Chin J Radiol 2002; 27: 251-256 251

Otogenic Deep Neck Abscess: A Rare

Complication of Cholesteatoma with Acute
Mastoiditis
YAO -L IANG C HEN S HU -H ANG N G H O -FAI W ONG M UN -C HING W ONG YAU -YAU WAI Y UNG -L IANG WAN

First Department of Diagnostic Radiology, Chang Gung Memorial Hospital, Chang Gung University

Deep neck abscess is a rare complication of acute Otitis media is a common disease of childhood.
mastoiditis in the era of antibiotics. In preantibiotic However, it has been estimated that 1.5% of all adults
era, Bezold’s abscess was the most common cause of suffered from active chronic otitis media [1].
the otogenic deep neck abscess. We reported a 19- Complications of otitis media can be categorized into
year-old male with cholesteatoma complicated by two groups: intracranial and extracranial. Intracranial
acute suppurative mastoiditis, lateral sinus throm- complications occur in 0.24 % of the patients and
bosis, thrombophlebitis of the ipsilateral internal include meningitis, encephalitis, brain abscess, epidur-
jugular vein and deep neck abscess formation. The al abscess and lateral sinus thrombosis. Extracranial
pathway of the deep neck abscess formation is dif- complications occur in 0.45% of the patients and
ferent from the classic presentations of Bezold’s include facial nerve paralysis, labyrinthitis, perichon-
abscess. Computed tomography, magnetic resonance dritis, coalescent mastoiditis and subperiosteal abscess
imaging and ultrasonography were complementary [2]. Deep neck abscess is extremely rare in the era of
for the detailed demonstration of the origin and the antibiotics. Herein, we present a rare transcranial com-
extent of the disease. Segmental mural lysis of the plication of cholesteatoma and acute mastoiditis with
infected internal jugular vein was considered to be resultant deep neck abscess formation. Imaging studies
responsible for the development of deep neck with different modalities are valuable for tracing the
abscess formation. pathway of disease extension.

Key words: mastoiditis; Bezold’s abscess; neck, CASE REPORT

abscess; sinus, thrombosis
A 19-year-old male came to our emergent unit
with pale and ill looking. He suffered from progressive
vertigo, vomiting, nystagmus, supervened chillness
and fluctuating fever (the spike up to 40.3˚C) for five
days. On physical examination, swelling, erythema,
heatness and tenderness on his left retroauricular
region were noticed. Otoscope displayed perforation of
the left tympanic membrane with purulent discharge.
Laboratory data showed elevated white blood cell
3
count (23500/mm ) and C-reactive protein (180 mg/dl).
Due to the past history of chronic otitis media, he was
clinically impressed as acute mastoiditis complicated
with Bezold’s abscess formation. High-resolution com-
puted tomography (HRCT) of temporal bone showed
Reprint requests to: Dr. Yao-Liang Chen soft tissue density filling the left tympanic cavity and
Address: First Department of Diagnostic Radiology, Chang
Gung Memorial Hospital. cloudiness of the left mastoid air cells with bony
No. 5 Fu Hsing Street, Kwei Shan, Taoyuan 333, Taiwan, erosion at the tympanic tegmen (Figure 1a). Magnetic
R.O.C. resonance images (MRI) further displayed swelling of
the left temporalis muscle, thrombosis of the sigmoid
sinus, jugular bulb and upper internal jugular vein
252 Otogenic deep neck abscess

(IJV) (Figure 1b, 2a). T1-based enhanced MR instances with serious complications. The mucosa of
angiogram of the neck confirmed IJV thrombosis the tympanic cavity and its extension into the mastoid
(Figure 2b). Enhanced CT of the neck disclosed deep cells has an inherent ability to overcome acute infec-
abscess formation that was contiguous to the throm- tion. As a result, acute otitis media and mastoiditis
botic left IJV and deep to the sternocleidomastoid may be self-limited. However, severe suppurative and
muscle (SCM)(Figure 3a). High-resolution ultrasonog- necrotizing infections of the middle ear can cause sys-
raphy (HRUS) clearly depicted focal lysis at the wall temic reaction [3].
of the infected left IJV (Figure 3b). The patient under- The incidence of complications resulting from
went left canal-down radical mastoidectomy, tym- suppurative otitis media has significantly decreased in
panoplasty, meatoplasty, incision and drainage of the the era of antibiotics. In the beginning of the 20th
left neck abscess. Left suppurative mastoiditis compli- century, 50% of all cases of otitis media developed
cated by attic cholesteatoma was explored. However, coalescent mastoiditis. Recent studies suggested a
there was no continuation between the mastoiditis and current incidence of only 0.24% [2]. Complications of
deep neck abscess either by imaging findings or by otitis media can be grouped into two broad categories:
surgical exploration. Pus culture showed moderate intracranial and extracranial. Intracranial complica-
growth of anaerobic bacteria including Peptostre- tions include meningitis, encephalitis and lateral sinus
ptococcus anaerobius and Peptostreptococcus asaccha- thrombosis. Prior to the widespread use of antibiotics,
rolyticus. Treated by thorough open drainage of 2.3% of patients with otitis media developed intracra-
abscess and intravenous antibiotic administration, the nial complications. Nowadays, the rate has fallen
patient was discharged three weeks later with the nearly 10-fold to 0.24%. The contemporary risk for
sequel of left hearing loss (over 100 decibel). developing extracranial complications of otitis media
is approximately twice of that for intracranial compli-
DISCUSSION cations, with 0.45% of patients experiencing problems
such as facial nerve paralysis, labyrinthitis, perichon-
Acute mastoiditis can be the complication of pre- dritis, coalescent mastoiditis, subperiosteal abscess or
existing secretory otits media or other chronic disease Bezold’s abscess [1].
of middle ear, including cholesteatoma. Before the use Bezold’s abscess was considered clinically when
of antibiotics it was common and associated in some mastoiditis coexisted with deep neck abscess. In 1908,

1a 1b
Figure 1. a. Coronal HRCT shows a focal break-through of the tympanic tegmen (double arrows) indicating the
possibility of intracranial complications. b. Axial enhanced T1-weighted MRI displays abnormal enhancement (double
arrowheads) in left sigmoid sinus and jugular bulb suggesting lateral sinus thrombosis.
 Otogenic deep neck abscess 253

Bezold was the first to describe abscess in the neck lateral sinus thrombosis, 19 were associated with sup-
arising from mastoiditis. Inflammation and infection purative otitis media and mastoiditis [6]. Suppuration
may result in necrosis of the mastoid tip, allowing the in the middle ear, mastoid, or both may spread to the
pus to track from the medial side of the mastoid adjacent intracranial structures through progressive
process through the incisura digastrica (digastric thrombophlebitis, bony erosion, or direct extension,
groove). The pus is prevented from reaching the resulting in meningitis, extradural abscess, subdural
surface by neck musculature, but can track along the empyema, focal encephalitis, brain abscess, lateral
fascial planes of the digastic muscle or SCM [1]. sinus thrombosis, and otic hydrocephalus. The clinical
Bezold’s abscess usually spreads into the substance of pictures of lateral sinus thrombosis are well document-
the SCM and confines to the posterior cervical and ed: an ill patient with high swinging pyrexia (‘picket
perivertebral spaces by the pharyngobasilar fascia and fence’ pattern), headache, neck pain and progressive
the deep layer of deep cervical fascia [4,5]. It may anemia with, less commonly, occipital edema [6].
extend into the carotid, prevertebral, danger, and The occurrence of deep neck abscess and lateral
retropharyngeal spaces. By gaining the access into the sinus thrombosis may be coincidental, since both are
danger space, an abscess may extend into the medi- complications of mastoiditis. There is also a possibili-
astinum or into the base of the skull [4]. Due to the ty that lateral sinus thrombosis may be arisen by retro-
depth of their location, Bezold’s abscess may be diffi- grade spread from the infected internal jugular vein
cult to be palpated. Pneumatization of the mastoid which had already been involved by Bezold’s abscess.
process leads to thinning of the bone and is considered It is however possible that the neck abscesses may be
an important factor in the development of Bezold’s formed by direct regional spread from the infected
abscess. Therefore, Bezold’s abscesses are more internal jugular vein that had autolysed [6], as in our
common in adults than in children because well case.
pneumatization of mastoid tip often occurs in adults. Radiological study is indicated in cases of acute
Mastoiditis contributes to most of the lateral mastoiditis or otitis media when there is clinical sug-
(sigmoid) sinus thrombosis. In a series of 22 cases of gestion of coalescent mastoiditis, which signifies the

2a 2b
Figure 2. a. Coronal enhanced T1-weighted MRI depicts thrombosis in the left upper internal jugular vein (IJV). A low-
signal gap and enhanced extramural tissue (double black arrows) imply thrombophlebitis and possibly segmental mural
lysis of the left IJV. As compared with the signal void in right IJV(open large arrow), the thrombosis of left IJV shows
slight low signal intensity (double white arrowheads) with thick mural enhancement. b. Venous phase of T1-based MR
angiogram shows obvious enhanced flow signal in the right IJV but absence of flow signal in the left IJV, confirming
left IJV thrombosis. (RIJV: right internal jugular vein, RCCA: right common carotid artery, RVA: right vertebral artery,
LCCA: left common carotid artery, LVA: left vertebral artery)
254 Otogenic deep neck abscess

3a 3b
Figure 3. a. Axial enhanced CT displays filling defects in the left IJV and a neighboring abscess (arrow) deep to the SCM.
Note increased soft tissue density in the left posterior cervical space due to cellulitis. b. Longitudinal scans of HRUS clearly
discloses a segmental mural lysis at the left IJV (arrowheads). Loss of compressibility and low echoic thrmobosis within the
IJV are also found.

transition from mucoperiosteal disease to bone disease absence of venous response to respiratory maneuvers
and even to intracranial complications. CT can show (Valsalva and sniff test) and incompressibility of the
stages of disease progression when infection spreads thrombotic jugular vein [9]. Because HRUS can depict
by way of soft tissue and bone pathways into dural both transverse and longitudinal planes, it can provide
venous sinuses, meninges, labyrinth, facial nerve, an accurate delineation of luminal compromise by
epidural and other intracranial spaces [3]. CT is also thrombus [10]. For the patient we reported, only
valuable in early diagnosis of cholesteatoma in the HRUS could depict the exact location of segmental
mastoid cavity and exact delineation of abscess forma- autolysis of the jugular wall. Based on the imaging
tion [5]. MRI is more useful than CT for evaluation of findings of CT, MRI and HRUS, we believe that the
the complications of acute mastoiditis in some aspects. deep neck abscess arose from the septic throm-
Septic thrombosis of the lateral sinus and jugular bulb bophlebitis of the internal jugular vein rather than
is a highly lethal condition. Enhanced CT may reveal direct extension of mastoiditis from the mastoid tip,
evidence of sinus thrombosis, manifested as a filling which is the typical pathway of Bezold’s abscess.
defect in the vessel (empty delta sign). However, Early surgery is mandatory to treat severe mas-
false-positive diagnosis up to 30% of cases has been toiditis such as coalescent mastoiditis and subpe-
reported [7]. In contrast, MRI can distinguish between riosteal abscess. The infected neck or abscess forma-
flowing blood and thrombus. Enhanced MRI with tion needs thorough drainage. Given the low incidence
gadolinium-DTPA is a valuable adjunct to achieve the and lack of consistent signs and symptoms, Spiegel et
diagnosis and to delineate the extent of the pathology al suggested contemporary practitioner must be rely
[8], whereas magnetic resonance angiography is the on radiological images to determine the presence and
procedure of choice for the confirmation of venous pathway of mastoid abscess [1].
thrombosis. CT and MRI can detect concomitant cere-
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 Otogenic deep neck abscess 255

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