Epidemiologic, Imaging, and Clinical Issues in Bezold's Abscess: A Systematic Review

Abstract

Bezold's abscess is a deep neck abscess related to otomastoiditis. Due to the insidious clinical presentation, diagnosis can be extremely challenging, leading to delays in treatment and possible life-threatening complications. The literature currently provides a fragmented picture, presenting only single or small number of cases. The present study aims at examining our experience and the literature findings (based on PRISMA criteria) of 97 patients with Bezold's abscess, summarizing their epidemiology, pathogenesis, clinical presentation, imaging findings, and treatments. Bezold's abscess is found at any age, with overt male prevalence among adults. The clinical presentation, as well as the causative pathogens, are strikingly heterogeneous. Otomastoiditis and cholesteatoma are major risk factors. A clinical history of otitis is commonly reported (43%). CT and MRI are the main diagnostic tools, proving the erosion of the mastoid tip in 53% of patients and the presence of a concomitant cholesteatoma in 40%. Intracranial vascular (24%) or infectious (9%) complications have also been reported. Diagnosis might be easily achieved when imaging (CT) is properly applied. MRI has a limited diagnostic role, but it might be crucial whenever intracranial complications or the coexistence of cholesteatoma are suspected, helping to develop proper treatment (prompt antibiotic therapy and surgery).

Keywords: Bezold; Bezold’s abscess; MRI; abscess; cholesteatoma.

Figure 1

Normal anatomy, post-contrast axial CT (a,b). In the same images with annotations (c,d), the digastric muscle (white arrowhead) and the sternocleidomastoid muscle (white arrow) delimitate the posterior cervical space (red). The carotid artery can be identified nearby (black arrow).

Figure 2

Literature search results according to PRISMA criteria.

Figure 3

Illustration of extracranial otogenic abscesses. Bezold’s abscess (orange), Citelli’s abscess (yellow), subperiosteal empyema (brown).

Figure 4

Eighty-seven-year-old man with history of external mycotic otitis. T2w MRI in axial (a) and coronal (c) planes show abnormal right mastoid (dotted rectangle) filled with hyperintense material that spreads into the neck (white arrows). Axial (b) and coronal (d) bone CT images show opacified right mastoid, absence of bone trabeculae, and a wide defect (black arrows) at the mastoid tip. Images were consistent with an infected cholesteatoma eroding the mastoid tip and spreading into the neck. The finding was confirmed at surgery.

Figure 5

Thirty-year-old woman with oculo-auricular-vertebral spectrum. Contrast-enhanced axial CT (a) shows hypodense left neck abscess in the parapharyngeal and pharyngeal mucosal spaces, with minor involvement of the visceral and posterior cervical space (dotted rectangle). Note the peripheral enhancement and the soft tissue oedema. Axial CT with bone kernel (b) shows hypodense cholesteatoma eroding the os tympanicum (black arrow) as the origin of the neck abscess. Coronal T2w MRI (c) shows an hyperintense neck collection (white arrow) medial to the sternocleidomastoid muscle (white arrowhead). The patient proved to have a Bezold’s abscess associated with an os tympanicum cholesteatoma.

Figure 6

Thirty-seven-year-old man with chronic otitis media and history of ear surgery. MRI T1w (a) and contrast-enhanced T1w (b) sequences showing hypo-isointense material in the left mastoid (black arrows) spreading in the neck, in the posterior cervical space (white arrowheads). Note the mastoid mucosal enhancement, suggestive for mastoiditis, and the peripheral enhancement of the neck component (b). The material in the mastoid is hyperintense in diffusion-weighted imaging (c) and shows inhomogeneous apparent diffusion coefficient values (d), consistent with purulent collection and cholesteatoma. Bezold’s abscess and left mastoid cholesteatoma were confirmed at surgery.

Figure 6

Thirty-seven-year-old man with chronic otitis media and history of ear surgery. MRI T1w (a) and contrast-enhanced T1w (b) sequences showing hypo-isointense material in the left mastoid (black arrows) spreading in the neck, in the posterior cervical space (white arrowheads). Note the mastoid mucosal enhancement, suggestive for mastoiditis, and the peripheral enhancement of the neck component (b). The material in the mastoid is hyperintense in diffusion-weighted imaging (c) and shows inhomogeneous apparent diffusion coefficient values (d), consistent with purulent collection and cholesteatoma. Bezold’s abscess and left mastoid cholesteatoma were confirmed at surgery.