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Bezold abscess

Case contributed by Derek Smith
Diagnosis certain

Presentation

Right ear discharge and right neck swelling for last few days. Otitis media with purulent discharge and fluctuant area overlying tip of mastoid and right sternocleidomastoid, 12 cm in diameter with mild trismus and pain on neck flexion.

Patient Data

Age: 50 years
Gender: Male
ct

Opacification in right middle ear and mastoid air cells. Although the external canal is intact, there is erosion of the mastoid bone into the lateral neck soft tissues. Small internal ossification compatible with a bone sequestrum.

Extension of this infectious process into a huge right deep neck space collection. Smaller components involve the stylomastoid foramen as well as the pre and post styloid regions of the parotid space. Replacement of the sternocleidomastoid muscle with a peripherally enhancing abscess measuring approximately 45 x 54 x 96 mm.

There is also thinning / erosion of the mastoid medially, with a trace of fluid superficial to the right sigmoid sinus, but no evidence of venous thrombus or other intracranial extension.

Separate to this, there is a rounded erosion in the right maxilla around the periapical region of the UR2 tooth. Other minor odontogenic disease.

Case Discussion

Although the typical teaching for Bezold abscesses is that they are clinically occult due to being obscured by the sternocleidomastoid muscle, this was clinically and radiologically easily evident.

Erosions of the mastoid should be carefully assessed for any neck soft tissue and / or intracranial extension. The presence of a bone sequestrum here (and on follow up imaging) supports a diagnosis of a skull base osteomyelitis further complicating this acute otomastoiditis / Bezold abscess.

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