Bezold’s Abscess in Children

How could something as simple as acute otitis media cause so many problems?  We have previous discussed Gradenigo’s Syndrome and Acute Mastoiditis as complications of otitis media.  We also know that mastoiditis can have further complications, such as Lemierre’s Syndrome.  Now, let’s talk about a complication of mastoiditis for which we should remain vigilant– Bezold’s abscess.

Bezold’s Abscess- Basics

• Rare deep neck abscess [Lepore 2022, Marioni 2001, Smouha 1989]
  • Complication of coalescent mastoiditis
  • Abscess erodes through lateral mastoid cortex
  • Direct extension into the perimastoid tissues and down the sternocleidomastoid muscle
  • Invades deep cervical fascia including the SCM, trapezius, and splenius capitis
  • Can spread along the great vessels to the perivisceral space, larynx, or mediastinum
  • Can spread down vertebral column muscles to retropharyngeal space

• Number of reported cases vastly fewer since dawn of antibiotics [Lepore 2022, Marioni 2001, Smouha 1989]
  • Some literature report <100 cases since 1967
  • Only 4 cases in children <5 years old
  • Preferentially affects patients after pneumatization of the mastoid air cells
    • Is rare in children, more common in adults
    • Typically happens in older children if so
    • Only a few case reports of younger children
    • There is a case report of a 10 week old who developed a Bezold’s abscess subsequent to chronic mastoiditis. [Schondorf 2004]

• Organisms [Lepore 2022, Marioni 2001, Smouha 1989]
  • Gram positive: Strep, Staph, Enterococcus
  • Gram negative aerobes: Klebsiella, Pseudomonas, Proteus
  • Gram negative anaerobes: Peptostreptococcus, Fusobacterium

• At risk populations [Lepore 2022]
  • Immunosuppressed
  • Patients without access to antibiotics
  • History of recurrent otitis media
  • History of chronic otitis media with tympanic membrane perforation
  • Prior mastoid surgery for cholesteatoma due to further thinning of mastoid walls

Bezold’s Abscess- Presentation and Exam 

• Occurs in children and adults with well-developed and pneumatized mastoid bones [Lepore 2022, Marioni 2001]
• Presentation includes fever and neck mass with signs of mastoiditis [Lepore 2022, Marioni 2001]
  • In young children, may not have clinical signs of mastoiditis
• On differential also are: [Lepore 2022]
  • Abscess of post-auricular lymph nodes
  • Other deep neck space abscess from oropharyngeal or odontogenic sources
  • Malignancy 

Bezold’s Abscess- Diagnosis

• CT of neck with contrast is gold standard [Lepore 2022, Marioni 2001]
  • Lateral Xray of the temporal bone to eval mastoid air cell system if no CT available [Lepore 2022]
  • Examples:
    • https://radiopaedia.org/articles/bezold-abscess
    • https://abcradiology.blogspot.com/2011/12/bezold-abscess.html
    • https://emj.bmj.com/content/28/11/985
• Cranial nerve exam– progression into infratemporal fossa can cause cranial neuropathies [Lepore 2022]
• Labs are not helpful. WBC and ESR may be normal or elevated. [Lepore 2022, Marioni 2001]
• POC Ultrasound with high frequency linear probe has been used to detect deep space fluid collections. [Lepore 2022]

Bezold’s Abscess- Treatment

• IV broad spectrum antibiotics
  • Should have good CSF penetration

• Obtain cultures if possible
  • Especially in diabetic or immunocompromised patients
    • Bacteriology may be different
  • Surgical drainage aspirate

• Surgical drainage of abscess
  • Drainage from mastoidectomy if coalescent mastoiditis present
  • Removal of osteitic bone and granulation tissue
  • Tympanostomy tube placement if concurrent suppurative otitis media

Moral of the Morsel

• Bezold’s Abscess is a RARE complication of otitis media and mastoiditis.
• Vigilance is required in patients with previous ear pathology and a new neck mass!
• Bezold’s abscess more common in developing countries where access to antibiotics is difficult, or in immunosuppressed patients. Keep this in mind, global health gurus!
• Early and broad-spectrum antibiotics and surgical drainage can prevent further or permanent complications.

References:

1. Lepore ML, Hogan CJ, Geiger Z. Bezold Abscess. [Updated 2022 Feb 1]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2022 Jan-. Available from: https://www.ncbi.nlm.nih.gov/books/NBK436004/
2. Gino Marioni, Cosimo de Filippis, Alberto Tregnaghi, Rosario Marchese-Ragona, Alberto Staffieri. Bezold’s abscess in children: case report and review of the literature, International Journal of Pediatric Otorhinolaryngology, Volume 61, Issue 2, 2001, Pages 173-177, ISSN 0165-5876. https://doi.org/10.1016/S0165-5876(01)00564-X
3. Smouha EE, Levenson MJ, Anand VK, Parisier SC. Modern Presentations of Bezold’s Abscess. Arch Otolaryngol Head Neck Surg. 1989;115(9):1126–1129. doi:10.1001/archotol.1989.01860330116031
4. Schöndorf HJ, Roth B, Streppel M. Bezold’s Abscess following Chronic Mastoiditis in a Newborn. Annals of Otology, Rhinology & Laryngology. 2004;113(10):843-845. doi:10.1177/000348940411301013
5. Sheikh FT, Murday DC, Abbas A, et al. Bezold’s abscess. Emergency Medicine Journal 2011;28:985. https://emj.bmj.com/content/28/11/985