Chronic otitis media (COM) is de\ufb01ned as persistent infection or in\ufb02am- mation of the middle ear and mastoid air cells. This condition typically in- volves a perforation of the tympanic membrane, with intermittent or continuous otorrhea. As chronic otomastoiditis and eustachian tube dys- function persist, the tympanic membrane is weakened, which increases the likelihood of an atelectatic ear or cholesteatoma formation.
The proximity of the middle ear cleft and mastoid air cells to the intra- temporal and intracranial compartments places structures located in these areas at increased risk of infectious complications. Acute otitis media (AOM) and its complications are more common in young children, whereas complications secondary to COM with and without cholesteatoma are more common in older children and adults. In a large series by Osma and col- leagues, 78% of subjects who had complications secondary to COM were found to have cholesteatoma.
The complications of AOM and COM, de\ufb01ned using the same classi\ufb01ca- tion system, are divided into intracranial and extracranial complications; extracranial complications are further divided into extratemporal and intra- temporal complications. The development and appropriate use of antibi- otics have led to a decrease in these potentially devastating complications. However, they continue to occur, and clinical vigilance is required for early detection and treatment. Furthermore, with the continued development of multi\u2013drug-resistant pathogens, these complications may again become more prevalent as our current antibiotics become less e\ufb00ective.
Subperiosteal abscess is the most common extratemporal complication that occurs with COM. This abscess occurs over the mastoid cortex when the infectious process within the mastoid air cells extends into the subperios- teal space. This extension most commonly occurs as a result of erosion of the cortex secondary to acute or coalescent mastoiditis, but can also occur as a result of vascular extension secondary to phlebitis of the mastoid veins
AOM, but are also found in chronic otitis with and without cholesteatoma. Cholesteatoma can block the aditus ad antrum, preventing communication of the infected contents of the mastoid with the middle ear space and the eu- stachian tube. This obstruction increases the possibility of infectious decom- pression through the mastoid cortex, presenting clinically as a subperiosteal abscess or Bezold\u2019s abscess.
Often, the diagnosis of a subperiosteal abscess is made on clinical grounds. Commonly, the patient will present with systemic symptoms, in- cluding fever and malaise, along with local signs, including a protruding au- ricle that is laterally and inferiorly displaced, and the presence of a \ufb02uctuant, erythematous, tender area behind the ear. When the diagnosis is not certain on clinical evaluation, a contrasted CT scan can demonstrate abscess and possibly the cortical defect in the mastoid (Fig. 1). A case can be made for a contrasted CT scan of the temporal bone in all patients presenting with these symptoms, to aid in therapeutic planning and to rule out other possible complications. Mastoiditis without abscess, lymphadenopathy, super\ufb01cial abscess, and an infected sebaceous cyst are other possibilities that must be excluded.
Fig. 1. An axial CT scan (A) of a 5-month-old child, demonstrating opaci\ufb01cation of the left ear and mastoid with coalescence, and a coronal CT scan (B) of the left temporal bone in the same patient, demonstrating a subperiosteal abscess.
The management of a postauricular subperiosteal abscess from otitis me- dia without cholesteatoma is debatable. Conventional teaching and current texts advocate draining the abscess, in conjunction with a cortical mastoid- ectomy[3,4]. In recent years, other, less invasive treatment options have emerged. Patients have been treated with simple incision and drainage of the abscess in conjunction with intravenous (IV) antibiotics and a myringot- omy without sequelae. One investigator advocates the use of IV antibi- otics, myringotomy, and needle aspiration of the abscess without formal drainage. In his experience, 14 of the 17 subjects treated in this manner re- solved their abscesses without the need for further intervention, and were discharged home signi\ufb01cantly sooner than those subjects who were managed with a mastoidectomy. The three subjects who failed needle aspiration went on to require cortical mastoidectomy. An argument for conservative treatment modalities for subperiosteal abscesses from AOM is reasonable, because the process likely will be self-limited; however, there is not yet a con- sensus advocating these less aggressive approaches. The approach to a sub- periosteal abscess resulting from chronic otitis in the presence of a cholesteatoma is not as controversial. In this setting, the cholesteatoma warrants surgical intervention, and therefore more conservative alternatives are not reasonable. The skin incision for the mastoidectomy should be mod- i\ufb01ed to incorporate the abscess cavity for adequate drainage. Once the ab- scess is drained, a mastoidectomy is performed and the cholesteatoma matrix is removed in the standard manner.
A Bezold\u2019s abscess is a cervical abscess that develops from pathology sim- ilar to the subperiosteal abscess. In the presence of coalescent mastoiditis, if the mastoid cortex is violated at its tip, as opposed to its lateral cortex, an abscess will develop in the neck, deep to the sternocleidomastoid. This ab- scess will present as a tender, deep, poorly de\ufb01ned mass in level two of the neck. Because the abscess develops from air cells at the tip of the mas- toid, it is found in older children and adults, where pneumatization of the mastoid has extended to the tip. Most of these abscesses result from direct extension through the cortex, but transmission through an intact cortex by way of mastoid vein phlebitis is known to occur. Although Bezold\u2019s ab- scess is more commonly a complication of AOM with mastoiditis in chil- dren, it is a known complication of COM with cholesteatoma.
A contrasted CT scan of the neck and mastoid is recommended to make the diagnosis of a Bezold\u2019s abscess. The presentation of an enlarged, ten- der, deep neck mass must be di\ufb00erentiated from in\ufb02ammatory cervical lymphadenopathy, which is di\ufb03cult on clinical grounds alone. CT scans
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