The Journal of Emergency Medicine, Vol. 44, No. 3, pp.

670–672, 2013
Published by Elsevier Inc.
Printed in the USA
0736-4679/$ - see front matter

http://dx.doi.org/10.1016/j.jemermed.2012.07.066

Visual Diagnosis
in Emergency Medicine

DIAGNOSIS OF BEZOLD ABSCESS USING BEDSIDE ULTRASOUND

Michael Secko, MD, RDMS and Andrew Aherne, MD

Department of Emergency Medicine, SUNY Downstate/Kings County Hospital Center, Brooklyn, New York
Reprint Address: Michael Secko, MD, RDMS, Department of Emergency Medicine, SUNY Downstate/Kings County Hospital Center,
451 Clarkson Ave., Brooklyn, NY 11203

CASE REPORT The patient’s vital signs were: blood pressure 112/76
mm Hg, heart rate 88 beats/min, respiratory rate 17
A 32-year-old man with human immunodeficiency virus breaths/min, temperature 37 C (98.6 F), oxygen satura-
(HIV) disease presented to the Emergency Department tion 99% on room air, and a glucose finger stick of 84.
complaining of right-sided earache and discharge accom- His physical examination was significant for mild ery-
panied by right-sided neck pain and swelling. He reported thema of the right external canal, with a ruptured tym-
that his symptoms started 12 days prior with sinus conges- panic membrane with suppurative drainage into the ear
tion, initially on the left side, with eventual spread to the canal. There was no deformation of the outer ear.
right. He had completed a full course of amoxicillin and
Avelox (Merck & Co., Whitehouse Station, NJ) for sinus-
itis but continued to have sinus congestion, and subse-
quently developed right ear pain. Approximately 5 days
before presentation, he noticed swelling to the anterolateral
aspect of his right neck, as well as purulent drainage from
his right ear. Review of systems revealed non-productive
cough and one episode of vomiting. In addition, he reported
mild neck pain when rotating his head to the left, but no
meningismus. He denied fever, chills, hearing loss, tinni-
tus, vision changes, or eye pain. Furthermore, he denied
headache, dizziness, chest pain, shortness of breath,
abdominal pain, recent trauma, or recent swimming.
His past medical history was significant for HIV dis-
ease on current HAART (highly active antiretroviral ther-
apy) with a recent CD4 count of >500. In the previous
Figure 1. A linear array ultrasound image in the coronal plane
month, the patient reported having two cutaneous ab- at the level of the mastoid bone. The left image demonstrates
scesses, one to the scalp and one to the right buttocks, the normal mastoid bone (M) with the attachment of the
which required incision and drainage, with no antibiotics. sternocleidomastoid muscle (SCM). The right image demon-
strates hypoechoic fluid collection (arrows) between the
Cultures and antibiotic sensitivities were not available for mastoid and sternocleidomastoid muscle concerning for an
these visits. abscess.

RECEIVED: 13 February 2012; FINAL SUBMISSION RECEIVED: 12 April 2012;

ACCEPTED: 4 July 2012

670

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Bezold Abscess
Figure 2. (A) Computed tomography (CT) of the head demonstrates edema of the maxillary, sphenoid, and mastoid air cells
(arrows) consistent with sinusitis. (B) CT of the neck at the level of the mandible demonstrates a small hypodense lesion in the
area of the sternocleidomastoid muscle (arrow) consistent with abscess.
The right mastoid was tender to palpation, with no fluctu-
ant or overlying skin changes. Approximately 3 cm below
the right mastoid and extending 10 cm inferiorly was an
area of firm, tender, edematous tissue with overlying
erythema but no induration, fluctuance, or drainage.
There was no right submental or sublingual swelling,
no uvular deviation or tonsillar exudates, and no trismus.
Lymph nodes were palpable over right posterior and
lower cervical chain. The remainder of his head and
neck examination, including eyes and contralateral ear,
were unremarkable, as was the remainder of his physical
examination.
A bedside soft-tissue ultrasound with the use of a high
frequency linear array probe to the mastoid was per-
formed to evaluate the right neck swelling for an abscess
or lymphadenopathy. Ultrasound revealed a complex
hypoechoic-anechoic fluid adjacent to mastoid bone and
sternocleidomastoid muscle concerning for an abscess
(Figure 1). Laboratory work revealed a white blood cell
count of 7.07. Intravenous (i.v.) ceftriaxone was adminis-
tered for presumed mastoiditis and probable abscess, and
a computed tomography (CT) scan of the neck and tem-
poral bone with i.v. contrast was performed (Figure 2).
CT scan of the neck and temporal bones revealed
a near-complete opacification of the right middle ear
and mastoid air cells, reported as compatible with otitis
media and mastoiditis. Also visualized on the patient
CT scan was an adjacent 8-mm hypodensity invading
the right sternocleidomastoid muscle consistent with
a small abscess. Bilateral prominent lymph nodes were
visualized along the submental, submandibular, and
jugular chain.
The patient was evaluated by an otolaryngologist and
went to the operating room for operative management of
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671
a Bezold abscess. The patient was placed on i.v. antibi-
otics for a few days and was discharged home on hospital
day 4 with an uneventful recovery.
DISCUSSION
A Bezold abscess is a complication of acute otomastoidi-
tis, in which an infectious collection develops deep to the
sternocleidomastoid and digastric muscles, or between
layers of deep cervical fascia, typically as a result of ero-
sion through the cortex of the mastoid. It can also develop
without mastoiditis if there is a propagation of local
infection in the same vicinity. Spread of the infection
can involve the larynx, mediastinum, paravertebral and
retropharyngeal space, as well as the axilla. Due to its
close proximity to the internal jugular vein, thrombosis
of this vessel is a potential complication (1).
It is most common in older children, in whom
pneumatization extends to the tip of the mastoid, allowing
for relatively easy perforation. Adults affected by this
complication are typically those with a history of chronic
sinusitis or cholesteatoma. Due to minimal pneumatiza-
tion of the mastoid, it is not commonly seen in infants
(2). Before widespread availability of antibiotics, up to
20% of reported cases of mastoiditis were complicated
by Bezold abscesses (1). With early antibiotic treatment
of mastoiditis, it has become a rare complication.
Diagnosis of a Bezold abscess should be a part of a
clinician’s differential diagnosis in patients presenting
with neck pain and swelling, as its depth makes it difficult
to palpate, and it is easily mistaken for tender lymphade-
nopathy in patients with localized infections in the same
region. Symptoms are non-specific, and can include fe-
ver, otalgia, neck swelling and pain, and limited motion.
672 M. Secko and A. Aherne

As such, any suspicion for a Bezold abscess should be in- REFERENCES

vestigated via diagnostic imaging, including CT scan, the
test of choice (3). Despite limited literature supporting its
use in the diagnosis of Bezold abscess, ultrasound can be
helpful in differentiating lymphadenopathy from fluid
collections in the soft tissues of the neck as well as the
mastoid itself, thereby directing the clinician toward CT
imaging and diagnosis (4,5). Patients with a confirmed
diagnosis of Bezold abscess require broad-spectrum
antibiotics and surgical excision of the affected mastoid
tissue and drainage of the abscess (2).
1. Gaffney RJ, O’Dwyer TP, Maguire AJ. Bezold’s abscess. J Laryngol
Otol 1991;105:765–6.
2. El-Kashlan HK et al. Complications of temporal bone infections.
Cummings otolaryngology: head & neck surgery. 5th edn. Maryland
Heights, MO: Mosby Inc.; 2010:1979–1998.
3. Castillo M, Albernaz VS, Mukerji SK, Smith MM, Weissman JL. Im-
aging of Bezold’s abscess. AJR Am J Roentgenol 1998;171:1491–5.
4. Ahuja AT, Ying M. Sonographic evaluation of cervical lymph nodes.
AJR Am J Roentgenol 2005;184:1691–9.
5. Squire BT, Fox JC, Anderson C. ABSCESS: applied bedside sonog-
raphy for convenient evaluation of superficial soft-tissue infections.
Acad Emerg Med 2005;12:601–6.

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