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Bezold Abscess

A rare otologic complication of acute coalescent mastoiditis in which infection erodes the medial cortex of the mastoid tip and tracks along the digastric groove into the deep upper neck spaces, forming a deep cervical abscess at the sternocleidomastoid muscle.

Written by: Saygı Hospital Health Guide Editorial Board
Last updated:

This content has been compiled by the Saygı Hospital Health Guide Editorial Board and is periodically reviewed by a specialist physician.

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This content is for informational purposes only and does not constitute medical advice. You can book an appointment at our KBB (Kulak Burun Boğaz) department. Book Appointment →

What is Bezold Abscess?

Bezold abscess is an uncommon but life-threatening complication of acute coalescent mastoiditis described by Friedrich Bezold in 1881. Purulent material breaks through the thin medial cortex of the mastoid tip (where the digastric muscle inserts) and dissects inferiorly along the posterior belly of the digastric and into deep cervical spaces—submandibular, parapharyngeal, retropharyngeal and carotid sheath.

Pathophysiology requires (1) acute or chronic suppurative otitis media with poor drainage, (2) coalescent mastoiditis with bony resorption of mastoid air-cell septae, and (3) cortical erosion at the digastric groove. Causative organisms are typically Streptococcus pneumoniae, Streptococcus pyogenes, Fusobacterium necrophorum, Staphylococcus aureus and anaerobes. Pediatric mastoid tip pneumatization occurs after age 2, so Bezold is rare in infants.

Modern management requires urgent imaging (contrast-enhanced CT temporal bone with neck), intravenous broad-spectrum antibiotics covering anaerobes (ampicillin-sulbactam or ceftriaxone + metronidazole or piperacillin-tazobactam), cortical mastoidectomy with drainage of the mastoid tip, neck abscess incision and drainage, and middle ear ventilation tube. Failure to recognize can lead to mediastinitis, Lemierre syndrome, sigmoid sinus thrombosis, meningitis or sepsis.

Symptoms

Painful neck swelling at the angle of the mandible / upper sternocleidomastoid
Torticollis with head tilt toward affected side
Otorrhea, otalgia, post-auricular pain or fluctuance
Hearing loss, fullness, tinnitus
High fever, malaise, leukocytosis with neutrophilia
Trismus, dysphagia, drooling in extensive cases
Cranial nerve palsies (VII, IX, X, XI, XII) if infection spreads

Risk Factors

Untreated or under-treated acute otitis media
Coalescent mastoiditis (delayed antibiotic therapy)
Pediatric age 2–10 years (after mastoid tip pneumatization)
Immunocompromised state (HIV, diabetes, steroid use, transplant)
Cholesteatoma with secondary infection
Inadequate ventilation tube management
Resistant organisms (MRSA, multidrug-resistant strains)

When to See a Doctor?

If you experience any of the following symptoms, seek medical attention promptly:

  • Painful neck swelling with recent ear infection
  • High fever, lethargy, refusal to feed in a child after AOM
  • Acute torticollis or limited neck motion
  • Persistent otorrhea > 2 weeks despite antibiotics
  • New cranial nerve dysfunction or facial weakness
  • Sepsis signs (hypotension, altered mental status)
  • Visible fluctuant mass under jaw or in neck

Treatment Methods

01
Urgent contrast-enhanced CT temporal bone with neck — coalescent mastoiditis, cortical erosion, deep neck abscess; MRI with venogram if intracranial complication suspected
02
Empiric IV antibiotics: ampicillin-sulbactam 50 mg/kg q6h OR ceftriaxone + metronidazole OR piperacillin-tazobactam; add vancomycin for MRSA
03
Urgent cortical mastoidectomy with drainage of the mastoid tip (gold standard) — preserve facial nerve and lateral semicircular canal landmarks
04
Cervical incision and drainage of the deep neck abscess (parapharyngeal-submandibular collection)
05
Middle ear ventilation tube (myringotomy + tympanostomy) for ongoing otitis drainage and culture
06
Tailor antibiotics to culture (typical 4–6 weeks IV course, often through PICC)
07
Postoperative monitoring for sigmoid sinus thrombosis, meningitis, Lemierre syndrome; consider anticoagulation per neurology/ENT guidance

Which Department to Visit?

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