An Extensive Cholesteatoma with Bezold’s Abscess

doi:10.4236/ijcm.2011.23049

Paper Menu >>

Journal Menu >>

International Journal of Clinical Medicine, 2011, 2, 292-294

doi:10.4236/ijcm.2011.23049 Published Online July 2011 (http://www.SciRP.org/journal/ijcm)

An Extensive Cholesteatoma with Bezold’s

Abscess

Norhafiza Mat Lazim1, Asma Abdullah2

1ORL-HNS Department, HUSM Kubang Kerian, Kota Bharu, Malaysia; 2Head of Department, ORL Head & Neck Surgery, UKM

Medical Centre, Jalan Ya’akob Latif, Kuala Lumpur, Malaysia.

Email: [email protected], [email protected]

Received March 20th, 2011; revised April 23rd, 2011; accepted May 6th, 2011.

ABSTRACT

Cholesteatoma has been known to be associated with multiple complications either extracranially or intracranially.

Among the extracranial complications, mastoiditis and mastoid abscess are the most common. Bezo ld’s abscess forma -

tion with cholesteatoma is a rare occurrence but when present can lead to sinister sequalae if not properly managed.

The treatment of cholesteatoma is mainly by surgical exploration namely mastoidectomy. The aim of treatment is to

eradicate the diseased mastoid and to prevent subsequent complications. Beside surgical intervention, the patient will

also require intensive systemic and topical antibiotic therapy. With proper treatment patient will be hindered from ex-

periencing unwanted complications.

Keywords: Cholesteatoma, Bezold’s Abscess, Mastoidectomy

1. Introduction

Cholesteatoma is a benign disease which affects various

spaces such as middle ear, mastoid or petrous bone. It is

known for its tendency to recur. It has capacity for pro-

gressive and independent growth and causes bony ero-

sion. If not properly managed it inevitably will result in

complications. These complications can be divided into

extracranial and intracranial. The extracranial complica-

tions are mastoid abscess, subperiosteal abscess, petrosi-

tis, labyrinthine fistula and Bezold’s abscess. Intracranial

complications range from meningitis, subdural abscess,

lateral sinus thrombosis and extradural abscess [1].

Among these complications, Bezold’s abscess is scarcely

reported in the literature. The reason being due to the

widespread use of antibiotics in this modern antibiotic

era which has exclusively prevented the forementioned

complications. We report a case of a young lady pre-

sented with cholesteatoma complicated with Bezold’s

abscess.

2. Case Report

A 25 year old Chinese lady with past history of chronic

otitis media since childhood presented to a private clinic

with history of left ear discharge for a four month dura-

tion. It was associated with post auricular swelling. The

swelling was initially small in size but has gradually in-

creased over few weeks. Her pain was relieved intermit-

tently with analgaesics. At the same time, she also had

reduced hearing on the same side which worsened over

few weeks prior to the presentation. She had facial

asymmetry three days prior to the admission. She denied

any history of vertigo or tinnitus, but there was history of

intermittent low grade fever. There was no history of

headache, blurring of vision or vomiting. According to

her she attended a local g eneral pr actition er for few times

and was prescribed with different antib iotics. Despite the

topical eardrops and antibiotics, her condition did not

improve. As far as past history is concerned, she had

history of otorrhoea during childhood which was settled.

There was no other significant history.

On clinical examination , the patient was febrile. There

was left sided facial nerve palsy grade II (House-

Brackman grading system). Ear examination showed

postauricu lar swelling over the left mastoid region which

was tender on palpation. The swelling measured 3.0 cm ×

3.0 cm × 4.0 cm. The overlying skin was mildly inflamed

and tender. However there was no discharge noted. Oto-

scopic examination revealed sagging of posterior wall of

left external auditory canal. Left tympanic membrane

was not visualized due to oedematous external auditory

canal. Right ear was normal. There was no palpable neck

node. Cranial nerves were all intact except the facial

An Extensive Cholesteatoma with Bezold’s Abscess 293

Figure 1. Pure Tone Audiogram shows profound sensor ine ura l hearing loss of left ear and normal hearing on right ear.

nerve and the vestibulocochlear nerve. There was no

nystagmus and no neck stiffness. Rinne’s test was posi-

tive on the right ear and negative on the left ear with

Weber’s test lateralised to right ear.

Pure Tone Audiogram showed profound sensorineural

hearing loss on the left ear (Figure 1). CT Scan of tem-

poral bone from previous private hospital revealed pres-

ence of well defined mass occupying the mastoid cavity

with extensive bony erosion and loss of ossicles and

semicircular canals (Figure 2). The mass has also ex-

tended inferiorly to the level of C2 vertebrae. It lies infe-

rior to sternocleidomastoid muscle (Figure 3).

The patient was admitted and started on IV Rocephine

1.0 gm twice daily. She was put under emergency list for

left mastoid exploration. The procedure and risk of facial

Figure 2. Axial CT Scan of temporal bone shows an exten-

sive cholesteatoma with bone erosion. All the ossicles and

semicircular canals are absent (arrow).

nerve injury was explained to the patient. Intraoperative

findings revealed an extensive cholesteatoma in the entire

external auditory can al with erosion of the posterior wall.

The pus was seen in the mastoid cavity when sternoclei-

domastoid was pressed. Tip of mastoid, zygomatic root,

ossicles, part of tegmen tympani, part of floor of hypo-

tympanum and part of petrous bone were all eroded. The

left facial nerve was exposed from tympanic segment to

two-third of vertical segment. Post operatively patient

recuperating well with minimal left ear discharge. Her

hearing otherwise did not improve post operatively.

However, her facial nerve palsy has resol ve d com ple te l y.

3. Discussion

Cholesteatoma is a disease that can occur in middle ear,

mastoid bone or petrous temporal bone. It is character-

Figure 3. Coronal CT Scan of neck shows collection under

left sternocleidomastoid muscle (arrow).

An Extensive Cholesteatoma with Bezold’s Abscess

294

ized by a tendency for bone erosion and recurrence. Once

established in the middle ear, mastoid or petrous bone,

cholesteatoma is destructive lesion that gradually ex-

pands and destroys adjacent structures leading to com-

plications [2]. These complications include subperiosteal

abscess, mastoid abscess, petrositis, labyrinthitis and fa-

cial nerve palsy. Intracranial complications ranging from

meningitis, brain abscess, lateral sinus thrombosis and

extradural abscess [3]. Bezold’s abscess however is a rare

complication of cholesteatoma.

Bezold’s abscess occur infrequently nowadays due to

the advent of antibiotics and early surgical interven tion. It

is defined as a collection of abscess deep to sternoclei-

domastoid muscle. It was introduced by a German otolo-

gist, Friedrich Bezold in 1881. Bezold distinguished this

form of abscess from other more common forms, such as

the subperiosteal abscess, which arise from the erosion of

the outer surface of the mastoid cortex [1]. In Bezold’s

abscess the pus discharge escapes via a perforation of the

inner side of mastoid process which then tracks down

along the fascia planes of the digastrics or sternocleido-

mastoid muscle in the neck.

The pathogenesis of the Bezold’s abscess has been at-

tributed to the degree of pneumatisation of the mastoid

bone. In a well pneumatised mastoid bone, the spaces

with the thin bone can easily act as a pathway for a dis-

ease process to spread through it. In the absence of

pneumatisation, the mastoid bony walls are thick and

hinder the erosion process [4]. As in our case, massive

cholesteatoma in the middle ear can certainly lead to

bony erosion of the mastoid tip with subsequent devel-

opment of the false track which acts as a conduit for the

abscess to track down through the fascia plane inferiorly

down to the neck.

The presence of cholesteatoma debris in the chroni-

cally infected mastoid may obstruct the infectious foci

into external auditory canal and allows the foci to find a

weak point in the mastoid tip [5]. The more devastating

sequalae can arise when infection spread downward

along great vessels to reach the perivisceral space, larynx

or mediastinum. It can also descend along the interverte-

bral muscle to reach the retropharyngeal space. Alterna-

tively, it could track down along the wall of subclavian

artery to reach the posterior triangle of the neck and

axilla or reach the suprasternal space and crosses to the

the contralateral neck with more hazardous complications

[5].

Clinical presentations vary and include pyrexia, otalgia,

neck swelling, otorrhoea, neck pain, restriction of neck

movements, facial nerve palsy and hypoacusia [6]. In

the early phase of abscess formation, the sign probably

was subtle and there should be a high index of suspicion

in treating patients b elonging to this group . The organ ism

that is most commonly cultured is Streptococcus. Gram

positive cocci and gram negative cocci as well as anaer-

obes have also been implicated. Other organism such as

Proteus mirabilis, Staph aureus, Proteus vulgaris have

also been isolated [2].

In our patient there was no risk factor for her to de-

velop such complications. We thought that her condition

worsened because of inadequate antibiotic treatment she

received previously, and a very much delay in presenta-

tion to our care. But with disease clearance by radical

mastoidectomy, her condition improved significantly.

CT Scan of the temporal bone and neck is the main

imaging modality for diagnosis of Bezold’s abscess. The

findings include the presence of fluid filled middle ear

and mastoid and demineralisation of the mastoid trabe-

culae [5]. CT Scan of neck showed the collection is infe-

rior to mastoid but not below the level of cricoid cartilage

together with obliteration of the fascia and fat plane, re-

ticulation of the subcutaneous tissues and thickening of

the skin overlying sternocleidomastoid muscle [7]. These

features are seen in the CT Scan film of this case.

REFERENCES

[1] Y. Uchida, H. Ueda and T. Nakashima, “Bezold’s Ab-

scess Arising with Recurrent Cholesteatoma 20 Years af-

ter Surgery: With a Review of the 18 Cases Published in

Japan since 1960,” Auris Nasus Larynx, Vol. 29, No. 4,

2002, pp. 375-378. doi:10.1016/S0385-8146(02)00057-3

[2] A. Mustaffa, A. Heta, B. Kastrati, et al., “Complication of

Chronic Otitis Media with Cholesteatoma during a Ten

Year Period in Kosovo,” European Archives of Otorhi-

nolaryngology, Vol. 265, No. 12, 2008, pp. 1477-1482.

doi:10.1007/s00405-008-0707-8

[3] S. Y. Yeh and P. W. Cheng, “Concurrent Intracranial and

Extracranial Complications Secondary to Cholesteatoma:

A Case Report,” Otolaryngology Head and Neck Surgery,

Vol. 128, No. 1, 2003, pp.163-164.

doi:10.1067/mhn.2003.75

[4] B. McMullan, “Bezold’s Abscess: A Serious Complica-

tion of Otitis Media,” Journal of Paediatrics and Child

Health, Vol. 45, No. 10, 2009, pp. 616-618.

doi:10.1111/j.1440-1754.2009.01575.x

[5] G. Marioni, C. D. Fillipis, A. Tregnaghi, R. M. Ragona

and A. Stafferi, “Bezold’s Abscess in Children: Case Re-

port and Review in Literature,” International Journal of

Paediatric Otorhinolaryngology, Vol. 61, No. 2, 2001, pp.

173-177.

[6] P. Zappata, D. H. Chi and F. Russel, “A Unique Case of

Bezold’s Abscess Associated with Multiple Dural Sinus

Thrombosis,” Laryngoscope, Vol. 111, No. 11, 2001, pp.

1944-1947. doi:10.1097/00005537-200111000-00013

[7] M. Castillo, V. S. Albernaz, S. K. Mukherji, M. M. Smith

and J. L. Weissman, “Imaging of Bezold’s Abscess,”

American Journal of Roentgenology, Vol. 171, No. 6,

1998, pp. 1491-1495.