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Bezold abscess

June 4, 2015 by Yu-Hsuan Lin, MD; Ming-Yee Lin, MD

Bezold abscess June 4, 2015 b <a href=y Yu-Hsuan Lin, MD; Ming-Yee Lin, MD | REPRINTS Otoscopic Clinic In some circumstances, the only sign or symptom of Bezold abscess is an unnoticed neck lump. Bezold abscess is an extremely rare otogenic complication. However, its initial manifestation might appear to be fairly nonthreatening, which can lead to a delay in diagnosis. Maintaining a high level of clinical suspicion and the early use of radiologic imaging can guide clinicians in the diagnosis and surgical or medical management of this condition. A 49-year-old man (a scuba diving instructor) came to our clinic with a 1-week history of a progressively enlarging asymptomatic lump in the right side of his neck. He had been treated for otitis media 20 days earlier, which led to a marked alleviation of his symptoms. On examination, otoscopy revealed the presence of a rounded mass that was adherent to a thickened eardrum, along with an active discharge (figure, A). Contrast-enhanced computed tomography (CT) of the neck detected a peripherally enhancing abscess that involved the right sternocleidomastoid muscle and an eroded mastoid tip (figure, B). Temporal bone CT revealed opacification within the middle ear cavity and mastoid bone, which established a diagnosis of otitis media complicated by Bezold abscess. Figure. A: Otoscopic examination shows the rounded mass (asterisk) adhering to the posterior aspect of the swollen right tympanic membrane and the discharge of pus. B: Postcontrast CT of the neck shows the peripheral enhancing abscess involving the sternocleidomastoid muscle and an eroded mastoid tip (arrows). " id="pdf-obj-0-8" src="pdf-obj-0-8.jpg">

| REPRINTS Otoscopic Clinic

In some circumstances, the only sign or symptom of Bezold abscess is an unnoticed neck lump.

Bezold abscess is an extremely rare otogenic complication. However, its initial manifestation might appear to be fairly nonthreatening, which can lead to a delay in diagnosis. Maintaining a high level of clinical suspicion and the early use of radiologic imaging can guide clinicians in the diagnosis and surgical or medical management of this condition.

A 49-year-old man (a scuba diving instructor) came to our clinic with a 1-week history of a progressively enlarging asymptomatic lump in the right side of his neck. He had been treated for otitis media 20 days earlier, which led to a marked alleviation of his symptoms.

On examination, otoscopy revealed the presence of a rounded mass that was adherent to a thickened eardrum, along with an active discharge (figure, A). Contrast-enhanced computed tomography (CT) of the neck detected a peripherally enhancing abscess that involved the right sternocleidomastoid muscle and an eroded mastoid tip (figure, B). Temporal bone CT revealed opacification within the middle ear cavity and mastoid bone, which established a diagnosis of otitis media complicated by Bezold abscess.

Figure. A: Otoscopic examination shows the rounded mass (asterisk) adhering to the posterior aspect of the swollen right tympanic membrane and the discharge of pus. B: Postcontrast CT of the neck shows the peripheral enhancing abscess involving the sternocleidomastoid muscle and an eroded mastoid tip (arrows).

Bezold abscess June 4, 2015 b <a href=y Yu-Hsuan Lin, MD; Ming-Yee Lin, MD | REPRINTS Otoscopic Clinic In some circumstances, the only sign or symptom of Bezold abscess is an unnoticed neck lump. Bezold abscess is an extremely rare otogenic complication. However, its initial manifestation might appear to be fairly nonthreatening, which can lead to a delay in diagnosis. Maintaining a high level of clinical suspicion and the early use of radiologic imaging can guide clinicians in the diagnosis and surgical or medical management of this condition. A 49-year-old man (a scuba diving instructor) came to our clinic with a 1-week history of a progressively enlarging asymptomatic lump in the right side of his neck. He had been treated for otitis media 20 days earlier, which led to a marked alleviation of his symptoms. On examination, otoscopy revealed the presence of a rounded mass that was adherent to a thickened eardrum, along with an active discharge (figure, A). Contrast-enhanced computed tomography (CT) of the neck detected a peripherally enhancing abscess that involved the right sternocleidomastoid muscle and an eroded mastoid tip (figure, B). Temporal bone CT revealed opacification within the middle ear cavity and mastoid bone, which established a diagnosis of otitis media complicated by Bezold abscess. Figure. A: Otoscopic examination shows the rounded mass (asterisk) adhering to the posterior aspect of the swollen right tympanic membrane and the discharge of pus. B: Postcontrast CT of the neck shows the peripheral enhancing abscess involving the sternocleidomastoid muscle and an eroded mastoid tip (arrows). " id="pdf-obj-0-24" src="pdf-obj-0-24.jpg">

The patient underwent neck debridement with pus drainage, an excisional biopsy of the ear canal mass, and a mastoidectomy, which showed the presence of granulation tissue visible under microscopy. The culture grew a sensitive strain of Klebsiella pneumoniae. The patient recovered uneventfully after receiving intravenous antibiotics.

Bezold abscess was first described in 1881 by Frederick Bezold as a complication of otitis media.1 It typically manifests as a nonfluctuating lateral neck abscess below the mastoid tip.2,3 Classically, the disease presents as pus oozing from the digastric groove and tracking along the fascial planes of the digastric and/or sternocleidomastoid muscles.2,3 The vast majority of patients with Bezold abscess are adults who have a well-pneumatized mastoid

process.2,3

The incidence of Bezold abscess declined dramatically after the introduction of antibiotics and the refinement of well-developed healthcare systems.2-4 However, reports still occasionally emerge from developed industrialized countries, suggesting that unresolved issues remain.4

In some circumstances, the only sign or symptom of Bezold abscess is an unnoticed neck lump.2 A tenacious course of infection often occurs in immunocompromised patients, in patients with an indomitable bacterial strain, and in patients with neglected latent mastoiditis.4 Therefore, a thorough understanding of the chronology of events and early use of CT scanning are necessary for the successful management of suspected cases.2-4 Surgical removal of actively infected tissue remains the principal form of management.2-4

References

  • 1. Bezold F. Ein neuer Weg für die Ausbreitung eitriger Entzündung aus den Räumen des Mittelohrs aus die Nachbarschaft. Dtsch Med Wochenschr 1881; 28:381-4.

  • 2. Spiegel JH, Lustig LR, Lee KC ,et al. Contemporary presentation and management of a spectrum of mastoid abscesses. Laryngoscope 1998; 108 (6): 822-8.

  • 3. Castillo M, Albernaz VS, Mukherji SK ,et al. Imaging of Bezold's abscess. AJR Am J Roentgenol 1998; 171 (6): 1491-5.

  • 4. Leskinen K, Jero J. Acute complications of otitis media in adults. Clin Otolaryngol 2005; 30 (6): 511-16.

From the Department of Otolaryngology-Head and Neck Surgery, Kaohsiung Veterans General Hospital, Kaohsiung, Taiwan.