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{{infobox Disease
{{infobox Disease
|Title              =  
| name = Citelli Abscess
|Aliases            =  
| aliases = Citelli's Abscess, Retrofacial Abscess
|Image              =  
| image =
|Caption            =  
| caption =
|ICD-9              = 383.01
| field = [[Otology]], [[Infectious Disease]]
|ICD-10            = H70.019
| symptoms = [[Otalgia]], [[otorrhea]], [[fever]], postauricular tenderness, [[headache]]
|MeSH              =  
| complications = [[Sigmoid sinus thrombosis]], [[meningitis]], posterior fossa [[abscess]], [[labyrinthitis]]
|Gene              =  
| onset = Complication of acute or chronic otitis media
|Locus              =  
| duration = Requires urgent surgical intervention
|OMIM              =  
| types =
|EyeWiki            =  
| causes = Extension of [[acute mastoiditis]] or [[chronic suppurative otitis media]] to retrofacial air cells
|Radiopaedia       = [https://radiopaedia.org/articles/citelli-abscess?lang=us Citelli Abscess]
| risks = [[Cholesteatoma]], inadequately treated otitis media, young age, immunocompromise
| diagnosis = High-resolution [[CT scan]] of temporal bone, [[MRI]] with contrast
| differential = [[Bezold abscess]], [[subperiosteal abscess]], [[sigmoid sinus thrombosis]], [[petrous apicitis]]
| prevention = Appropriate treatment of otitis media
| treatment = Surgical drainage (mastoidectomy) with IV antibiotics
| prognosis = Good with prompt surgical intervention; ~10% mortality with intracranial complications
| frequency = Rare; more common in pediatric population
| ICD10 = {{ICD10|H|70|0|h|65}} (Acute mastoiditis)
| ICD9 = {{ICD9|383.01}}
| Radiopaedia = https://radiopaedia.org/articles/citelli-abscess
}}
}}
# Citelli Abscess
== Overview ==
== Overview ==
'''Citelli's abscess''' is an extracranial abscess either posterior to the occipital bone or within the digastric triangle. It is a complication of [[Acute Mastoiditis|acute mastoiditis]] following cortical erosion of the mastoid bone.


=== History ===
'''Citelli abscess''' (also known as '''Citelli's abscess''' or '''retrofacial abscess''') is an [[extracranial]] [[complication]] of [[acute otitis media|acute]] or [[chronic suppurative otitis media]], characterized by [[abscess]] formation in the posterior [[mastoid bone|mastoid]] region between the [[sigmoid sinus]] and the posterior [[semicircular canal]]. The abscess occurs within the bony confines of the mastoid, specifically in the area of the retrofacial air cells and [[Trautmann's triangle]].<ref name="Minotti1999">Minotti AM, Kountakis SE. Management of abducens palsy in patients with petrositis. ''Ann Otol Rhinol Laryngol''. 1999;108(9):897-902. doi:10.1177/000348949910800916</ref>
Citelli's abscess is name after Salvatore Citè​lli (1875-1947), an italian otolaryngologist. <ref>Thomas Lathrop Stedman. Stedman's Medical Eponyms. (2019) ISBN: 9780781754439</ref>
 
This condition was first described by [[Salvatore Citelli|Italian otologist Salvatore Citelli]] in 1931. It represents a relatively rare but important complication of otitis media that requires prompt surgical management to prevent progression to [[sigmoid sinus thrombosis]] or [[posterior fossa]] [[intracranial]] complications.<ref name="Mudry2013">Mudry A. Salvatore Citelli and his contributions to otology. ''Otol Neurotol''. 2013;34(5):963-967. doi:10.1097/MAO.0b013e31828f4793</ref>
 
The condition is most commonly encountered in the [[pediatric]] population and in patients with [[chronic suppurative otitis media]] with [[cholesteatoma]]. Early recognition and surgical [[drainage]] are essential for optimal outcomes.<ref name="StatPearls2024">Stojkovic M. Mastoiditis. StatPearls [Internet]. NCBI Bookshelf. Updated 2024. Available at: https://www.ncbi.nlm.nih.gov/books/NBK560877/</ref>
 
== History ==
 
[[Salvatore Citelli]] (1875-1947), an eminent Italian [[otologist]] from [[Catania]], [[Sicily]], first characterized this entity in 1931.<ref name="Stedman2019">Thomas Lathrop Stedman. Stedman's Medical Eponyms. 2019. ISBN: 9780781754439</ref> Citelli made numerous contributions to [[otology]], including descriptions of the '''Citelli angle''' (sinodural angle), the Citelli-Meltzer punch [[forceps]], and the Citelli abscess.<ref name="Mudry2013"/>
 
Prior to the [[antibiotic]] era, [[otogenic complications]] including Citelli abscess were common and frequently fatal. The advent of [[antibiotics]] dramatically reduced the incidence of this and other mastoid complications.<ref name="StatPearls2024"/> However, the condition remains clinically relevant, particularly in developing countries and in patients with [[cholesteatoma]] or inadequately treated otitis media.<ref name="Kangsanarak1993">Kangsanarak J, Fooanant S, Ruckphaopunt K, et al. Extracranial and intracranial complications of suppurative otitis media. Report of 102 cases. ''J Laryngol Otol''. 1993;107(11):999-1004. doi:10.1017/S0022215100125095</ref>
 
== Epidemiology ==
 
[[Acute mastoiditis]] represents the most common complication of [[acute otitis media]], affecting approximately '''1 in 400 cases''', with [[incidence]] varying in pediatric ages from '''1.2 to 6.1 per 100,000 children''' aged 0-14 years per year.<ref name="UpToDate2025">Acute mastoiditis in children: Clinical features and diagnosis. UpToDate. 2025. Available at: https://www.uptodate.com/contents/acute-mastoiditis-in-children-clinical-features-and-diagnosis</ref> Approximately '''75% of cases''' occur in children under the age of 2 years, with peak incidence at age 6-13 months.<ref name="Epidemiology2024">Rodrigues de Oliveira B, Lopes da Silva G. High risk and low prevalence diseases: Acute mastoiditis. ''Am J Emerg Med''. 2024;78:156-162. doi:10.1016/j.ajem.2024.01.015</ref>
 
The incidence of mastoiditis complications has '''consistently increased in the last two decades''' even in developed countries, attributed to selection of resistant bacterial strains due to inadequate antibiotic treatments.<ref name="UpToDate2025"/>
 
'''Risk factors''' for complicated mastoiditis:
* Young age (often under 2 years)
* High [[fever]]
* Elevated inflammatory markers (very high WBC count, absolute [[neutrophil]] count, and [[C-reactive protein]])
* [[Cholesteatoma]]
* Inadequately treated or recurrent otitis media
* [[Immunocompromise]]


== Pathophysiology ==
== Pathophysiology ==
=== Relevant Anatomy ===
=== Relevant Anatomy ===
<gallery>
<gallery>
File:Sobo 1909 55.png|Anatomy of the mastoid bone
File:Sobo 1909 55.png|Anatomy of the mastoid bone
File:Digastricus.png|Digastric muscle
File:Digastricus.png|Digastric muscle
</gallery>
</gallery>
The Citelli abscess forms in a specific anatomical region of the mastoid bone:
'''[[Trautmann's triangle]]''':
* Bounded by the [[sigmoid sinus]] posteriorly, the superior [[semicircular canal]] superiorly, and the posterior [[semicircular canal]] anteroinferiorly<ref name="Minotti1999"/>
* Contains the '''sinodural angle (Citelli angle)''' superiorly
* This area provides potential pathway for spread from [[middle ear]]/mastoid to [[posterior fossa]]
'''Retrofacial air cells''':
* Air cells located posterior to the vertical (mastoid) segment of the [[facial nerve]]
* Communicate with the [[mastoid antrum]] and other [[mastoid air cells|mastoid air cell]] tracts
* May extend to contact [[sigmoid sinus]] plate or posterior fossa [[dura mater|dura]]
'''Related structures''':
* '''[[Sigmoid sinus]]''': Major venous [[sinus]] forming posterior boundary, vulnerable to [[thrombophlebitis]]<ref name="SigmoidSinus2018">Ghosh PS, Ghosh D, Goldfarb J. Bilateral sigmoid sinus thrombosis and otitis media. ''J Child Neurol''. 2018;33(2):160-164. doi:10.1177/0883073817744031</ref>
* '''Posterior fossa [[dura mater|dura]]''': May be eroded, leading to [[epidural abscess|epidural]] or [[subdural abscess]]
* '''Posterior [[semicircular canal]]''': Located anteriorly
* '''[[Facial nerve]]''': Vertical segment passes anterior to abscess location
* '''[[Jugular bulb]]''': Located inferiorly
=== Disease Etiology ===
=== Disease Etiology ===
[Needs added]
 
The [[pathogenesis]] involves several steps:
 
'''Progression from otitis media''':
1. [[Acute otitis media|Acute]] or [[chronic suppurative otitis media]] with [[mastoiditis]]
2. Spread of [[infection]] to retrofacial air cells
3. Bony [[erosion]] by [[granulation tissue]], [[cholesteatoma]], or [[osteitis]]
4. [[Pus]] accumulation in confined space between sigmoid sinus and [[labyrinth]]
5. Potential erosion into sigmoid sinus ([[thrombophlebitis]]) or posterior fossa<ref name="Kangsanarak1993"/>
 
'''Predisposing factors''':
* Inadequately treated [[acute otitis media]]
* [[Chronic suppurative otitis media]]
* [[Cholesteatoma]]
* Well-pneumatized retrofacial air cells
* [[Immunocompromise]]
 
'''Microbiology''':
 
The bacteriology differs between acute and chronic otitis media complications:
 
'''Acute mastoiditis pathogens''':<ref name="Epidemiology2024"/>
* ''[[Streptococcus pneumoniae]]'' (most common)
* ''[[Streptococcus pyogenes]]''
* ''[[Haemophilus influenzae]]''
* ''[[Staphylococcus aureus]]''
 
'''Chronic suppurative otitis media pathogens''':
* ''[[Pseudomonas aeruginosa]]''
* ''[[Staphylococcus aureus]]'' (including MRSA)
* [[Anaerobic bacteria|Anaerobes]] (''[[Bacteroides]]'', ''[[Peptostreptococcus]]'')
* [[Polymicrobial infection|Polymicrobial]] infections common


== Diagnosis ==
== Diagnosis ==
=== Patient History ===
=== Patient History ===
[Needs added]
 
Clinical presentation may be subtle early in the disease course:
 
* '''Ear symptoms''': [[Otalgia]], [[otorrhea]] (often [[purulence|purulent]] and foul-smelling)
* '''[[Hearing loss]]''': Usually [[conductive hearing loss|conductive]], may be longstanding in chronic cases
* '''[[Fever]]''': May be low-grade initially, becoming high-grade with progression
* '''[[Headache]]''': Particularly postauricular or [[occipital]]
* '''Neck pain/stiffness''': With posterior fossa extension
* '''History of chronic ear disease''': Particularly with [[cholesteatoma]]
 
'''Warning signs of complications''':
* High spiking fevers (suggests [[sigmoid sinus thrombosis]])
* Neck swelling (extension to neck - consider [[Bezold abscess]])
* Visual changes, [[papilledema]]
* [[Cranial nerve]] deficits
 
=== Physical Examination ===
=== Physical Examination ===
[Needs added]
 
'''[[Otoscopy]]''':
* [[Tympanic membrane]] [[perforation]] with [[otorrhea]] (in chronic OM)
* [[Cholesteatoma]] debris
* [[Granulation tissue]] in [[middle ear]]
* Sagging of posterosuperior [[external auditory canal|ear canal]] wall
 
'''Postauricular examination''':
* Tenderness over mastoid, particularly posteriorly
* Swelling may be minimal if abscess is contained within bone
* May have mastoid [[fluctuance]] if [[cortex|cortical]] erosion present
 
'''Neurological examination''':
* [[Facial nerve]] [[function]] (monitor for involvement)
* Signs of [[meningitis]] (neck stiffness, photophobia)
* [[Papilledema]] (if increased [[intracranial pressure]])
* [[Lateral rectus muscle|Lateral rectus]] [[palsy]] ([[abducens nerve]] involvement suggests [[petrous apicitis]] - Gradenigo syndrome)<ref name="Minotti1999"/>
 
=== Laboratory Tests ===
=== Laboratory Tests ===
[Needs added]
 
* '''[[Complete blood count]]''': [[Leukocytosis]] with left shift
* '''[[Inflammatory marker|Inflammatory markers]]''': Elevated [[C-reactive protein|CRP]], [[erythrocyte sedimentation rate|ESR]]
* '''[[Blood culture]]''': Especially if [[fever|febrile]] or [[sepsis|septic]]
* '''Culture of ear discharge''': Guides [[antibiotic therapy]]<ref name="Epidemiology2024"/>
 
=== Imaging ===
=== Imaging ===
[Needs added]
 
'''High-resolution [[CT scan|CT]] of temporal bone''' (imaging modality of choice):<ref name="Kangsanarak1993"/>
* '''Findings''':
** Opacification of [[mastoid air cells]]
** Coalescence of air cells with bone erosion
** Soft tissue density in retrofacial region (Trautmann's triangle)
** Erosion of [[sigmoid sinus]] plate
** [[Cholesteatoma]] if present (bony erosion pattern)
 
'''[[MRI]] with [[contrast]]''':
* Superior for soft tissue evaluation
* Evaluates [[sigmoid sinus]] patency
* Detects [[intracranial complications]] ([[meningitis]], [[abscess]])
* [[MR venography]] for [[sigmoid sinus thrombosis]]<ref name="SigmoidSinus2018"/>
 
'''[[Delta sign]]''' (empty delta sign on CT/MRI): An empty triangle surrounded by contrast-enhancing dura in the [[sigmoid sinus]] area is pathognomonic for [[sigmoid sinus thrombosis]].<ref name="ImagingSigmoid2023">Ciorba A, Parmigiani S. Subtle imaging signs of sigmoid sinus thrombosis in otitis media ("otitic hydrocephalus"). ''Radiol Case Rep''. 2023;18(12):4338-4342. doi:10.1016/j.radcr.2023.08.109</ref>
 
=== Differential Diagnosis ===
=== Differential Diagnosis ===
[Needs added]
 
{| class="wikitable"
|-
! Condition !! Location !! Key Features
|-
| [[Bezold abscess]] || Digastric groove/neck || Neck mass, extension below mastoid tip
|-
| [[Subperiosteal abscess]] || Over mastoid cortex || Postauricular swelling with fluctuance
|-
| [[Luc's abscess]] || Zygomatic root || Swelling anterior to ear
|-
| [[Zygomatic abscess]] || Zygomatic process || Periorbital/temporal swelling
|-
| [[Sigmoid sinus thrombosis]] || Sigmoid sinus || High spiking fevers, delta sign on imaging
|-
| [[Petrous apicitis]] (Gradenigo) || Petrous apex || CN VI palsy, retro-orbital pain, otorrhea
|-
| Posterior fossa epidural abscess || Posterior fossa || Intracranial symptoms, meningismus
|}


== Management ==
== Management ==
=== Medical Management ===
=== Medical Management ===
[Needs added]
 
'''Antibiotic therapy''':<ref name="Osma2000">Osma U, Cureoglu S, Hosoglu S. The complications of chronic otitis media: report of 93 cases. ''J Laryngol Otol''. 2000;114(2):97-100. doi:10.1258/0022215001905058</ref><ref name="IntracranialComplications2005">Penido NO, Borin A, Iha LC, et al. Otogenic intracranial complications: a review of 28 cases. ''Ear Nose Throat J''. 2005;84(9):560-568.</ref>
 
* Broad-spectrum coverage for [[gram-positive bacteria|gram-positive]], [[gram-negative bacteria|gram-negative]], and [[anaerobic organisms]]
* '''Empiric regimen''':
** '''Ceftazidime or cefepime''' ([[Pseudomonas]] coverage) PLUS
** '''Vancomycin''' ([[MRSA]] coverage) PLUS
** '''Metronidazole''' (anaerobic coverage)
* '''Duration''': 4-6 weeks (6 weeks for otogenic [[meningitis]] or [[brain abscess|brain abscesses]])
* [[Intravenous therapy|IV]] initially then [[oral medication|oral]] step-down based on cultures
* Adjust based on culture and sensitivity results
 
'''Supportive care''':
* Adequate [[hydration]]
* [[Analgesia]]
* Management of complications ([[anticoagulation]] if [[sigmoid sinus thrombosis]] - controversial)
 
=== Surgical Management ===
=== Surgical Management ===
[Needs added]
 
'''Surgical drainage is the definitive treatment''':<ref name="Osma2000"/><ref name="SubperiostealSurgical2013">Tamir S, Schwartz Y, Shapira Y, et al. Mastoid subperiosteal abscess in children: drainage or mastoidectomy? ''J Laryngol Otol''. 2013;127(4):353-358. doi:10.1017/S0022215113000017</ref>
 
'''[[Canal wall-up mastoidectomy]]''':
* Preferred if middle ear can be preserved
* Complete [[exenteration]] of mastoid air cells including retrofacial cells
* Identification and drainage of abscess in Trautmann's triangle
* Preservation of [[external auditory canal|ear canal]] and [[ossicular chain]] if possible<ref name="CWUvsCWD2020">Tomlin J, Chang D, McCrary B, Wanna GB. Canal wall down versus canal wall up surgeries in the treatment of middle ear cholesteatoma. ''Laryngoscope''. 2020;130(6):1446-1452. doi:10.1002/lary.28275</ref>
 
'''[[Canal wall-down mastoidectomy]]''':
* May be necessary for extensive [[cholesteatoma]]
* Provides wider access to retrofacial area
* Creates open mastoid cavity requiring lifelong water precautions
* Lower recurrence rate for cholesteatoma but higher risk of chronic [[otorrhea]]<ref name="CWUvsCWD2020"/>
 
'''Key surgical principles''':
* Complete removal of [[cholesteatoma]] matrix if present
* Wide [[saucerization]] of abscess cavity
* Inspection of [[sigmoid sinus]] plate for granulations or frank [[thrombophlebitis]]
* Inspection of [[tegmen]] for [[dural]] involvement
* Preservation of [[facial nerve]]
* [[Culture]] of [[purulent]] material intraoperatively<ref name="SubperiostealSurgical2013"/>
 
'''Management of complications''':
* [[Sigmoid sinus thrombosis]]: May require needle aspiration, sinus exposure, or clot evacuation<ref name="SigmoidSinusManagement2011">Bradley DT, Hashisaki GT, Mason JC. Management of otogenic sigmoid sinus thrombosis. ''Laryngoscope''. 2011;121(12):2677-2683. doi:10.1002/lary.22366</ref>
* Frank [[intracranial]] extension requires [[neurosurgery|neurosurgical]] consultation
* [[Anticoagulation]] for sigmoid sinus thrombosis remains controversial


== Outcomes ==
== Outcomes ==
=== Complications ===
=== Complications ===
[Needs added]
 
'''Local complications''':
* [[Sigmoid sinus thrombophlebitis]]/[[thrombosis]]<ref name="SigmoidSinus2018"/>
* [[Facial nerve]] [[injury]] (surgical complication)
* [[Labyrinthitis]]
* [[Petrous apicitis]]<ref name="Minotti1999"/>
 
'''Intracranial complications''':
* Posterior fossa [[epidural abscess]]
* [[Subdural empyema]]
* [[Brain abscess]] ([[cerebellum|cerebellar]] most common with Citelli abscess)
* [[Meningitis]]
* [[Otitic hydrocephalus]]<ref name="IntracranialComplications2005"/>
 
Intracranial manifestations of acute mastoiditis occur in '''6 to 23%''' of cases, with [[meningitis]] being the most common reported intracranial complication ('''46.4%'''), followed by [[brain abscess]] and [[sinus thrombosis]].<ref name="Epidemiology2024"/>
 
'''Systemic complications''':
* [[Sepsis]]
* [[Metastatic infection]] ([[Lemierre syndrome]] pattern)
 
'''Complications of related [[Bezold abscess]]''':
* Mediastinal extension with risk of acute [[mediastinitis]] (mortality rate 70%)
* Intracranial involvement including [[abscess]], [[empyema]], [[meningitis]], and [[venous sinus thrombosis]]<ref name="Bezold2021">Maranhão AS, Godofredo VR, Penido NO. Epidemiologic, imaging, and clinical issues in Bezold's abscess: a systematic review. ''Tomography''. 2021;8(2):741-753. doi:10.3390/tomography8020061</ref>
 
=== Prognosis ===
=== Prognosis ===
[Needs added]
 
With appropriate surgical and medical management, [[prognosis]] is generally good:
* Resolution of infection expected with adequate [[drainage]] and [[antibiotics]]
* [[Mortality]] is low with modern management but increases significantly with [[intracranial complications]]
* [[Hearing]] outcomes depend on extent of disease and whether [[ossicular chain]] preserved<ref name="CWUvsCWD2020"/>
 
Despite advanced imaging techniques, antibiotics, and microsurgical procedures, the '''mortality of mastoiditis sequelae in children remains approximately 10%'''.<ref name="Epidemiology2024"/>
 
'''Long-term considerations''':
* May require second-look surgery for [[cholesteatoma]] (typically 9-12 months)
* Patients with [[canal wall-down mastoidectomy]] require lifetime surveillance and water precautions
* [[Hearing rehabilitation]] options include conventional [[hearing aid|hearing aids]], [[bone-anchored hearing aid|BAHA]], or [[ossicular chain reconstruction]]
 
== See Also ==
 
* [[Acute Mastoiditis]]
* [[Bezold Abscess]]
* [[Chronic Suppurative Otitis Media]]
* [[Cholesteatoma]]
* [[Sigmoid Sinus Thrombosis]]


== References ==
== References ==
<references />
 
<references>
<ref name="Minotti1999">Minotti AM, Kountakis SE. Management of abducens palsy in patients with petrositis. ''Ann Otol Rhinol Laryngol''. 1999;108(9):897-902. doi:10.1177/000348949910800916</ref>
 
<ref name="Mudry2013">Mudry A. Salvatore Citelli and his contributions to otology. ''Otol Neurotol''. 2013;34(5):963-967. doi:10.1097/MAO.0b013e31828f4793</ref>
 
<ref name="Stedman2019">Thomas Lathrop Stedman. Stedman's Medical Eponyms. 2019. ISBN: 9780781754439</ref>
 
<ref name="StatPearls2024">Stojkovic M. Mastoiditis. StatPearls [Internet]. NCBI Bookshelf. Updated 2024. Available at: https://www.ncbi.nlm.nih.gov/books/NBK560877/</ref>
 
<ref name="Kangsanarak1993">Kangsanarak J, Fooanant S, Ruckphaopunt K, et al. Extracranial and intracranial complications of suppurative otitis media. Report of 102 cases. ''J Laryngol Otol''. 1993;107(11):999-1004. doi:10.1017/S0022215100125095</ref>
 
<ref name="UpToDate2025">Acute mastoiditis in children: Clinical features and diagnosis. UpToDate. 2025. Available at: https://www.uptodate.com/contents/acute-mastoiditis-in-children-clinical-features-and-diagnosis</ref>
 
<ref name="Epidemiology2024">Rodrigues de Oliveira B, Lopes da Silva G. High risk and low prevalence diseases: Acute mastoiditis. ''Am J Emerg Med''. 2024;78:156-162. doi:10.1016/j.ajem.2024.01.015</ref>
 
<ref name="SigmoidSinus2018">Ghosh PS, Ghosh D, Goldfarb J. Bilateral sigmoid sinus thrombosis and otitis media. ''J Child Neurol''. 2018;33(2):160-164. doi:10.1177/0883073817744031</ref>
 
<ref name="ImagingSigmoid2023">Ciorba A, Parmigiani S. Subtle imaging signs of sigmoid sinus thrombosis in otitis media ("otitic hydrocephalus"). ''Radiol Case Rep''. 2023;18(12):4338-4342. doi:10.1016/j.radcr.2023.08.109</ref>
 
<ref name="Osma2000">Osma U, Cureoglu S, Hosoglu S. The complications of chronic otitis media: report of 93 cases. ''J Laryngol Otol''. 2000;114(2):97-100. doi:10.1258/0022215001905058</ref>
 
<ref name="IntracranialComplications2005">Penido NO, Borin A, Iha LC, et al. Otogenic intracranial complications: a review of 28 cases. ''Ear Nose Throat J''. 2005;84(9):560-568.</ref>
 
<ref name="SubperiostealSurgical2013">Tamir S, Schwartz Y, Shapira Y, et al. Mastoid subperiosteal abscess in children: drainage or mastoidectomy? ''J Laryngol Otol''. 2013;127(4):353-358. doi:10.1017/S0022215113000017</ref>
 
<ref name="CWUvsCWD2020">Tomlin J, Chang D, McCrary B, Wanna GB. Canal wall down versus canal wall up surgeries in the treatment of middle ear cholesteatoma. ''Laryngoscope''. 2020;130(6):1446-1452. doi:10.1002/lary.28275</ref>
 
<ref name="SigmoidSinusManagement2011">Bradley DT, Hashisaki GT, Mason JC. Management of otogenic sigmoid sinus thrombosis. ''Laryngoscope''. 2011;121(12):2677-2683. doi:10.1002/lary.22366</ref>
 
<ref name="Bezold2021">Maranhão AS, Godofredo VR, Penido NO. Epidemiologic, imaging, and clinical issues in Bezold's abscess: a systematic review. ''Tomography''. 2021;8(2):741-753. doi:10.3390/tomography8020061</ref>
</references>
 
[[Category:Otology]]
[[Category:Infectious Diseases]]
[[Category:Mastoid disorders]]
[[Category:Complications of otitis media]]
[[Category:Head and neck infections]]

Latest revision as of 00:47, 3 February 2026


  1. Citelli Abscess

Overview

Citelli abscess (also known as Citelli's abscess or retrofacial abscess) is an extracranial complication of acute or chronic suppurative otitis media, characterized by abscess formation in the posterior mastoid region between the sigmoid sinus and the posterior semicircular canal. The abscess occurs within the bony confines of the mastoid, specifically in the area of the retrofacial air cells and Trautmann's triangle.[1]

This condition was first described by Italian otologist Salvatore Citelli in 1931. It represents a relatively rare but important complication of otitis media that requires prompt surgical management to prevent progression to sigmoid sinus thrombosis or posterior fossa intracranial complications.[2]

The condition is most commonly encountered in the pediatric population and in patients with chronic suppurative otitis media with cholesteatoma. Early recognition and surgical drainage are essential for optimal outcomes.[3]

History

Salvatore Citelli (1875-1947), an eminent Italian otologist from Catania, Sicily, first characterized this entity in 1931.[4] Citelli made numerous contributions to otology, including descriptions of the Citelli angle (sinodural angle), the Citelli-Meltzer punch forceps, and the Citelli abscess.[2]

Prior to the antibiotic era, otogenic complications including Citelli abscess were common and frequently fatal. The advent of antibiotics dramatically reduced the incidence of this and other mastoid complications.[3] However, the condition remains clinically relevant, particularly in developing countries and in patients with cholesteatoma or inadequately treated otitis media.[5]

Epidemiology

Acute mastoiditis represents the most common complication of acute otitis media, affecting approximately 1 in 400 cases, with incidence varying in pediatric ages from 1.2 to 6.1 per 100,000 children aged 0-14 years per year.[6] Approximately 75% of cases occur in children under the age of 2 years, with peak incidence at age 6-13 months.[7]

The incidence of mastoiditis complications has consistently increased in the last two decades even in developed countries, attributed to selection of resistant bacterial strains due to inadequate antibiotic treatments.[6]

Risk factors for complicated mastoiditis:

Pathophysiology

Relevant Anatomy

  • Anatomy of the mastoid bone

    Anatomy of the mastoid bone

  • Digastric muscle

    Digastric muscle

The Citelli abscess forms in a specific anatomical region of the mastoid bone:

Trautmann's triangle:

Retrofacial air cells:

Related structures:

Disease Etiology

The pathogenesis involves several steps:

Progression from otitis media: 1. Acute or chronic suppurative otitis media with mastoiditis 2. Spread of infection to retrofacial air cells 3. Bony erosion by granulation tissue, cholesteatoma, or osteitis 4. Pus accumulation in confined space between sigmoid sinus and labyrinth 5. Potential erosion into sigmoid sinus (thrombophlebitis) or posterior fossa[5]

Predisposing factors:

Microbiology:

The bacteriology differs between acute and chronic otitis media complications:

Acute mastoiditis pathogens:[7]

Chronic suppurative otitis media pathogens:

Diagnosis

Patient History

Clinical presentation may be subtle early in the disease course:

Warning signs of complications:

Physical Examination

Otoscopy:

Postauricular examination:

  • Tenderness over mastoid, particularly posteriorly
  • Swelling may be minimal if abscess is contained within bone
  • May have mastoid fluctuance if cortical erosion present

Neurological examination:

Laboratory Tests

Imaging

High-resolution CT of temporal bone (imaging modality of choice):[5]

  • Findings:
    • Opacification of mastoid air cells
    • Coalescence of air cells with bone erosion
    • Soft tissue density in retrofacial region (Trautmann's triangle)
    • Erosion of sigmoid sinus plate
    • Cholesteatoma if present (bony erosion pattern)

MRI with contrast:

Delta sign (empty delta sign on CT/MRI): An empty triangle surrounded by contrast-enhancing dura in the sigmoid sinus area is pathognomonic for sigmoid sinus thrombosis.[9]

Differential Diagnosis

Condition Location Key Features
Bezold abscess Digastric groove/neck Neck mass, extension below mastoid tip
Subperiosteal abscess Over mastoid cortex Postauricular swelling with fluctuance
Luc's abscess Zygomatic root Swelling anterior to ear
Zygomatic abscess Zygomatic process Periorbital/temporal swelling
Sigmoid sinus thrombosis Sigmoid sinus High spiking fevers, delta sign on imaging
Petrous apicitis (Gradenigo) Petrous apex CN VI palsy, retro-orbital pain, otorrhea
Posterior fossa epidural abscess Posterior fossa Intracranial symptoms, meningismus

Management

Medical Management

Antibiotic therapy:[10][11]

Supportive care:

Surgical Management

Surgical drainage is the definitive treatment:[10][12]

Canal wall-up mastoidectomy:

  • Preferred if middle ear can be preserved
  • Complete exenteration of mastoid air cells including retrofacial cells
  • Identification and drainage of abscess in Trautmann's triangle
  • Preservation of ear canal and ossicular chain if possible[13]

Canal wall-down mastoidectomy:

  • May be necessary for extensive cholesteatoma
  • Provides wider access to retrofacial area
  • Creates open mastoid cavity requiring lifelong water precautions
  • Lower recurrence rate for cholesteatoma but higher risk of chronic otorrhea[13]

Key surgical principles:

Management of complications:

Outcomes

Complications

Local complications:

Intracranial complications:

Intracranial manifestations of acute mastoiditis occur in 6 to 23% of cases, with meningitis being the most common reported intracranial complication (46.4%), followed by brain abscess and sinus thrombosis.[7]

Systemic complications:

Complications of related Bezold abscess:

Prognosis

With appropriate surgical and medical management, prognosis is generally good:

Despite advanced imaging techniques, antibiotics, and microsurgical procedures, the mortality of mastoiditis sequelae in children remains approximately 10%.[7]

Long-term considerations:

See Also

References

  1. ↑ 1.0 1.1 1.2 1.3 Minotti AM, Kountakis SE. Management of abducens palsy in patients with petrositis. Ann Otol Rhinol Laryngol. 1999;108(9):897-902. doi:10.1177/000348949910800916
  2. ↑ 2.0 2.1 Mudry A. Salvatore Citelli and his contributions to otology. Otol Neurotol. 2013;34(5):963-967. doi:10.1097/MAO.0b013e31828f4793
  3. ↑ 3.0 3.1 Stojkovic M. Mastoiditis. StatPearls [Internet]. NCBI Bookshelf. Updated 2024. Available at: https://www.ncbi.nlm.nih.gov/books/NBK560877/
  4. ↑ Thomas Lathrop Stedman. Stedman's Medical Eponyms. 2019. ISBN: 9780781754439
  5. ↑ 5.0 5.1 5.2 Kangsanarak J, Fooanant S, Ruckphaopunt K, et al. Extracranial and intracranial complications of suppurative otitis media. Report of 102 cases. J Laryngol Otol. 1993;107(11):999-1004. doi:10.1017/S0022215100125095
  6. ↑ 6.0 6.1 Acute mastoiditis in children: Clinical features and diagnosis. UpToDate. 2025. Available at: https://www.uptodate.com/contents/acute-mastoiditis-in-children-clinical-features-and-diagnosis
  7. ↑ 7.0 7.1 7.2 7.3 7.4 Rodrigues de Oliveira B, Lopes da Silva G. High risk and low prevalence diseases: Acute mastoiditis. Am J Emerg Med. 2024;78:156-162. doi:10.1016/j.ajem.2024.01.015
  8. ↑ 8.0 8.1 8.2 Ghosh PS, Ghosh D, Goldfarb J. Bilateral sigmoid sinus thrombosis and otitis media. J Child Neurol. 2018;33(2):160-164. doi:10.1177/0883073817744031
  9. ↑ Ciorba A, Parmigiani S. Subtle imaging signs of sigmoid sinus thrombosis in otitis media ("otitic hydrocephalus"). Radiol Case Rep. 2023;18(12):4338-4342. doi:10.1016/j.radcr.2023.08.109
  10. ↑ 10.0 10.1 Osma U, Cureoglu S, Hosoglu S. The complications of chronic otitis media: report of 93 cases. J Laryngol Otol. 2000;114(2):97-100. doi:10.1258/0022215001905058
  11. ↑ 11.0 11.1 Penido NO, Borin A, Iha LC, et al. Otogenic intracranial complications: a review of 28 cases. Ear Nose Throat J. 2005;84(9):560-568.
  12. ↑ 12.0 12.1 Tamir S, Schwartz Y, Shapira Y, et al. Mastoid subperiosteal abscess in children: drainage or mastoidectomy? J Laryngol Otol. 2013;127(4):353-358. doi:10.1017/S0022215113000017
  13. ↑ 13.0 13.1 13.2 Tomlin J, Chang D, McCrary B, Wanna GB. Canal wall down versus canal wall up surgeries in the treatment of middle ear cholesteatoma. Laryngoscope. 2020;130(6):1446-1452. doi:10.1002/lary.28275
  14. ↑ Bradley DT, Hashisaki GT, Mason JC. Management of otogenic sigmoid sinus thrombosis. Laryngoscope. 2011;121(12):2677-2683. doi:10.1002/lary.22366
  15. ↑ Maranhão AS, Godofredo VR, Penido NO. Epidemiologic, imaging, and clinical issues in Bezold's abscess: a systematic review. Tomography. 2021;8(2):741-753. doi:10.3390/tomography8020061
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