Bezold's Abscess
Overview
A Bezold's abscess is a complication of mastoiditis where the mastoid infection erodes through the cortical surface of the mastoid bone and forms a secondary abscess pocket near the attachment of the sternocleidomastoid (SCM) muscle.[1]
History
Bezold's abscess is named after Friedrich Bezold, a German otologist that first described it in 1881.[2]
Pathophysiology
Relevant Anatomy
Bezold's abscess is an extension of mastoiditis into the neck space deep to the mastoid attachment of the sternocleidomastoid muscle.
-
Transected view of the mastoid bone.
-
Inferior view of the mastoid bone.
-
Attachment of the sternocleidomastoid muscle to the mastoid bone.
Disease Etiology
Bezold abscesses present in the setting of a long-standing untreated acute mastoiditis. It is typically more common in adults than younger children due to the degree of pneumatization of the mastoid bone and subsequent cortical thinning. Perforation of the mastoid infection through the digastric groove will result in extension of the infection into a space deep to the attachment of the sternocleidomastoid muscle.[3] This infection can further spread to connecting deep neck spaces.
Diagnosis
Patient History
Patients presenting with Bezold's abscess typically have long-standing otologic issues. This can be in the form of untreated acute mastoiditis, chronic mastoiditis, or cholesteatoma. As Bezold's abscesses have become rare in the post-antibiotic world, this diagnosis should be lower on your differential diagnosis among patients that have been receiving antibiotics.
Physical Examination
Patients can experience the following symptoms:[4]
- Neck pain
- Neck stiffness
- Dysphagia
- Otalgia
- Otorrhea (in the setting of a perforated tympanic membrane)
Physical exam can reveal the following findings:
- Neck swelling
- Auricular proptosis
- Mastoid swelling
- Mastoid tenderness
- Fever
Laboratory Tests
Laboratory tests should primarily focus on your typical infectious workup:
- CBC
- CRP / ESR
- Blood cultures
- Gram stain and culture of otorrhea (if present)
Imaging
CT scan is the imaging modality of choice. It is important to get imaging early in these patients for identification of the extent of the neck abscess and subsequent surgical planning. The following scans should be considered, based on local scanner and sequencing availability:
- CT Temporal Bone
- CT Soft Tissue Neck w/ Contrast
Temporal bone imaging will typically reveal complete opacification of the ipsilateral middle ear and mastoid cavity. There will be erosion of the mastoid tip adjacent to the neck abscess, which is typically best visualized in the coronal view. Neck imaging will typically show an abscess extending from the inferior aspect of the mastoid bone near an area of cortical dehiscence. The abscess pocket is typically peripherally enhancing and irregular with loss of definition of fat and fascial planes. [5]
Differential Diagnosis
Differential diagnosis should include other infectious complications of acute mastoiditis:
- Subperiosteal Abscess
- Citelli Abscess
Management
Medical Management
Patients with suspected Bezold's abscess should receive broad-spectrum intravenous antibiotics. Antibiotics should not be withheld in order to get accurate cultures in the operating room. Antibiotics are not definitive treatment; these patients require operative debridement of the infection.
In patients that have active otorrhea or a suspected tympanic membrane perforation, antibiotic drops can be considered with or without otowick placement.
Surgical Management
Bezold's abscess requires surgical drainage. This ***
Outcomes
Complications
With patients that have Bezold's abscess, all complications of mastoiditis should be considered. With the addition of the abscess in the neck, the following complications should be considered:
- Thrombosis of the internal jugular vein
Prognosis
[Needs added]
References
- ↑ Marioni, G., de Filippis, C., Tregnaghi, A., Marchese-Ragona, R., & Staffieri, A. (2001). Bezold's abscess in children: case report and review of the literature. International journal of pediatric otorhinolaryngology, 61(2), 173-177.
- ↑ Bezold, F. (1881). Ein neuer Weg für Ausbreitung eitriger Entzündung aus den Räumen des Mittelohrs auf die Nachbarschaft und die in diesem Falle einzuschlagende Therapie. DMW-Deutsche Medizinische Wochenschrift, 7(28), 381-385.
- ↑ Smouha, E. E., Levenson, M. J., Anand, V. K., & Parisier, S. C. (1989). Modern presentations of Bezold's abscess. Archives of Otolaryngology–Head & Neck Surgery, 115(9), 1126-1129.
- ↑ Gaffney, R. J., O'Dwyer, T. P., & Maguire, A. J. (1991). Bezold's abscess. The Journal of Laryngology & Otology, 105(9), 765-766.
- ↑ Castillo, M., Albernaz, V. S., Mukherji, S. K., Smith, M. M., & Weissman, J. L. (1998). Imaging of Bezold's abscess. AJR. American journal of roentgenology, 171(6), 1491-1495.