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)
Copyright © 2011 SciRes. IJCM
An Extensive Cholesteatoma with Bezold’s
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@example.com, firstname.lastname@example.org
Received March 20th, 2011; revised April 23rd, 2011; accepted May 6th, 2011.
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
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 .
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
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.
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).
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An Extensive Cholesteatoma with Bezold’s Abscess
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 . 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 . 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 . 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 . 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 . 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
Clinical presentations vary and include pyrexia, otalgia,
neck swelling, otorrhoea, neck pain, restriction of neck
movements, facial nerve palsy and hypoacusia . 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 .
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 . 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 . These
features are seen in the CT Scan film of this case.
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