Bezold Abscess


Article Author:
Michael Lepore


Article Editor:
Zachary Geiger


Editors In Chief:
Venkat Minnaganti
John Brusch
Janak Koirala


Managing Editors:
Avais Raja
Orawan Chaigasame
Carrie Smith
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Khalid Alsayouri
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Heba Mahdy
Ahmad Malik
Mark Pellegrini
James Hughes
Beata Beatty
Nazia Sadiq
Hajira Basit
Phillip Hynes
Tehmina Warsi


Updated:
1/11/2019 6:10:15 PM

Introduction

Bezold Abscess is a rare deep neck abscess resulting from an intertemporal complication of a coalescent mastoiditis. It was first described by a German Otologist Dr. Friedrich Bezold in 1881. Since the introduction of antibiotics, the number of reported cases of Bezold abscesses have significantly decreased. According to some authors, since 1967 there have been only 35 reported cases in the English literature, of which only four cases occurred in children under the age of five. [1][2][3]

Etiology

The organisms commonly cultured from Bezold abscesses include gram-positive aerobes: Streptococcus, Staphylococcus, and Enterococcus species; gram-negative aerobes: Klebsiella, Pseudomonas, and Proteus species and anaerobes, particularly Peptostreptococcus and Fusobacterium species. [1] 

Epidemiology

Many factors have been shown to play a role in the development of acute, chronic, and suppurative otitis media in children. Factors include the following: 

  1. Socioeconomic conditions: there is an increase in the number of the cases in children living in poorer socioeconomic conditions.
  2. Daycare: there appears to be an increase in children attending day care.
  3. Underlying medical conditions that affect the Eustachian tube function: children with cleft palate, craniofacial anomalies, congenital or acquired immune dysfunction, conditions affecting the ciliary function of the Eustachian tube and middle ear mucosa.

In adults, medical considerations that must be considered are the patient HIV status, history of uncontrolled diabetes, renal failure, and patients who are immunosuppressed.

Pathophysiology

The most important contributing factor in the development of a Bezold abscess is the presence of a well-aerated and pneumatized mastoid bone. At birth, the mastoid bone consists mainly of an antral cell. From this antral cell, air cells begin to develop until there is complete pneumatization of the mastoid bone around the age of five. As the process of pneumatization of the mastoid bone occurs, the surrounding walls of the mastoid bone thin, particularly at the tip of the mastoid bone on its medial surface along the incisura digastrica (digastric groove) where the digastric muscle attaches. If the infection is left unchecked, the outer walls of the mastoid tip become involved with the spread of the infection along the sternocleidomastoid muscle, the trapezius, and splenius capitis muscles. Secretions and bacteria can enter the middle ear through the eustachian tube and from the middle ear can pass directly into the mastoid bone through a small opening the aditus ad antrum. During an inflammatory process (suppurative otitis media), obstruction of the aditus ad antrum occurs. Purulent secretions cannot escape and will accumulate in the mastoid bone. The pressure created by this purulent material with its enzymatic activity within the mastoid bone causes osteitis and osteonecrosis of the fragile pneumatized air cells further thinning the walls of the mastoid bone. This stage is Coalescent Mastoiditis. The inflammatory process can spread in many directions. If it spreads inferiorly towards the mastoid tip, the purulent material will eventually erode the very thin bone along the digastric ridge at the insertion of the digastric muscle. Consequently, a purulent material will spread into the neck between the digastric and sternocleidomastoid muscles.[4]

History and Physical

Bezold abscess may occur in both children and adults with well-developed mastoid bones. Both may have had a history of recurrent otitis media or chronic otitis media with tympanic membrane perforation and a draining ear. Prior mastoid surgery for cholesteatoma normally causes further thinning of the mastoid walls making it easier for infection to spread. An important early clinical sign of a coalescent mastoiditis on physical examination is sagging of the posterior superior external auditory canal. Other common clinical signs include the following:

  • neck pain
  • swelling in the lateral neck
  • post auricular tenderness over the affected mastoid bone
  • otalgia
  • otorrhea
  • hearing loss

If any of the above are documented, and the patient presents with fever with an associated neck mass one should have a high index of suspicion that the infection has spread to adjacent regions within the head and neck. Thus a thorough head and neck evaluation should always be conducted. In the differential diagnosis, one must always consider an abscess of post-auricular lymph nodes. If CT scanning is not available, then a simple lateral x-ray of the temporal bone may be helpful in ascertaining the status of the mastoid air cell system.

Evaluation

Laboratory evaluations are often not helpful since the leukocyte count and erythrocyte sedimentation rate may be normal. Contrast computed tomography should be obtained if there is any indication or suspicion of a deep neck abscess, regardless of a lack of evidence of an infection in the mastoid bone since prior antibiotics may have truncated the infection in the mastoid bone while the abscess was still developing in the neck. Recently, in the emergency room setting, a bedside soft-tissue ultrasound with the use of a high-frequency linear array probe to the mastoid was used to detect a complex hypoechoic-anechoic fluid collection in the neck. An intravenous contrast CT scan was used to confirm the ultrasound findings, and both an abscess in the neck and ear pathology were identified.[5][6]

Treatment / Management

If a Bezold abscess is present or suspected, practitioners should use intravenous broad-spectrum antibiotics. Once antibiotic therapy is initiated, a contrast CT scan should be obtained. Naturally, cultures are important, particularly if you are dealing with a diabetic or immunocompromised patient since the bacteriology in these cases may be different. If surgical management is indicated, in adults, a post-auricular incision is made, and a simple, complete mastoidectomy should be performed. The objective is to remove as much osteitic bone and granulation tissue present in the mastoid bone. In rare cases, a Bezold abscess may appear in children before there is a complete development of the mastoid air cell system. In these patients, the practitioner must pay particular attention to the position of the facial nerve. Therefore, they should not make a standard post-auricular incision since the facial nerve may be more superficial than anticipated. In this case, a post-auricular superior linear incision is made to drain the purulent material and carefully debride as much granulation tissue as possible. At the same time, the neck abscess should be thoroughly drained. Broad-Spectrum antibiotics should be continued until a final resolution is obtained to prevent further extension of the inflammatory process to adjacent vascular structures.[1][7]

Differential Diagnosis

Lymph nodes are present in the postauricular region. If an abscess occurs within the lymph node post auricular swelling and protrusion of the ear may occur that can mimic the beginning of a Bezold Abscess. 

A lateral x-ray of the mastoid bone in this case will have a normal pneumatization present.

Prognosis

The prognosis is good if the infection has not spread beyond the temporal bone and, if antibiotic intervention occurs early on. 

Complications

If the infection is not contained and treated, the infection may spread to the following areas: the sigmoid sinus, the transverse sinus, the meninges and along the carotid sheath which can complicate the overall prognosis for the patient.

Consultations

  • ENT
  • Neurosurgeon
  • Infectious disease

Pearls and Other Issues

As mentioned previously, because of the advent of antibiotic therapy in the treatment of acute, chronic and suppurative otitis media, Bezold abscesses are rarely seen. Still, practitioners should have a high index of suspicion in cases where patients present with a neck mass and clinical signs of previous ear pathology or concurrent ear pathology.

Enhancing Healthcare Team Outcomes

Bezold abscess is a deep neck abscess resulting from a complication of mastoiditis. Bezold abscess is not a common condition and is unlikely to be seen by most surgeons in their practice. However, even though rare, it has to be considered in the differential diagnosis of neck abscesses. If the diagnosis is delayed, the abscess can extend both extracranially and intracranially, causing a high morbidity. 

The diagnosis of a Bezold abscess can be missed if it is simply considered to be just another neck abscess. For this reason, an interprofessional team with a systemic approach to neck abscesses is recommended. Once a neck abscess around the ear is noted, the following should be consulted:

  • Radiology to obtain imaging tests to determine the origin, location, and extent of the abscess
  • ENT for debridement and drainage of the abscess
  • Laboratory technologists to determine the type of bacterial growth
  • Pharmacists to recommend the most appropriate antibiotics and manage the emesis
  • Nurses to monitor vital signs and presence of altered mental status
  • Neurologist to monitor the patient for neurological deficits (e.g., facial paralysis)
  • Neurosurgeon if there is an intracranial extension of the abscess.[8]

Outcomes

So far there have only been anecdotal reports on Bezold abscess and its management. There are no randomized clinical trials that have evaluated treatment or outcomes. The few isolated reports indicate that when the condition is diagnosed promptly and treated with drainage, the prognosis is good. The key is prompt drainage.[1] (Level III) However, delay in diagnosis and treatment usually leads to poor outcomes and even death.


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Bezold Abscess - Questions

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Where is one is most likely to find a Bezold abscess?



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What organism rarely is associated with a Bezold abscess?



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Considering the procedures below, what is the most common surgical procedure performed on the temporal bone when a Bezold abscess is present?



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There are many factors contributing to the development of a Bezold abscess. Which of the factors listed below is one of the most important?



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Bezold Abscess - References

References

Govea-Camacho LH,Pérez-Ramírez R,Cornejo-Suárez A,Fierro-Rizo R,Jiménez-Sala CJ,Rosales-Orozco CS, [Diagnosis and treatment of the complications of otitis media in adults. Case series and literature review]. Cirugia y cirujanos. 2016 Sep-Oct     [PubMed]
Lin YH,Lin MY, Bezold abscess. Ear, nose,     [PubMed]
Nelson D,Jeanmonod R, Bezold abscess: a rare complication of mastoiditis. The American journal of emergency medicine. 2013 Nov     [PubMed]
Walls A,Pierce M,Krishnan N,Steehler M,Harley EH Jr, Pediatric head and neck complications of Streptococcus pneumoniae before and after PCV7 vaccination. Otolaryngology--head and neck surgery : official journal of American Academy of Otolaryngology-Head and Neck Surgery. 2015 Feb     [PubMed]
Mantsopoulos K,Wurm J,Iro H,Zenk J, Role of ultrasonography in the detection of a subperiosteal abscess secondary to mastoiditis in pediatric patients. Ultrasound in medicine     [PubMed]
Stokroos R, Radiology quiz case: Bezold abscess. Archives of otolaryngology--head     [PubMed]
Spiegel JH,Lustig LR,Lee KC,Murr AH,Schindler RA, Contemporary presentation and management of a spectrum of mastoid abscesses. The Laryngoscope. 1998 Jun     [PubMed]
Wu JF,Jin Z,Yang JM,Liu YH,Duan ML, Extracranial and intracranial complications of otitis media: 22-year clinical experience and analysis. Acta oto-laryngologica. 2012 Mar     [PubMed]

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