What is Bezold Abscess?
Bezold’s abscess is a rare abscess, which is a collection of pus, located deep in the neck. It’s a complication from a disease called coalescent mastoiditis, where the infection spreads from the mastoid bone in the ear to the area near where the sternocleidomastoid muscle, a major muscle in the side of the neck, attaches. Once the infection gets to this area, it can move further into the space beneath the jaw and beneath a layer of tissue in the neck called the deep cervical fascia.
When the infection spreads in this layer, it can cause progressive cellulitis, which is a skin infection that can result in an abscess, or even travel towards the sheath protecting the carotid artery, which is a major blood vessel in the neck. This can cause a dangerous condition called thrombosis in the jugular vein, which is a clot that slows or stops blood flow.
This condition was first discovered by a German ear doctor named Dr. Friedrich Bezold in 1881. However, since the development of antibiotics, cases of Bezold’s abscess have dropped dramatically. Some say that since 1967, there have been less than 100 cases reported in English medical literature, with only four of them occurring in children under five years old.
What Causes Bezold Abscess?
A Bezold’s abscess is an infection that is typically caused by certain types of bacteria. These bacteria usually include Streptococcus, Staphylococcus, and Enterococcus species, which are gram-positive aerobes, meaning these bacteria thrive in oxygen-rich environments. Additionally, gram-negative aerobes, such as Klebsiella, Pseudomonas, and Proteus species, as well as certain types of anaerobes, specifically Peptostreptococcus and Fusobacterium species, are also commonly found.
These are the same types of bacteria involved in an infection called coalescent mastoiditis, which often develops into a Bezold’s abscess. Today, a Bezold’s abscess is a very rare type of infection, thanks to modern medicine. However, people with weakened immune systems or those who don’t have access to antibiotics are more likely to get this infection.
Risk Factors and Frequency for Bezold Abscess
Several factors can contribute to the development of different types of ear infections in children, such as acute, chronic, and suppurative otitis media. Bezold’s abscess is a severe complication that can occur if a specific kind of ear infection, known as suppurative otitis media (SOM), is not recognized or treated adequately.
- Socioeconomic conditions: children from lower socioeconomic backgrounds seem to have a higher risk.
- Daycare attendance: The number of cases seems to increase amongst kids who attend daycare.
- Medical conditions affecting the Eustachian tube: Children with conditions like a cleft palate, craniofacial defects, inherited or developed immune system problems, or diseases affecting the ciliary function of the ear’s Eustachian tube and middle ear lining are at risk.
In adults,
- HIV status, uncontrolled diabetes, kidney failure, or being immunosuppressed for various reasons are significant factors to consider.
- Also, individuals who have chronic, untreated ear problems and do not have regular access to medical care and antibiotics may develop severe, late-stage manifestations of SOM.
Signs and Symptoms of Bezold Abscess
Bezold’s abscess is a condition that can affect both children and adults, particularly those with well-developed mastoid bones in the ear. It’s often associated with a history of recurring or chronic ear infections, and ear drum perforation with pus draining from the ear. Having prior ear surgery to remove skin growths (cholesteatoma) can thin the walls of this bone, making it easier for infections to spread. An early sign of Bezold’s abscess is a sagging appearance in the upper rear part of the ear canal.
Other common symptoms include:
- Neck pain
- Swelling in the side of the neck
- Tenderness behind the ear over the affected mastoid bone
- Ear pain
- Pus draining from the ear
- Hearing loss
If these symptoms are present and the patient has a fever and a neck lump, it’s important to consider that the infection may have spread within the head and neck area. Consequently, a comprehensive evaluation of the head and neck should be conducted. Other conditions such as post-ear lymph node abscesses, deep neck abscesses from throat or tooth origin, and cancer should also be considered in the diagnosis. To check the status of the mastoid air cells, a simple side X-ray of the bone near the ear can be helpful if a CT scan isn’t available. Monitoring the cranial nerves is crucial, as the infection’s spread into the space under the temple can affect these nerves and cause related problems.
Testing for Bezold Abscess
The diagnosis for certain medical conditions isn’t always straightforward, as blood test results, like white blood cell count and erythrocyte sedimentation rate (which is a test that detects inflammation in the body) may be normal. This makes an initial diagnosis primarily based on a doctor’s observations and examination.
If there’s any reason to suspect a deep neck abscess, which is a pocket of pus that gathers around the neck due to an infection, contrast-enhanced computed tomography (CT) of the neck should be performed, regardless if there’s no clear evidence of infection in the mastoid bone, the bone behind your ear. This is because previous antibiotics might have curtailed the infection in the mastoid bone while the abscess in the neck was developing.
Recently, a bedside ultrasound, which is a scan that uses high frequency sound waves to create images of the inside of the body, has been used in the emergency room to identify abnormal fluid collections in the neck. This was followed by an intravenous contrast CT scan to verify the ultrasound findings. This process helped to identify both neck abscess and ear issues.
If a palpable fluctuance (a swollen area that feels like it’s filled with fluid) is found, doctors may perform a needle aspiration. This is a procedure where a needle is used to draw out the fluid. However, great care needs to be taken during this procedure.
Treatment Options for Bezold Abscess
If a Bezold’s abscess, a type of deep neck infection, is detected or suspected, the patient should immediately receive intravenous broad-spectrum antibiotics, which are designed to kill many different types of bacteria. After starting on antibiotics, the patient will need to undergo a contrast-enhanced CT scan. This is a type of X-ray test that uses a dye to make clearer pictures of the body. Taking cultures, which are lab tests used to detect bacteria or other microorganisms in a sample, is also vital, especially in patients who have diabetes or weakened immune systems as the bacteria involved might differ.
If the CT scan shows a pocket of fluid, this would require surgical drainage. For a neck-based abscess, the surgeon will perform this procedure through the neck. If the patient also has infected mastoiditis, an infection of certain bones in the skull, another cut is made behind the ear and a simple procedure called a complete mastoidectomy should be done alongside draining the abscess. This procedure is done to remove as much infected bone and granulation tissue (an early form of scar tissue) from the mastoid bone as possible. Sometimes, different cuts may be needed to avoid potential injury to various nerves in that region.
If the patient also has a certain type of middle ear infection called suppurative OM, a small, tiny tube known as a tympanostomy tube or “grommet” should be put in place. It’s rare, but in some children, Bezold’s abscess can appear before the complete development of certain skull structures. In these cases, doctors must be careful with where they make their cut, as the facial nerve could be closer to the surface than expected, and a specific type of incision is called for.
Finally, doctors will continue giving the patient broad-spectrum antibiotics that can penetrate the cerebrospinal fluid, a clear, colorless body fluid found within the brain and spine. This helps prevent the infection from spreading to other nearby blood vessels, and will continue until the lab results from the cultures are ready.
What else can Bezold Abscess be?
When dealing with neck pain or swelling, your doctor might consider a number of possible causes, including:
- Other forms of deep neck abscess (like those caused by dental infections)
- Surface (cutaneous) abscess
- Pus-filled lymph nodes (suppurative lymphadenopathy)
- Cancer (malignancy)
- Cysts or tumors in the parotid gland (which produces saliva)
- Infection in the parotid gland (suppurative parotitis)
- Tuberculosis
- Infection of the mastoid bone near the ear (coalescent mastoiditis)
It’s crucial to rule out these conditions to guarantee a proper diagnosis and treatment plan.
What to expect with Bezold Abscess
The chances of a full recovery are generally good if the infection hasn’t spread beyond the temporal bone (a bone in the skull), especially if treatment with antibiotics is started quickly.
Possible Complications When Diagnosed with Bezold Abscess
If an infection is not properly managed and treated, it may spread to other areas within the body. The infection can spread upwards into the brain, affecting parts such as:
- The sigmoid sinus
- The transverse sinus
- The membranes covering the brain, or meninges
More commonly, the infection spreads along a deep layer of connective tissue in the neck, leading to:
- Blood clot in the jugular vein
- Damage to cranial nerves
- Lockjaw or difficulty opening the mouth, medically called Trismus
- Growth of the infection towards the skin resulting in abnormal openings, also known as cutaneous fistulas
Long-term complications can be severe and may potentially include:
- Death
- Brain infection or Meningitis
- Cranial nerve damage
- Hearing loss
