An Extensive Cholesteatoma with Bezold’s Abscess
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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.
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