Skull base osteomyelitis (SBO) is a rare and potentially life-threatening infection often complicated by multiple cranial nerve palsies. A case of SBO, complicated by multiple cranial nerve palsies, in which antimicrobial therapy was guided by gallium scintigraphy uptake, resulting in a favorable clinical course without recurrence, is reported. A 79-year-old man presented with right otalgia, otorrhea, hearing loss, and facial nerve paralysis. He was initially diagnosed with otitis media-related labyrinthitis and treated with antibiotics and corticosteroids. Two months later, the patient developed recurrent otorrhea and multiple cranial neuropathies. Contrast-enhanced computed tomography/magnetic resonance imaging revealed bone destruction and strong enhancement from the petrous apex to the clivus and nasopharynx. The patient was diagnosed with SBO and was administered intravenous antibiotics for 2 months. Oral antibiotics were continued for approximately 3 months post-discharge. Gallium-67 scintigraphy revealed near-complete resolution 5 months after discharge; accordingly, oral antibiotics were discontinued at that time. No recurrences were observed during 18 months of follow-up.

This case highlights the importance of considering SBO in patients with cranial neuropathies, even when initial middle ear findings improve. Long-term culture-directed antibiotics guided by functional imaging, such as gallium scintigraphy, can optimize treatment, prevent recurrence, and improve outcomes in severe cases.