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 Table of Contents  
REVIEW ARTICLE
Year : 2016  |  Volume : 22  |  Issue : 3  |  Page : 148-151

Bezold's abscess: A case report and review of cases over 14 years


Department of Otolaryngology, Qatif Central Hospital, Eastern Province, Saudi Arabia

Date of Web Publication8-Aug-2016

Correspondence Address:
Hussain Al-Baharna
4568 Mahmud Al Warraq Street, Al Qatif 32631-7047, Eastern Province
Saudi Arabia
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/0971-7749.187978

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  Abstract 

Bezold's abscess is one of the rare complications of otitis media. It was named after Friedrich Bezold in 1881, who described the pus escaping through the medial side of the mastoid process into the incisura digastrica (digastric grove) and forming an abscess. This article reports a case report of a 73-year-old male who presented with right otitis media complicated with Bezold's abscess. The diagnosis is confirmed radiologically by magnetic resonance imaging. The patient was managed by intravenous antibiotic, drainage of abscess, and cortical mastoidectomy. Then, we conducted a literature review for all the cases reported between 2000 and 2014. We found around 17 cases in the literature, and additional eight reported cases but we have excluded them because some are not in English language and the others are not registered in PubMed. We think that because of the evolution in imaging technology, these cases are easier to be diagnosed nowadays. Bezold's abscesses case reports were seen more in adults (10 of 18, 55.6%) than in pediatric of 18 years old and below (8 of 18, 44.4%). It is found more in males (11 of 18, 61%) than in females (7 of 18, 39%). In this review, the time latency between the presentation of the patient and the diagnosis of Bezold's abscess is ranging between 2 days and 2 weeks. The pattern of mastoid pneumatization is the main factor behind developing Bezold's abscess. Since this review confirms that the most common organisms are Gram-positive organisms, it is wise to choose the antibiotic directed against Gram-positive organisms. Finally, we conclude that the surgical treatment can be tailored according to the pneumatization of the mastoid bone and the extension of neck abscess.

Keywords: Bezold's abscess, Complications, Mastoiditis, Otitis media


How to cite this article:
Al-Baharna H, Al-Mubaireek H, Arora V. Bezold's abscess: A case report and review of cases over 14 years. Indian J Otol 2016;22:148-51

How to cite this URL:
Al-Baharna H, Al-Mubaireek H, Arora V. Bezold's abscess: A case report and review of cases over 14 years. Indian J Otol [serial online] 2016 [cited 2019 Oct 16];22:148-51. Available from: http://www.indianjotol.org/text.asp?2016/22/3/148/187978


  Introduction Top


A lot of complications were described as a consequence of otitis media. These complications turn to be less common in the era of antibiotic than before. Bezold's abscess is one of them. Mastoid antrum is present since birth, but air cells start to develop at age of 1 year and become fully developed at age of 5 years. The mastoid process has a thicker outer surface where the muscles attached and weaker medial surface. Bezold published a paper describing the effects of pus escaping through the medial side of the mastoid process into the incisura digastrica (digastric grove) and forming an abscess.[1] This variety of abscess was known as Bezold's mastoiditis. In his classic description, the pus spread along the digastric muscle to the chin, filling the retromaxillary fossa, and along the course of the occipital artery. If left untreated, further deep extensions occurred due to the resistance to direct extension by sternomastoid, trapezius, and splenius muscles. Bezold observed that pus tracked along these muscles and if it reached the short deep muscles of the neck, it might extend to the transverse processes of the vertebrae as low as the second thoracic vertebra. The present day literature describes a Bezold's abscess as an abscess arising within the substance of the sternomastoid muscle, following the spread of pus through the tip of the mastoid process.[2]

This article describes a case report of this rare complication and reviewing all reports from 2000 to 2014 to discuss the following:

  • The frequency of reported cases in the last 14 years in compare to previous reviews
  • Demographic distribution of Bezold's abscess
  • Risk factors of Bezold's abscess
  • Is there any change in the trend of management?



  Case Top


A 73-year-old male patient who was known case of diabetes, hypertension, renal impairment, and cardiomyopathy presented to our clinic with 1-week history of the right ear discharge. After 1 week of presentation, he developed right neck mass. The mass was located on the sternomastoid muscle area. It was hard, tender with skin erythematous changes [Figure 1]. Because the patient has renal impairment, computed tomography (CT) with contrast was difficult to be done. Instead contrasted, magnetic resonance imaging was done and showed abscess collection within the sternocleidomastoid muscle continuous with mastoid collection [Figure 2].
Figure 1: Right side hard and tender neck mass on the sternomastoid muscle area with skin erythematous changes

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Figure 2: Coronal T1 magnetic resonance imaging of the neck showing abscess collection in the right sternomastoid muscle

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Diagnosis of Bezold's abscess was made. The patient was taken to the operation room for cortical mastoidectomy and drainage of the neck abscess. The neck abscess was drained first by incising and evacuating the pus from the sternocleidomastoid muscle. Then, cortical mastoidectomy was done exposing the aditus and opening the air cells up the tip of mastoid where the defect was identified and drilled out.

The mastoid cavity was full of granulation tissue and all ossicles were intact. No tympanoplasty was done. The culture of the abscess yield Peptostreptococcus species. Postoperation, the patient was covered with intravenous (IV) ceftriaxone for 2 weeks and then discharge home in good condition.


  Discussion Top


The incidence of complications of otitis media was declined in the antibiotic era. However, the overall incidence seems to be steady over the last 20 years.[3] The incidence of Bezold's abscess was 20% of total complications. In one review, approximately 35 cases of Bezold's abscess have been reported between 1967 and 2001.[4] Another review showed 18 reported cases in Japanese literature between 1960 and 2000.[1]

We have searched for all cases presented in English literature between 2000 and 2014 using the words “Bezold's abscess” in PubMed. We found around 17 cases as summarized in [Table 1]. There are additional 8 reported cases in the literature, but we excluded them because of two reasons. Some of them are not in English language and the others are not registered in PubMed. We think that because of the evolution in imaging technology, these cases are easier to be diagnosed nowadays. Bezold's abscesses case reports were seen more in adults (10 of 18, 55.6%) than in pediatric of 18 years old and below (8 of 18, 44.4%). It is found more in males (11 of 18, 61%) in females (7 of 18, 39%).
Table 1: Review of all reported cases of Bezold's abscess in the English literature between 2000 and 2014

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The mastoid tip, pneumatized in adults, is composed of thin-walled air cells. The lateral mastoid wall composed of thicker bone than that of the medial wall. Furthermore, the lateral aspect serves as the insertion point for the digastric, sternocleidomastoid, splenius capitis, and longissimus capitis muscles. Pus in the mastoid erodes through the area of least resistance, the mastoid tip, which is inferior and medial. Hence, abscesses are formed deep in the neck musculature and delay its detection. There are other causes attributed to delay diagnoses,[1] low antibiotic dose or less duration,[2] developmental of more resistant pathogen species,[3] and unfamiliarity of the disease to the physician.

In this review, the time latency between the presentation of the patient and the diagnosis of an abscess is ranging between 2 days and 2 weeks. Those with a history of cholesteatoma or previous mastoid surgery appear to be at increased risk for Bezold's abscess (6 of 18, 33.3%) Presence of cholesteatoma in mastoiditis cases may block the aditus and direct the inflammatory process to the mastoid tip that means the pattern of mastoid pneumatization is the main factor behind developing Bezold's abscess. The other fact to support this is the incidence of Bezold's abscess in adults which is more than pediatrics because of more pneumatized mastoid. In our review, Bezold's abscess incidence in pediatric is 44.4% of the cases which is higher incidence than what was published in other reviews. This is most likely because the pediatric cases are reported more in the literature since they are less common.

Diagnosis of Bezold's abscess requires a high index of suspicion because of its rarity. Contrast-enhanced CT imaging of the temporal bone and neck provides the most useful information for both diagnosis and subsequent surgical intervention. Indeed, the evolution in the imaging technology makes the diagnosis easier and shortens the time latency after the presentation.

It is wise to choose the antibiotic directed against Gram-positive organisms since they are the most common causative pathogens, then shifting to culture based antibiotic. In particular, streptococci species are the most common causative organism although Bezold's abscess can be caused by all types of organisms. In our review, 5 cases of 12 (41%) showed Streptococci species. Other Gram-positive is two cases of Staphylococcus species and one case of acid-fast bacilli. Only one patient with Gram-negative (Pseudomonas aeruginosa) and another one with anaerobes (Peptostreptococcus) are reported. Three cases showed no growth and the rest of cases have no available culture result. In almost all cases, the gold standard management is surgery (IV antibiotic, drainage of abscess, and mastoidectomy). As it showed in this review, all cases required antibiotics. However, among the cases in this review, two cases are treated with no neck drainage, one of them without mastoidectomy even (18 months child). On the other hand, 5 cases required no mastoidectomy (two of them are pediatrics with not fully pneumatized mastoid). This concludes that the surgical treatment can be tailored according to the pneumatization of the mastoid bone and the extension of neck abscess.


  Conclusion Top


Bezold's abscess is a rare complication of otitis media. It occurs when the abscess escapes from the mastoid cavity to the sternocleidomastoid muscle through the digastrics ridge. This review supports the fact that the pattern of mastoid pneumatization is the main factor behind developing Bezold's abscess. There are more cases diagnosed nowadays due to improvement of imaging technology. However, there is no difference in the standard care of management over the last 14 years..

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.[19]

 
  References Top

1.
Uchida Y, Ueda H, Nakashima T. Bezold's abscess arising with recurrent cholesteatoma 20 years after the first surgery: With a review of the 18 cases published in Japan since 1960. Auris Nasus Larynx 2002;29:375-8.  Back to cited text no. 1
    
2.
Gaffney RJ, O'Dwyer TP, Maguire AJ. Bezold's abscess. J Laryngol Otol 1991;105:765-6.  Back to cited text no. 2
    
3.
Osma U, Cureoglu S, Hosoglu S. The complications of chronic otitis media: Report of 93 cases. J Laryngol Otol 2000;114:97-100.  Back to cited text no. 3
    
4.
Marioni G, de Filippis C, Tregnaghi A, Marchese-Ragona R, Staffieri A. Bezold's abscess in children: Case report and review of the literature. Int J Pediatr Otorhinolaryngol 2001;61:173-7.  Back to cited text no. 4
    
5.
Zapanta PE, Chi DH, Faust RA. A unique case of Bezold's abscess associated with multiple dural sinus thromboses. Laryngoscope 2001;111(11 Pt 1):1944-8.  Back to cited text no. 5
    
6.
Jose J, Coatesworth AP, Anthony R, Reilly PG. Life threatening complications after partially treated mastoiditis. BMJ 2003;327:41-2.  Back to cited text no. 6
    
7.
Schöndorf HJ, Roth B, Streppel M. Bezold's abscess following chronic mastoiditis in a newborn. Ann Otol Rhinol Laryngol 2004;113:843-5.  Back to cited text no. 7
    
8.
Ching HY, Ramsden JD, Bottrill I. A unique presentation: Bezold's abscess and glomerulonephritis. Eur J Pediatr 2006;165:569-70.  Back to cited text no. 8
    
9.
Bhat V, Manjunath D. Cerebrospinal fluid otorrhea presenting in complicated chronic suppurative otitis media. Ear Nose Throat J 2007;86:223-5.  Back to cited text no. 9
    
10.
McMullan B. Bezold's abscess: A serious complication of otitis media. J Paediatr Child Health 2009;45:616-8.  Back to cited text no. 10
    
11.
Vlastos IM, Helmis G, Athanasopoulos I, Houlakis M. Acute mastoiditis complicated with bezold abscess, sigmoid sinus thrombosis and occipital osteomyelitis in a child. Eur Rev Med Pharmacol Sci 2010;14:635-8.  Back to cited text no. 11
    
12.
Patel N, Goodman J, Singh A. Bezold's abscess in the setting of untreated HIV infection. Laryngoscope 2010;120 Suppl 4:S134.  Back to cited text no. 12
    
13.
Sheikh FT, Murday DC, Abbas A, Main C, King AJ, Rao S, et al. Bezold's abscess. Emerg Med J 2011;28:985.  Back to cited text no. 13
    
14.
Mascarinas CA, Singer MC, Hanson MB. Bezold's abscess in the setting of radiation induced mastoiditis. Laryngoscope 2010;120 Suppl 4:S211.  Back to cited text no. 14
    
15.
Li L, Ren J. Aural cholesteatoma with upper neck extension. Auris Nasus Larynx 2012;39:534-6.  Back to cited text no. 15
    
16.
Janardhan N, Nara J, Peram I, Palukuri S, Chinta A, Satna K. Congenital cholesteatoma of temporal bone with Bezold's abscess: Case report. Indian J Otolaryngol Head Neck Surg 2012;64:97-9.  Back to cited text no. 16
    
17.
Secko M, Aherne A. Diagnosis of Bezold abscess using bedside ultrasound. J Emerg Med 2013;44:670-2.  Back to cited text no. 17
    
18.
Nelson D, Jeanmonod R. Bezold abscess: A rare complication of mastoiditis. Am J Emerg Med 2013;31:1626.e3-4.  Back to cited text no. 18
    
19.
Lionello M, Manara R, Lora L, Mylonakis I, Fasanaro E, La Torre FB, et al. Case report of cholesteatoma recurrence with Bezold's abscess presenting as a deep neck infection. B-ENT 2013;9:255-8.  Back to cited text no. 19
    


    Figures

  [Figure 1], [Figure 2]
 
 
    Tables

  [Table 1]


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