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Bezold abscess

June 4, 2015 by Yu-Hsuan Lin, MD; Ming-Yee Lin, MD


| REPRINTS
Otoscopic Clinic

In some circumstances, the only sign or symptom of Bezold abscess is an unnoticed neck
lump.
Bezold abscess is an extremely rare otogenic complication. However, its initial manifestation
might appear to be fairly nonthreatening, which can lead to a delay in diagnosis. Maintaining
a high level of clinical suspicion and the early use of radiologic imaging can guide clinicians
in the diagnosis and surgical or medical management of this condition.
A 49-year-old man (a scuba diving instructor) came to our clinic with a 1-week history of a
progressively enlarging asymptomatic lump in the right side of his neck. He had been treated
for otitis media 20 days earlier, which led to a marked alleviation of his symptoms.
On examination, otoscopy revealed the presence of a rounded mass that was adherent to a
thickened eardrum, along with an active discharge (figure, A). Contrast-enhanced computed
tomography (CT) of the neck detected a peripherally enhancing abscess that involved the
right sternocleidomastoid muscle and an eroded mastoid tip (figure, B). Temporal bone CT
revealed opacification within the middle ear cavity and mastoid bone, which established a
diagnosis of otitis media complicated by Bezold abscess.

Figure. A: Otoscopic examination shows the rounded mass (asterisk)


adhering to the posterior aspect of the swollen right tympanic
membrane and the discharge of pus. B: Postcontrast CT of the neck
shows the peripheral enhancing abscess involving the
sternocleidomastoid muscle and an eroded mastoid tip (arrows).

The patient underwent neck debridement with pus drainage, an excisional biopsy of the ear
canal mass, and a mastoidectomy, which showed the presence of granulation tissue visible
under microscopy. The culture grew a sensitive strain of Klebsiella pneumoniae. The patient
recovered uneventfully after receiving intravenous antibiotics.
Bezold abscess was first described in 1881 by Frederick Bezold as a complication of otitis
media.1 It typically manifests as a nonfluctuating lateral neck abscess below the mastoid
tip.2,3 Classically, the disease presents as pus oozing from the digastric groove and tracking
along the fascial planes of the digastric and/or sternocleidomastoid muscles.2,3 The vast
majority of patients with Bezold abscess are adults who have a well-pneumatized mastoid
process.2,3
The incidence of Bezold abscess declined dramatically after the introduction of antibiotics
and the refinement of well-developed healthcare systems.2-4 However, reports still
occasionally emerge from developed industrialized countries, suggesting that unresolved
issues remain.4
In some circumstances, the only sign or symptom of Bezold abscess is an unnoticed neck
lump.2 A tenacious course of infection often occurs in immunocompromised patients, in
patients with an indomitable bacterial strain, and in patients with neglected latent
mastoiditis.4 Therefore, a thorough understanding of the chronology of events and early use
of CT scanning are necessary for the successful management of suspected cases.2-4 Surgical
removal of actively infected tissue remains the principal form of management.2-4

References
1.
2.
3.
4.

Bezold F. Ein neuer Weg fr die Ausbreitung eitriger Entzndung aus den Rumen des Mittelohrs aus
die Nachbarschaft. Dtsch Med Wochenschr 1881; 28:381-4.
Spiegel JH, Lustig LR, Lee KC ,et al. Contemporary presentation and management of a spectrum of
mastoid abscesses. Laryngoscope 1998; 108 (6): 822-8.
Castillo M, Albernaz VS, Mukherji SK ,et al. Imaging of Bezold's abscess. AJR Am J Roentgenol 1998;
171 (6): 1491-5.
Leskinen K, Jero J. Acute complications of otitis media in adults. Clin Otolaryngol 2005; 30 (6): 511-16.

From the Department of Otolaryngology-Head and Neck Surgery, Kaohsiung Veterans General Hospital,
Kaohsiung, Taiwan.

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