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 Table of Contents  
Year : 2022  |  Volume : 28  |  Issue : 2  |  Page : 178-180

A case of mastoiditis complicated with bezold abscess in the only hearing ear

1 Department of Otorhinolaryngology-Head and Neck Surgery, University Kebangsaan Malaysia Medical Centre, Kuala Lumpur, Malaysia
2 Department of Otorhinolaryngology-Head and Neck Surgery, University Kebangsaan Malaysia Medical Centre, Kuala Lumpur; Institute of Ear, Hearing and Speech, Faculty of Medicine, University Kebangsaan, Malaysia
3 Department of Radiology, University Kebangsaan Malaysia Medical Centre, Kuala Lumpur, Malaysia

Date of Submission20-Jan-2022
Date of Acceptance06-Mar-2022
Date of Web Publication21-Sep-2022

Correspondence Address:
Prof. Noor Dina Hashim
Department of Otolarhinolaryngology, Univerisiti Kebangsaan Malaysia Medical Center, Jalan Yaacob Latif, 56000 Cheras, Kuala Lumpur
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/indianjotol.indianjotol_13_22

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Bezold abscess (BZ) is defined as a deep neck abscess as the result of mastoiditis with mastoid tip erosion after otitis media (OM). Despite its rare occurrence due to the early intervention of ear infection with antibiotics, diligently looking for this complication is important, especially in the immunodeficient population. The utilization of radio imaging remains crucial in the management of acute OM with complications. The contrast-enhanced computed tomography facilitates the diagnosis and provides a glimpse of the disease extension. Early recognition and intervention are vital for a good outcome. The authors present a case report of a mastoiditis complicated with a BZ in the only hearing ear. The risk factors, presentations, and treatment options are discussed, along with the review of the literature.

Keywords: Abscess, hearing loss, mastoiditis, otitis media

How to cite this article:
Goh SP, Hashim ND, Zaki FM, Abdullah A. A case of mastoiditis complicated with bezold abscess in the only hearing ear. Indian J Otol 2022;28:178-80

How to cite this URL:
Goh SP, Hashim ND, Zaki FM, Abdullah A. A case of mastoiditis complicated with bezold abscess in the only hearing ear. Indian J Otol [serial online] 2022 [cited 2022 Sep 25];28:178-80. Available from: https://www.indianjotol.org/text.asp?2022/28/2/178/356445

  Introduction Top

Bezold abscess (BZ) was first described in 1881 by Dr. Friedrich Bezold, thereby leading to the bearing of his name. BZ is one of the extracranial complications of otitis media (OM), in which the medial mastoid tip is eroded as the result of OM and the infection spreads downward along with the sternocleidomastoid muscle (SCM). Late recognition and treatment, the abscess may progress to deep neck abscess and spread further downward to mediastinum. BZ is uncommonly seen in the pediatric population as its poorly pneumatized mastoid air cell. In the preantibiotics era, 50% of acute OM (AOM) advanced to mastoiditis in which 20% would be complicated by BZ. With the discovery and advancement in antibiotics and increased awareness of ear infections, BZ is rarely encountered in the era of modern medicine.[1] Herein, the authors report a case of a BZ in the only hearing ear (OHE). The authors wish to highlight the awareness of such unusual complications in OM and discuss the management algorithm OM in OHE.

  Case Report Top

A 59-year-old with underlying diabetes mellitus presented with 5 days of right ear pain and purulent discharge, associated with a painful neck swelling. For the past 5 months, he suffered from two episodes of AOM on the same ear, with a complete resolution of his symptoms with antibiotic treatment. Of note, he has a nonserviceable left ear as a result of complication of chronic OM which was treated with left mastoid surgery 17 years ago.

Physical examination revealed a right-sided neck swelling extending from the mastoid tip to the middle third of the SCM. The overlying skin was indurated, and the swelling was tender on palpation [Figure 1]. Torticollis and trismus were observed. Otoscopy showed an edematous right ear canal with an intact tympanic membrane. The facial nerve function was intact. Free-field voice test and tunning showed a severe conductive hearing loss, coherent with the pure-tone audiometry finding of a right severe to profound hearing loss with 10–45 dB air-bone gap.
Figure 1: (a) Right neck swelling extending from the right mastoid tip to the mid of the sternocleidomastoid muscle. (b) Purulent ear discharge with stenosed meatus

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An urgent contrast-enhanced computed tomography revealed a contrast-enhanced heterogonous soft-tissue opacification within the right sternocleidomastoid muscle with medial extension into the right parapharyngeal space. The right mastoid was sclerotic and soft-tissue density within mastoid air cells. Right mastoid segment of facial canal and ossicles was eroded [Figure 2]. Broad-spectrum intravenous ceftriaxone was commenced. He underwent an emergency cortical mastoidectomy with incision and drainage of the neck abscess, with an intention to evacuate the disease and promote ventilation of the middle ear. His symptoms markedly improved throughout the hospitalization. The culture yielded Klebsiella sp. He was discharge after completion of 10 days of antibiotics and optimization of sugar control. A subsequent follow-up at 6 months showed a distinct improvement on the hearing level of the right ear [Figure 3].
Figure 2: (a and b) Contrasted computed tomography showing collection in the parapharyngeal space (white asterisk). (c and d) Bony phase computed tomography depicted soft-tissue density within external auditory canal (white arrowheads), sclerotic mastoid (white arrow), and the evidence of mastoid tip erosion (black arrow)

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Figure 3: (a) Preintervention pure tone audiometry exhibited mixed severe to profound hearing loss with air-bone gap 45 dB. (b) Resolution of hearing loss with reduction of air-bone gap was observed in postsurgery pure-tone audiometry

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  Discussion Top

Mastoiditis is one of the complications of OM. BZ often occurs in well-pneumatized, thin mastoid tips. Further thinning of these pneumatized air cells is observed in coalescent mastoiditis. An ongoing inflammation in poorly ventilated mastoid air cells leads to erosion or breach of the lateral mastoid tip cortex, spreading the infection along with the deep neck spaces.[1] In the worst scenario, it may extend downward to cause mediastinitis.[2]

Conventionally, a constellation of symptoms which include fever, neck swelling, or limited neck movement in the presence of prior ear infection was observed in patients with BZ. In this antibiotics era, often, patients will not present with ongoing ear infections because of the masked mastoiditis preceding incomplete resolution of middle ear infection and mastoid air cells. In addition, Katayama et al. recently reported a BZ in a patient who only complained of generalized weakness after months of resolution of OM without the typical neck presentation.[3] Therefore, it is important to be more vigilant in managing immunocompromised patients with a history of acute or recurrent ear infections.

Timely medical and surgical interventions are the keys to successful treatment for mastoiditis with complications; immunocompromise causes should be addressed and optimized. Broad-spectrum antibiotics should be used, and the choice of antibiotics should be as per local recommendation. The more targeted antibiotics should be adjusted according to the culture and sensitivity results. A prolonged antibiotics course should be considered in those with immunosuppressed patients.

Surgical management of middle ear disease in OHE remains controversial. The main concern is that mastoid surgery may deteriorate the hearing. Risk of hearing loss can be minimized by experienced otologists with modern surgical techniques and instruments.[4] Yoo et al. and Kalcioglu et al. demonstrated that good surgical outcomes with hearing improvement and disease-free are observed in majority of the OHE patients.[4],[5] If surgery results of the total hearing loss, cochlear implant can be an option to help this group of patients regaining their hearing and to have a better quality of life.

In conclusion, early recognition of the complications is crucial in those who had prior or ongoing ear middle ear infections presenting with fever and painful neck swelling. Timely intervention is needed to stop the disease progression. Patients with OHE suffering from chronic ear infections should be managed by experienced otologists to eradicate the ear infection.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Financial support and sponsorship


Conflicts of interest

There are no conflicts of interest.

  References Top

Lepore ML, Hogan CJ, Geiger Z. Bezold Abscess. In: StatPearls. Treasure Island (FL): StatPearls Publishing; 2021.  Back to cited text no. 1
Silva VA, Almeida AS, Lavinsky J, Pauna HF, Castilho AM, Chone CT, et al. Thorax necrotizing fasciitis following Bezold's abscess. Clin Case Rep 2020;8:2848-51.  Back to cited text no. 2
Katayama K, Gomi H, Shirokawa T, Akizuki H, Kobayashi H. Bezold's abscess in a diabetic patient without significant clinical symptoms. IDCases 2018;12:e1-2.  Back to cited text no. 3
Kalcioglu MT, Cetinkaya Z, Toplu Y, Hanege FM, Kokten N. Chronic otitis media surgery in the only hearing ear. B-ENT 2015;11:223-7.  Back to cited text no. 4
Yoo MH, Kang BC, Park HJ, Yoon TH. Middle ear surgery in only hearing ears and postoperative hearing rehabilitation. Korean J Audiol 2014;18:54-7.  Back to cited text no. 5


  [Figure 1], [Figure 2], [Figure 3]


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