Bezold abscess in a 4-year-old: an exceptionally rare complication of otitis media

A 4-year-old male patient presented to the emergency department with 2 days of low-grade fever and neck stiffness. He was sent to the emergency department by his pediatrician with initial concern for meningitis. The child had not complained of photophobia or ear or throat pain. Prior to lumbar puncture, CT of the head and neck identified bilateral otomastoiditis and a Bezold abscess (Fig. 1). The patient underwent urgent abscess drainage and mastoidectomy and was admitted to the pediatric intensive care unit. The child was discharged home with antibiotics after several days, ultimately making a full recovery.

Fig. 1.

Computed tomography scan of Bezold abscess. (A) The coronal view. The arrow indicates the Bezold abscess. (B) The zoomed-in view.

A Bezold abscess is an exceptionally rare complication of untreated acute otitis media or mastoiditis, with only about 100 cases described in the English literature and only four reports in children younger than 5 years [1]. Bezold abscesses occur when an infection in the mastoid space erodes through the bony cortex and into the deep spaces of the neck [2]. The infection can spread to the carotid sheath, mediastinum, and brain with devastating consequences if source control is not promptly obtained [2]. Urgent intervention with antibiotics and surgical drainage is required to prevent disease progression and death. While exceptionally rare in the modern age due to the widespread use of antibiotics, emergency physicians must consider this diagnosis in children presenting with neck pain, as failure to identify this late complication can have devastating consequences.

Ethics statement

Informed consent was waived due to the retrospective nature of the study.

Capsule Summary

What is already known

Bezold abscesses are exceptionally rare, with only four other cases in children younger than 5 years reported in the last 100 years in the English literature.

What is new in the current study

Though our case presented with concern for meningitis, a proper diagnosis allowed prompt intervention and a favorable outcome of a rare event that initially was not considered.