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REVIEW ARTICLE

Bezold’s abscess: A case report and review

of cases over 14 years
Hussain Al‑Baharna, Hassan Al‑Mubaireek, Viresh Arora
Department of Otolaryngology, Qatif Central Hospital, Eastern Province, Saudi Arabia

Bezold’s abscess is one of the rare complications of otitis media. It was named after Friedrich Bezold in
Abstract
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

Introduction surface. Bezold published a paper describing the effects of

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
Address for correspondence: Dr. Hussain Al‑Baharna,
4568 Mahmud Al Warraq Street, Al Qatif 32631‑7047, Eastern Province,
Saudi Arabia.
E‑mail: h.albaharna@gmail.com
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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
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DOI: How to cite this article: Al-Baharna H, Al-Mubaireek H, Arora V.

10.4103/0971-7749.187978 Bezold's abscess: A case report and review of cases over 14 years.
Indian J Otol 2016;22:148-51.

148 © 2016 Indian Journal of Otology | Published by Wolters Kluwer - Medknow |

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Al‑Baharna, et al.: Bezold's abscess: Review article
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
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].
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
Figure 1: Right side hard and tender neck mass on the sternomastoid
muscle area with skin erythematous changes
Indian Journal of Otology | July 2016 | Vol 22 | Issue 3 |
abscess yield Peptostreptococcus species. Postoperation, the
patient was covered with intravenous  (IV) ceftriaxone for
2 weeks and then discharge home in good condition.
Discussion
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%).
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]
Figure 2: Coronal T1 magnetic resonance imaging of the neck showing
abscess collection in the right sternomastoid muscle
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Al‑Baharna, et al.: Bezold's abscess: Review article

Table 1: Review of all reported cases of Bezold’s abscess in the English literature between 2000 and 2014
Author Year of Cases Age/sex Management Culture Coexistence complications/
publication number comorbidities
Marioni et al.[4] 2001 1 18 months/female IV cefotaxime Not available None
Zapanta et al.[5] 2001 1 17 years/female Mastoidectomy + decompression Alpha-hemolytic Multiple dural sinus thrombosis
of an epidural abscess + I and D + streptococci
IV clindamycin, ceftriaxone, and
vancomycin + myringotomy and tube
Uchida et al.[1] 2002 1 25 years/male Mastoidectomy + I and D + IV Staphylococcus + Cholesteatoma
antibiotics Veillonella species
Jose et al.[6] 2003 1 19 years/male I and D + IV flucloxacillin Staphylococcus None
aureus
Schöndorf et al.[7] 2004 1 10 weeks/female Mastoidectomy + IV antibiotic No growth None
Ching et al.[8] 2006 1 14 years/male Mastoidectomy + IV ceftriaxone and Streptococcus Lateral sinus thrombosis,
metronidazole milleri poststreptococcal
glomerulonephritis
Bhat and 2007 1 12 years/male I and D + IV ceftazidime + temporal Pseudomonas Pyogenic meningitis +
Manjunath[9] craniotomy + radical mastoidectomy aeruginosa cholesteatoma + sigmoid sinus
thrombosis + cerebellar abscess +
CSF otorrhea + perilymph fistula
McMullan[10] 2009 1 8 years/male Mastoidectomy + insertion of grommet No growth Sigmoid sinus thrombus
tube + I and D + IV cefotaxime,
clindamycin, vancomycin, meropenem
Vlastos et al.[11] 2010 1 3 years/female Mastoidectomy + IV clindamycin and Streptococcus Sigmoid sinus thrombosis and
ceftriaxone pneumoniae occipital osteomyelitis
Patel et al.[12] 2010 1 35 year/male Mastoidectomy + I and D + IV Not available HIV
piperacillin/tazobactam and
vancomycin
Sheikh et al.[13] 2011 1 26 years/male I and D of neck abscess Acid-fast Bacilli Prior cholesteatoma and
mastoidectomy
Mascarinas et al.[14] 2011 1 77 years/female Mastoidectomy+ I and D + IV Streptococcus Postradiation
antibiotic viridans
Li and Ren[15] 2012 1 32 years/female Mastoidectomy and I and D Not available Cholesteatoma
Janardhan et al.[16] 2012 1 60 years/male Mastoidectomy + I and D + IV Not available Congenital cholesteatoma
antibiotics
Secko and 2013 1 32 years/male I and D + IV ceftriaxone Not available HIV
Aherne[17]
Nelson and 2013 1 12 years/female IV clindamycin + dexamethasone + I Streptococcus None cholesteatoma
Jeanmonod[18] and D pyogenes
Lionello et al.[19] 2013 1 35 years/male Mastoidectomy + I and D + IV No growth
ceftriaxone and metronidazole
Our case 2014 1 73 years/male Mastoidectomy + I and D + IV Peptostreptococcus Diabetes, hypertension, renal
ceftriaxone species impairment, and cardiomyopathy
I and D: Incision and drainage, IV: Intravenous, CSF: Cerebrospinal fluid

developmental of more resistant pathogen species,[3] and other reviews. This is most likely because the pediatric cases
unfamiliarity of the disease to the physician. are reported more in the literature since they are less common.

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
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

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Al‑Baharna, et al.: Bezold's abscess: Review article
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
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.
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