What is the management of Bezold's abscess, a subperiosteal postauricular abscess?

Management of Bezold's Abscess (Subperiosteal Postauricular Abscess)

Surgical drainage combined with intravenous antibiotics is the primary treatment for Bezold's abscess, as this approach most effectively reduces morbidity and mortality associated with this serious complication of mastoiditis. 1

Understanding Bezold's Abscess

Bezold's abscess is a rare but serious complication where infection from the mastoid spreads through the mastoid tip near the digastric groove, forming a collection of pus that tracks along the digastric and sternocleidomastoid muscles into the neck. This condition requires prompt diagnosis and treatment to prevent further complications.

Diagnostic Approach

• CT temporal bone without IV contrast is the initial imaging modality of choice when complications of otitis media are suspected, including subperiosteal abscess formation 1
• MRI with contrast may be needed if intracranial complications are suspected, as it has higher sensitivity for detecting intracranial spread 1
• Ultrasound can be useful for initial evaluation of soft tissue swelling around the mastoid area 1

Treatment Algorithm

First-Line Management:

1. Surgical drainage with antibiotics

   • Surgical incision and drainage is the primary management for subperiosteal abscesses including Bezold's abscess 1
   • This approach has been shown to be most effective in preventing further complications 1

2. Antibiotic therapy

   • Broad-spectrum intravenous antibiotics should be initiated immediately 1
   • Common pathogens include Streptococcus pyogenes and Staphylococcus aureus 2
   • Empiric coverage typically includes:
     • High-dose amoxicillin-clavulanate or
     • Ceftriaxone plus metronidazole for anaerobic coverage 3

Alternative Approaches:

• Needle aspiration with antibiotics

  • May be considered in select cases, particularly in children 4
  • Studies show successful resolution in approximately 82% of subperiosteal abscess cases with this less invasive approach 4
  • Should be followed by close monitoring for clinical improvement 1

• Conservative management with antibiotics alone

  • Reserved only for very small collections without systemic symptoms 1
  • High failure rate when used alone for established abscesses 1

Surgical Considerations

• Simple mastoidectomy is often required in addition to abscess drainage 5
• More extensive procedures (radical mastoidectomy) may be needed if cholesteatoma is present 2
• Myringotomy with tympanostomy tube placement is often performed concurrently to provide middle ear drainage 1

Monitoring and Follow-Up

• Close monitoring for 48 hours after initial treatment 1
• If no improvement or clinical deterioration occurs, CT scan should be performed to assess for:
  • Inadequate drainage
  • Intracranial complications
  • Need for more extensive surgical intervention 1

Special Considerations

• Long-term follow-up is essential as approximately 49% of patients may develop sequelae including recurrent middle ear infections, hearing impairment, or recurrent abscesses 2
• In pediatric patients, cholesteatoma should be ruled out, especially in cases of recurrent abscess formation 2

Pitfalls to Avoid

• Delaying surgical intervention can lead to spread of infection intracranially with potentially fatal outcomes 3
• Needle aspiration alone has a high recurrence rate and should not be the definitive treatment in most cases 1
• Relying solely on antibiotics without drainage is associated with treatment failure in established abscesses 1
• Underestimating the severity - what appears as a simple postauricular swelling may represent a more extensive deep neck infection 6