as necrotizing otitis externa/skull base osteomyelitis has high morbidity and mortality 1
• Do not assume benign etiology without imaging when cranial nerve deficits are present, as this indicates skull base involvement requiring urgent evaluation 1
• Do not rely on CT alone for soft tissue evaluation of skull base pathology, as MRI provides superior visualization of early marrow involvement and soft tissue extension 1, 4
• Do not overlook the need for skull base to thoracic inlet imaging when vocal cord paralysis or lower cranial nerve palsies are present 1