American Journal of Emergency Medicine 31 (2013) 1626.e3–1626.
e4
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Case Report
Bezold abscess: a rare complication of mastoiditis☆
Abstract
Bezold abscess is a rare complication of mastoiditis in which
patients are often well appearing but require urgent intervention to
prevent serious sequelae. We describe the case of a Bezold abscess in a
12-year-old girl.
A 12-year-old Hispanic girl presented to the emergency depart-
ment (ED) with a chief complaint of neck swelling. She reported
approximately 1 week of upper respiratory symptoms consisting of
sore throat and, later, left ear pain. Mildly tender left neck swelling
was noted over the past 36 hours and did not limit range of motion.
The patient had felt febrile during the day but otherwise had a
negative review of symptoms. The child was immunized and had no
other relevant medical history.
Vital signs were notable for a temperature of 100.5°F and a
heart rate of 125 beats per minute. The child was nontoxic. The
child's examination was otherwise normal except for her left ear
and neck examination. The left ear canal was edematous and filled
with purulent exudate. The left auricle was without displacement
or skin change and was nontender with movement. Behind the left
ear, there was mild swelling with tenderness and erythema
(Fig. 1). Tender left-sided lateral neck swelling without appreciable
warmth or erythema was noted, involving the upper half of the
posterior triangle.
The patient underwent computed tomography (CT) of the neck
with intravenous contrast for concern of mastoiditis and abscess
formation (Fig. 2). The CT demonstrated extensive opacification of the
left mastoid temporal bone consistent with acute otomastoiditis. In
addition, there was bony erosion and destruction of the mastoid tip
inferiorly (Fig. 2) with extensive surrounding inflammation within
the adjacent soft tissues and a 1 cm peripherally enhancing,
developing Bezold abscess with diffuse reactive adenopathy within
the left neck.
Otolaryngology was consulted in the ED, and the patient was
started on intravenous clindamycin and dexamethasone and cipro-
floxacin-dexamethasone otic drops pending surgery. The next day
the patient underwent operative intervention where cultures
demonstrated group A β-hemolytic Streptococcus pyogenes. The
patient continued to improve and was discharged on hospital day 3
to her home.
In 1881, Friedrich Bezold first reported the finding of purulent
collection tracking from the medial side of the mastoid process
through the incisura digastrica [1]. He found that 20% of mastoiditis
cases developed this abscess now named after him. In the post-
☆ Reprints not available from the authors.
0735-6757/$ – see front matter © 2013 Elsevier Inc. All rights reserved.
antibiotic era, Bezold abscess is now considered a very rare
complication of mastoiditis, which itself is a rare complication of
acute otitis media, occurring in an estimated 2 of 1000 to 2 of 100 000
of cases [2,3]. A recent review by Uchida et al in 2002 documented
only 18 cases in the Japanese literature of Bezold abscess since 1960,
and a recent review by Marioni et al in 2001 documented only 35
cases in literature available to them since 1967 [4,5]. Cross-examining
these 2 reviews shows no overlap between these documented cases.
Bezold abscess may occur in any age group, but most commonly
occurs in older children and adults. Pneumatiziation of the mastoid
bone in late childhood causes thinning of the mastoid bone, making
erosion through the bone and abscess formation easier [4]. The thick
bone throughout infancy and early childhood protects against this
process, although cases have been described [4,5]. Streptococcus
pneumoniae and Streptococcus pyogenes have been implicated as the
most common organisms in cases of Bezold abscess. Both Uchida et al
and Marioni et al noted associations of cholesteatoma and chronic
otitis media with Bezold abscess.
Patients diagnosed with Bezold abscess typically present with
gradual fever, otorrhea, otalgia, and neck tenderness with or
without obvious swelling over a period of days. This neck swelling
may also cause torticollis, restriction in range of motion, odyno-
phagia, or trismus. Patients may not appear toxic and often appear
less ill than patients with mastoiditis without Bezold abscess. As a
result, they are typically triaged to lower acuity levels. This
difference may be attributed to the rupture of the mastoid air
cells, alleviating some of the discomfort (similar to the decreased
pain seen in ruptured acute otitis media). Overall, their symptoms
may appear similar to a ruptured acute otitis media with
lymphadeonpathy. Important distinguishing characteristics are
physical examination findings suggestive of mastoiditis (postauri-
cular erythema, swelling, auricular displacement) and tenderness
along the sternocleidomastoid muscle near the course of the
abscess. Postoperative and immune-suppressed individuals may
have atypical presentations.
Laboratory testing is typically unhelpful in the diagnosis and
management of Bezold abscess [4]. If Bezold abscess is suspected,
CT is the diagnostic test of choice [6]. Computed tomography
allows for the diagnosis of mastoiditis and may identify complica-
tions of mastoiditis that are not clinically apparent, such as Bezold
abscess or intracranial sinus thrombosis. Computed tomography
also aids in the surgical approach to abscess drainage and
determining if mastoidectomy is warranted. Once identified, Bezold
abscess should be treated aggressively with broad-spectrum
antibiotic therapy until culture results can be obtained. Otolaryn-
gology should be consulted urgently to provide surgical drainage
[3]. There is no clear indication for the use of steroids or otic drops
in the management of Bezold abscess, and this should be left to the
discretion of the otolaryngologist.
1626.e4 D. Nelson, R. Jeanmonod / American Journal of Emergency Medicine 31 (2013) 1626.e3–1626.e4
Fig. 1. Mild swelling with tenderness and erythema behind the left ear.
Complications associated with Bezold abscess stem from tracking
of the infection along the fascial planes of the digastric and
sternocleidomastoid muscles, invading the caroitid sheath [4]. This
may lead to internal jugular venous thrombosis or subsequent
intracranial sinus thrombosis [5]. Typically, patients with Bezold
abscess without other significant comorbidities, who are treated
aggressively with broad-spectrum antibiotic therapy and urgent
otolaryngology consultation for possible surgical intervention, have
complete recovery within 5 to 10 days [3].
Emergency physicians must be aware of this rare, serious
complication of mastoiditis as patients may paradoxically appear
less toxic. Physicians should remember the associations with chronic
otitis media and cholesteatoma, distinguish lymphadenopathy from
sternocleidomastoid infection, and have a low threshold for diagnos-
Fig. 2. CT showing extensive opacification of the left mastoid temporal bone con-
sistent with acute otomastoiditis and bony erosion and destruction of the mastoid
tip inferiorly.
tic imaging with CT. With appropriate intervention, systemic infection
and other complications may be avoided.
Drew Nelson MD
Rebecca Jeanmonod MD
St Luke's University Health Network, Bethlehem, PA 18015, USA
E-mail address: drew.m.nelson@gmail.com
http://dx.doi.org/10.1016/j.ajem.2013.06.036
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