Bezold’s Abscess in the Setting of Untreated HIV Infection

Nitin Patel, B.Sc1; Joseph Goodman, MD1; Ameet Singh, MD1

1The George Washington University, Division of Otolaryngology – Head and Neck Surgery

INTRODUCTION DISCUSSION

CASE STUDY

Figure 1. CT axial bone windows, showing left mastoid opacification and coalescence of air cells

ABSTRACT

IntroductionReports of Bezold's abscess are rare. Classically, Bezold's abscess is described as a complication of mastoiditis in which infection spreads deep to the sternocleidomastoid muscle and throughout the fascial planes of the neck. Antibiotic treatment of suppurative otitis media has considerably decreased the incidence of complications resulting from this disease. We present a unique case report of Bezold's abscess in the setting of a patient with untreated HIV. To our knowledge, this is the first reported case of Bezold's abscess and HIV. Despite its rarity, clinicians must have a high suspicion for Bezold's abscess in the setting of complicated otitis media and HIV; it must be recognized early in immunocompromised patients and treated aggressively due to its potentially fatal outcome.

Study DesignCase report and review of the literature.

MethodsWe review the clinical course of a thirty-five year old male HIV patient with a chronically draining ear and progressive neck stiffness, found to have a Bezold's abscess on CT. The incidence, pathogenesis and treatment of Bezold's abscess are discussed with special reference to the clinical presentation in the setting of an immunocompromised host.

ResultsAfter broad-spectrum intravenous antibiotic therapy, mastoidectomy and surgical incision and drainage of the neck abscess, the patient recovered and had begun antiretroviral therapy at six-month follow-up.

ConclusionsBezold's abscess should be considered in the setting of complicated otitis media with neck stiffness and immunocompromise, specifically untreated HIV. The diagnosis and prompt, aggressive treatment of Bezold's abscess is necessary for an optimal clinical outcome. A 35-year-old male with a history of untreated HIV diagnosed several

months previously was seen by a physician for worsening left-sided otalgia, neck stiffness and neck tenderness of 3-day duration. He had a 6-month history of left-sided otalgia and intermittent otorrhea.

On presentation to the emergency department, he described left-sided otalgia, neck stiffness and pain but denied photophobia, or dizziness. He was afebrile, but slightly tachycardic and mildly hypotensive. Neurologically, he was lethargic but oriented and his cranial nerves were intact. Examination of the right ear was normal, but the left postauricular area was tender to palpation and erythematous; swelling was appreciated posterior to the left auricle. His left tympanic membrane was noted to be inflammed, thickened and perforated. His left neck was tender to palpation and there was mild torticollis to left. No meningeal signs were evident. Pertinent laboratory data included a CD4+ lymphocytic count of 2 and a leukocyte count of 8,600 per mm3 with a left shift.

Radiographic computed tomography (CT) scan with contrast revealed left-sided coalescent mastoiditis (Figs 1 and 2). A 3.6 x 1.8 cm abscess at the level of the left mastoid tip tracked deep to the left sternocleidomastoid and extended medially and anteriorly into the pre-vertebral space surrounding the anterior arch of C1 (Fig 3). Contrast study showed a hypoplastic left jugular bulb and no flow in the internal jugular bulb or sigmoid sinus (Fig 4).

The patient was admitted to the hospital and started on a regimen of intravenous piperacillin/tazobactam and vancomycin. Within several hours he was taken to the operating room for cortical mastoidectomy, neck exploration and irrigation and drainage of a neck abscess.

In the pre-antibiotic era, 50 percent of cases of otitis media developed coalescent mastoiditis. Bezold found that 20 percent of these patients developed an abscess that he originally described. In these cases, the most common organism found was Pneumococcus.2 Since the introduction of antibiotics for the management of suppurative otitis media, the incidence of complications from this disease has significantly decreased. Bezold’s abscess remains a rare clinical occurrence with only 24 cases reported in the English literature from 1975 to 2000.4 To our knowledge, this is the first reported case of Bezold's abscess in an HIV patient.

More recent literature describes Bezold’s abscess as occurring within the confines of the sternocleidomastoid muscle; however, in this patient’s case, the pattern of spread was similar to that classically described by Bezold. Our patient’s abscess was confined to the perivertebral space, and because the deep cervical fascia delimits this space outwardly, clinical signs and symptoms were not readily evident. Extension of Bezold’s abscess superficial to the sternocleidomastoid did not occur and fluctuance was not observed. The patient did present with swelling the region of the mastoid and neck stiffness and tenderness to palpation as predicted with a history of mastoiditis and deep neck abscess.

Despite its rarity, given the ever-increasing population of immunocompromised HIV patients, clinicians must have a high index of suspicion for this disease in the setting of chronic otitis media and neck pain. Although potentially fatal, Bezold’s abscesses are treatable if diagnosed early. Therefore, the diagnosis and rapid, aggressive treatment of Bezold's abscess is necessary for an optimal clinical outcome.

In 1881, Frederick Bezold, a German otologist, was the first to describe the effects of complicated otitis media eroding through the mastoid process and forming an abscess within the deep fascial planes of the neck.

In Bezold’s classic description, the infectious process erodes through the mastoid tip, into the digastric groove. The infection then spreads anteriorly along the digastric muscle to the submental triangle, filling the retromaxillary fossa.1 The strong attachments of the sternocleidomastoid, trapezius, splenius capitis and longissimus capitis muscles form a physical barrier that force the inflammatory process into deeper, more inferior spaces.2 Contemporary literature describes Bezold’s abscess as within the substance of the sternocleidomastoid muscle. In this description, the abscess is confined to the posterior cervical and perivertebral spaces by the deep cervical fascia.3

The clinical significance of Bezold’s abscess is that due to the strong muscular attachments to the mastoid and the anatomy of the deep cervical fascia, clinical fluctuance is rare; therefore, the abscess may not be evident on examination. Neck stiffness and pain are more commonly encountered physical signs. In the era before antibiotics, these abscesses often went untreated and persisted for prolonged periods of time. Bezold observed that, in this condition, death occurred from involvement of the central nervous system due to extension of the abscess into the skull base or the vertebrae.

1. Smouha EE, Levenson MJ, Anand VK, Parisier SC. Modern presentations of Bezold’s abscess. Arch Otolaryngol 1989;115:1126-1129.

2. Gaffney RJ, O’Dwyer TP, Maguire AJ. Bezold’s abscess. J Laryngol Otol 1991;105:765-766.

3. Castillo M, Albernaz VS, Mukherji SK, Smith MM, Weissman JL. Imaging of Bezold’s abscess. AJR Am J Roentgenol1998;171:1491-1495.

4. Zapanta PE, Chi DH, Faust RA. A unique case of Bezold’s abscess associated with multiple dural sinus thrombosis. The Laryngoscope 2001;111:1944-1948.

CONCLUSIONS

REFERENCES

Nitin Patel, B.Sc.The George Washington University2300 Eye St, NWWashington, DC 20037njpatel@gwu.edu

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Figure 2. CT coronal bone windows, showing left mastoid opacification and loss of bony septations

Figure 4. CT axial soft tissue, post-contrast, showing abscess medial to mastoid tip, abutting skull base and no flow of contrast

through internal jugular vein

Figure 3. CT axial bone window, showing hypoplastic left jugular bulb and no flow of contrast in sigmoid sinus

Additionally, the patient’s CT scan was concerning for filling defect in the internal jugular vein and lateral sinus. In the setting of acute infection and lethargy, the decision was made for emergent mastoidectomy and drainage of the neck abscess. The jugular vein was noted to be patent on post-op CT scan (Fig 5). In Bezold’s time, suppurative mastoiditis would linger in patients, with complications developing weeks to months after the initial otitis media. In our experience, our immunocompromised patient with untreated, chronic otitis media followed a similar time course to the development of Bezold’s abscess.

Figure 5. CT axial temporal bone cuts, showing post-operative mastoid cavity, communication of air cells, and patent sigmoid sinus