What is the treatment and prognosis for a subperiosteal postauricular abscess, also known as Bezold's abscess?

Treatment and Prognosis of Bezold's Abscess

The primary management of Bezold's abscess (subperiosteal postauricular abscess) is surgical incision and drainage followed by antibiotic therapy. 1

Understanding Bezold's Abscess

Bezold's abscess is a rare complication of mastoiditis in which pus collects in the subperiosteal space behind the ear. It occurs when infection from the mastoid process erodes through the mastoid tip and spreads into the neck tissues. 2

Key characteristics include:

• Often associated with otomastoiditis and cholesteatoma 2
• Commonly presents with a history of otitis media (43% of cases) 2
• Shows male predominance among adult patients 2
• Can occur at any age 2

Diagnostic Approach

Diagnosis of Bezold's abscess requires:

• CT imaging as the primary diagnostic tool, which can show erosion of the mastoid tip (present in 53% of cases) 2
• MRI when intracranial complications or cholesteatoma are suspected (cholesteatoma present in 40% of cases) 2
• Clinical evaluation for signs of systemic infection 1

Treatment Protocol

1. Surgical Management

• Surgical incision and drainage is the cornerstone of treatment 1
• Needle aspiration alone is often insufficient and may lead to recurrence 1
• In some cases, postauricular needle aspiration may be attempted first, particularly in pediatric patients, reserving mastoidectomy for non-responsive cases 3
• Mastoidectomy is frequently required for definitive treatment, especially with extensive disease 1

2. Antibiotic Therapy

• Empiric broad-spectrum antibiotics covering Gram-positive, Gram-negative, and anaerobic bacteria should be initiated promptly 1, 4
• Common regimens include:
  • Ceftriaxone and metronidazole combination 4
  • Continue antibiotics for an adequate duration after surgical drainage 1

3. Additional Interventions

• Daily ear toilet and myringotomy may be beneficial adjuncts to treatment 3
• For cases with intracranial complications, additional interventions may be necessary 5

Complications and Prognosis

Potential Complications

• Intracranial vascular complications (24% of cases) 2
• Intracranial infectious complications (9% of cases) 2
• Dural sinus thrombosis (rare but serious complication) 5
• Cavernous sinus thrombosis (extremely rare) 5

Prognosis

• With prompt surgical drainage and appropriate antibiotic therapy, prognosis is generally good 3
• Length of hospital stay is typically shorter with early intervention 3
• Full recovery is possible with aggressive treatment, even in cases with serious complications 5
• Delayed treatment can lead to life-threatening complications including brain infection 4

Special Considerations

• During infectious disease outbreaks (like COVID-19), treatment strategies may need modification to minimize exposure risk 4
• In pediatric patients, a less invasive approach with needle aspiration may be attempted first 3
• Patients with concomitant cholesteatoma require more extensive surgical management 2
• Vigilance for intracranial complications is essential, as they may develop rapidly 2, 5

Bezold's abscess, though rare in the antibiotic era, remains a serious condition requiring prompt recognition and aggressive treatment to prevent potentially fatal complications. 5