Bezold's abscess is a rare but serious deep neck space infection resulting from coalescent mastoiditis eroding through the medial or inferior aspect of the mastoid tip, with pus tracking along the digastric muscle and sternocleidomastoid (SCM) into the deep cervical fascial planes. [1-3] Named after Friedrich Bezold (1824–1908), it remains an important "cannot-miss" complication of otitis media in the antibiotic era. Delay in diagnosis is a frequent commonality, and diagnostic vigilance is paramount. [1]
The following illustration from an NEJM case demonstrates the anatomic pathway of infection spread from the middle ear through the mastoid into the neck (Bezold's abscess) and intracranially:
1. History
- Duration and severity of ear pain, otorrhea, hearing loss — often preceding neck symptoms by days to weeks
- History of recurrent or chronic otitis media, prior ear surgery, or known cholesteatoma [1-2][5]
- Failed outpatient antibiotic course for otitis media [6]
- Progressive neck pain, stiffness, or swelling — particularly lateral/posterior neck
- Fever, malaise, poor oral intake
- Headache, visual changes, or altered mental status (suggests intracranial extension) [7]
- Immunosuppression, diabetes, steroid use [8]
- In children: irritability, refusal to turn head, torticollis [9]
2. Alarm Features
- Neck mass with concurrent ear symptoms — classic but frequently missed presentation [1][10]
- High fever with rigors or sepsis physiology
- Meningismus, seizures, or focal neurological deficits → intracranial complication (meningitis, brain abscess, subdural empyema) [6-7]
- Facial nerve palsy [6]
- Rapidly expanding neck swelling or airway compromise
- Trismus or dysphagia suggesting parapharyngeal extension
- Signs of dural venous sinus thrombosis (headache, papilledema, cranial nerve VI palsy) [7][11]
- Concurrent Lemierre syndrome (septic jugular vein thrombophlebitis) [8]
3. Medications
- Empiric IV antibiotics should cover Streptococcus, Staphylococcus, gram-negatives, and anaerobes:
- Ampicillin-sulbactam or ceftriaxone + metronidazole are first-line [6][12]
- Vancomycin added if MRSA concern or critically ill [13]
- Anaerobic coverage is essential — Fusobacterium and Bacteroides species are associated with severe complications [12][14]
- Anticoagulation (e.g., heparin) if concurrent sigmoid sinus thrombosis — used in ~64% of cases in one series [7][15]
- Avoid ototoxic agents (aminoglycosides) if hearing preservation is a concern
- Prior oral antibiotics may mask symptoms and delay diagnosis [2][6]
4. Diet
- NPO if surgical intervention anticipated or airway compromise is a concern
- Adequate hydration — patients are often dehydrated from fever and poor oral intake
- No specific dietary triggers; long-term dietary management is not applicable
5. Review of Systems
- ENT: Otalgia, otorrhea, hearing loss, tinnitus, vertigo, facial asymmetry
- Neurologic: Headache, vision changes, neck stiffness, confusion, seizures
- Constitutional: Fever, chills, weight loss, fatigue
- Respiratory: Dyspnea, stridor (if airway compromise from neck extension)
- MSK: Neck pain, limited range of motion, torticollis
- GI: Dysphagia (parapharyngeal involvement)
6. Collateral History and Family History
- Caregiver history in pediatric patients — duration of ear symptoms, antibiotic compliance, prior ENT visits
- Vaccination status — pneumococcal vaccination reduces S. pneumoniae mastoiditis risk [16]
- Family history of cholesteatoma or recurrent otitis media
- Social context: access to healthcare, immunization status, recent travel
7. Risk Factors
- Acute or chronic otitis media — the primary antecedent [1][3]
- Cholesteatoma — associated with Bezold's abscess in adults [2][5][17]
- Prior mastoidectomy [17]
- Incomplete or inadequate antibiotic treatment of otitis media [6]
- Immunosuppression (diabetes, HIV, chronic steroid use) [8]
- Pediatric age group (most mastoiditis occurs in children, though Bezold's abscess is more common in adults with well-pneumatized mastoids) [1][9]
- Under-immunization [16]
8. Differential Diagnosis
- Subperiosteal (postauricular) abscess — more common; swelling is postauricular rather than in the neck [2][6]
- Parapharyngeal or retropharyngeal abscess from odontogenic or pharyngeal source [18]
- Cervical lymphadenitis with suppuration
- Lemierre syndrome (septic thrombophlebitis of internal jugular vein) — may coexist [8]
- Infected branchial cleft cyst
- Lymphoma or other neck malignancy — especially if indolent presentation
- Tuberculous mastoiditis (rare) [18]
- Necrotizing otitis externa (in elderly/diabetic patients — Pseudomonas)
- Distinguishing feature: concurrent otologic findings (otorrhea, TM abnormality, mastoid tenderness) with a deep neck collection should raise suspicion for Bezold's abscess specifically [1][10]
9. Past Medical History
- Prior episodes of otitis media or mastoiditis
- History of ear surgery (tympanoplasty, mastoidectomy, PE tubes)
- Known cholesteatoma
- Immunocompromising conditions
- Chronic ear drainage
10. Physical Exam
- Vital signs: Fever (often >38.5°C), tachycardia; hypotension if septic
- Ear: Otoscopy may show TM erythema, perforation, otorrhea, or cholesteatoma — but only one-third of patients show pathologic TM changes [2]
- Postauricular: Tenderness, erythema, pinna protrusion (classic mastoiditis signs)
- Neck: Tender, fluctuant mass deep to the SCM — typically in the upper lateral neck; torticollis with head tilted toward the affected side [1][3]
- Cranial nerves: Facial nerve (CN VII) function — palsy suggests intracranial or intratemporal extension [6]
- Neurologic: Meningeal signs, papilledema, altered consciousness
- Oropharynx: Medial bulging of lateral pharyngeal wall (parapharyngeal extension)
- Airway assessment: Stridor, drooling, voice changes
11. Lab Studies
- CBC with differential: Leukocytosis (mean WBC ~15–16 K/μL in mastoiditis series), but a normal WBC does not exclude the diagnosis [6][19]
- CRP: Typically elevated (mean ~60–112 mg/L in mastoiditis cohorts) [19-20]
- ESR: Elevated; useful for monitoring treatment response
- Blood cultures: Should be obtained before antibiotics — may identify causative organism [8]
- Procalcitonin: May help assess severity of bacterial infection
- BMP/CMP: Assess renal function (for antibiotic dosing), electrolytes
- Coagulation studies: If anticoagulation anticipated for sinus thrombosis
- Abscess culture: Aspirate should be sent in anaerobic transport for both aerobic and anaerobic culture, plus Gram stain [18]
Common organisms identified in mastoiditis/Bezold's abscess: [1][15][18]
- Streptococcus pneumoniae, S. pyogenes, S. anginosus group
- Staphylococcus aureus (including MRSA)
- Pseudomonas aeruginosa
- Fusobacterium necrophorum/varium
- Anaerobic bacteria (Prevotella, Bacteroides, Peptostreptococcus)
- Polymicrobial infections are common
12. Imaging
- CT temporal bone with IV contrast — first-line imaging [6][21]
- Demonstrates coalescent mastoiditis (loss of bony septae), mastoid tip erosion, abscess collection tracking into the neck
- Identifies intracranial complications (epidural abscess, sinus thrombosis)
- Essential for surgical planning
- CT neck with IV contrast — should be obtained concurrently to delineate the full extent of the neck abscess [17]
- MRI brain with and without contrast — superior for intracranial complications (meningitis, brain abscess, subdural empyema, dural venous sinus thrombosis) [21]
- Imaging is not needed for uncomplicated otitis media but is mandatory when complications are suspected [21-22]
Key imaging findings:
- Erosion of the mastoid tip cortex with fluid/abscess tracking medially into the digastric groove and along the SCM [2][17]
- Ring-enhancing collection in the deep neck spaces
- Opacification of mastoid air cells with bony erosion
13. Special Tests
- Tympanocentesis/myringotomy: Provides middle ear fluid for culture; therapeutic drainage [18][23]
- Audiometry: Assess for conductive or sensorineural hearing loss (when stable)
- Point-of-care ultrasound (POCUS): May identify neck fluid collection at bedside, though CT remains definitive
- No validated scoring system specific to Bezold's abscess; clinical diagnosis is primarily imaging-based
14. ECG
- ECG is not routinely indicated for Bezold's abscess
- Consider ECG if:
- Sepsis with hemodynamic instability
- Suspicion for descending necrotizing mediastinitis — deep neck infections can extend to the mediastinum and cause pericarditis with diffuse ST elevation [24]
- Pre-operative assessment
- Dangerous pattern: Diffuse ST elevation in a patient with deep neck infection should prompt consideration of mediastinal extension [24]
15. Assessment
Bezold's abscess is a rare but dangerous complication of coalescent mastoiditis in which infection erodes through the mastoid tip and tracks into the deep neck along the SCM and digastric muscles. [1-3] It is frequently associated with serious neurologic and systemic complications — a systematic review found that delay in diagnosis was a common theme. [1] The condition may present atypically, with neck symptoms predominating over ear complaints, and only one-third of patients demonstrate pathologic TM changes on otoscopy. [2]
Severity stratification:
- Uncomplicated: Isolated neck abscess without intracranial involvement
- Complicated: Concurrent intracranial complications (sinus thrombosis, epidural/subdural abscess, meningitis) — reported in up to 13.7% of mastoiditis cases [15-16]
- Complications to consider: Airway compromise, mediastinitis, sepsis, permanent hearing loss, facial nerve palsy, death [1][6-7]
16. Treatment Plan
Initial stabilization
- ABCs — assess and secure airway if neck swelling threatens patency
- IV access, fluid resuscitation, antipyretics
- Blood cultures before antibiotics
Antibiotics
- IV ampicillin-sulbactam (3 g q6h adults) or ceftriaxone (2 g IV daily) + metronidazole (500 mg IV q8h) [6][12]
- Add vancomycin (15–20 mg/kg IV q8–12h) if MRSA suspected or critically ill [13]
- Tailor based on culture results
- IV antibiotics for 4.5–11 days (mean), followed by 7–14 days oral antibiotics [25]
Surgical management
- Cortical mastoidectomy with neck abscess drainage — the definitive treatment [1-2][23]
- Myringotomy ± tympanostomy tube placement [23]
- Aggressive surgical extirpation is recommended given the high complication rate [1]
- Neurosurgical consultation if intracranial complications present [15]
Adjunctive
17. Disposition
- All patients require admission — typically to a monitored setting
- ICU admission if: sepsis, airway compromise, intracranial complications, need for emergent surgery
- Mandatory ENT/otolaryngology consultation — emergent [6]
- Neurosurgery consultation if intracranial extension (epidural abscess, subdural empyema, brain abscess) [15]
- Infectious disease consultation for complex or polymicrobial infections, immunocompromised patients
- Mean hospital stay: ~9.8–15.5 days depending on complications [12][23]
18. Follow Up / Return Precautions
- Follow-up: ENT within 1–2 weeks post-discharge; repeat imaging if clinical concern for residual disease
- Audiometry after acute phase resolves to assess for hearing loss (permanent hearing loss reported in ~2.7% of complicated mastoiditis cases) [26]
- Return immediately for: Recurrent fever, worsening neck swelling, new headache, vision changes, facial weakness, confusion, difficulty breathing or swallowing
- Expected recovery: Clinical improvement typically within 48–72 hours of appropriate antibiotics and surgical drainage; complete resolution over weeks
- Long-term: Monitor for recurrent otitis media (reported in ~32% of mastoiditis patients); consider PE tubes if recurrent [27]
- Ensure completion of full antibiotic course
References
1. A Systematic Review of Cases With Bezold's Abscess. — Young K, Ilustre J, Tang DM, Wu AW, Wong YT. Otology & Neurotology : Official Publication of the American Otological Society, American Neurotology Society European Academy of Otology and Neurotology. 2022.
2. Contemporary Presentation and Management of a Spectrum of Mastoid Abscesses. — Spiegel JH, Lustig LR, Lee KC, Murr AH, Schindler RA. The Laryngoscope. 1998.
3. Bezold's Abscess. — Gaffney RJ, O'Dwyer TP, Maguire AJ. The Journal of Laryngology and Otology. 1991.
4. Case 2-2013. — Stankovic KM, Eskandar E, El Khoury JB, Lev MH, Sadow PM. The New England Journal of Medicine. 2013.
5. Subperiosteal and Bezold's Abscesses Complicating Cholesteatoma: A Case Report. — Moisa II, Danziger EJ, Brauer RJ. Otolaryngology--Head and Neck Surgery : Official Journal of American Academy of Otolaryngology-Head and Neck Surgery. 1987.
6. High Risk and Low Prevalence Diseases: Acute Mastoiditis. — Bridwell RE, Koyfman A, Long B. The American Journal of Emergency Medicine. 2024.
7. A Unique Case of Bezold's Abscess Associated With Multiple Dural Sinus Thromboses. — Zapanta PE, Chi DH, Faust RA. The Laryngoscope. 2001.
8. The Co-Existence of Lemierre's Syndrome and Bezold's Abscesses Due to Streptococcus Constellatus: A Case Report. — Yaita K, Sugi S, Hayashi M, et al. Medicine. 2018.
9. Bezold's Abscess in Children: Case Report and Review of the Literature. — Marioni G, de Filippis C, Tregnaghi A, Marchese-Ragona R, Staffieri A. International Journal of Pediatric Otorhinolaryngology. 2001.
10. Bezold Abscess: A Rare Complication of Mastoiditis. — Nelson D, Jeanmonod R. The American Journal of Emergency Medicine. 2013.
11. Acute Mastoiditis Complicated With Bezold Abscess, Sigmoid Sinus Thrombosis and Occipital Osteomyelitis in a Child. — Vlastos IM, Helmis G, Athanasopoulos I, Houlakis M. European Review for Medical and Pharmacological Sciences. 2010.
12. Intracranial Complications of Acute Mastoiditis: Surgery Not Always Necessary. — Shinnawi S, Khoury M, Cohen-Vaizer M, Cohen JT, Gordin A. American Journal of Otolaryngology. 2024.
13. Epidemiology and Variability in Management of Acute Mastoiditis in Children. — Edwards S, Kumar S, Lee S, et al. American Journal of Otolaryngology. 2022.
14. Anaerobic Mastoiditis: A Report of Two Cases With Complications. — Moloy PJ. The Laryngoscope. 1982.
15. Management of Acute Complicated Mastoiditis at an Urban, Tertiary Care Pediatric Hospital. — Ghadersohi S, Young NM, Smith-Bronstein V, Hoff S, Billings KR. The Laryngoscope. 2017.
16. Contemporary Management of Acute Mastoiditis in Children: Insights From a U.S. National Database. — Hamdi O, Ramos L, Jamil T, et al. International Journal of Pediatric Otorhinolaryngology. 2026.
17. Imaging of Bezold's Abscess. — Castillo M, Albernaz VS, Mukherji SK, Smith MM, Weissman JL. AJR. American Journal of Roentgenology. 1998.
18. Guide to Utilization of the Microbiology Laboratory for Diagnosis of Infectious Diseases: 2024 Update by the Infectious Diseases Society of America (IDSA) and the American Society for Microbiology (ASM). — Miller JM, Binnicker MJ, Campbell S, et al. Clinical Infectious Diseases : An Official Publication of the Infectious Diseases Society of America. 2024.
19. The Significance of Subperiosteal Abscess Volume in Acute Mastoiditis. — Abu-Eta R, Salameh R, Oron Y, et al. The Laryngoscope. 2025.
20. A Novel Diagnostic and Treatment Algorithm for Acute Mastoiditis in Children Based on 109 Cases. — Häußler SM, Peichl J, Bauknecht C, et al. Otology & Neurotology : Official Publication of the American Otological Society, American Neurotology Society European Academy of Otology and Neurotology. 2024.
21. ACR Appropriateness Criteria® Inflammatory Ear Disease. — Agarwal M, Juliano AF, Hagiwara M, et al. Journal of the American College of Radiology : JACR. 2025.
22. ESR Essentials: Acute Infections of the Head and Neck-Practice Recommendations by the European Society of Head and Neck Radiology. — Hirvonen J, Lingam RK, Connor S. European Radiology. 2025.
23. Algorithmic Management of Pediatric Acute Mastoiditis. — Psarommatis IM, Voudouris C, Douros K, et al. International Journal of Pediatric Otorhinolaryngology. 2012.
24. Descending Necrotizing Mediastinitis With Diffuse ST Elevation Mimicking Pericarditis: A Case Report. — Cho YS, Choi JH. The Journal of Emergency Medicine. 2014.
25. Antibiotic Duration and Timing of the Switch From Intravenous to Oral Route for Bacterial Infections in Children: Systematic Review and Guidelines. — McMullan BJ, Andresen D, Blyth CC, et al. The Lancet. Infectious Diseases. 2016.
26. Surgical Management of Mastoiditis With Intratemporal and Intracranial Complications in Children. Outcome, Complications, and Predictive Factors. — Guillén-Lozada E, Bartolomé-Benito M, Moreno-Juara Á. International Journal of Pediatric Otorhinolaryngology. 2023.
27. Acute Mastoiditis: 30 Years Review in a Tertiary Hospital. — Veiga-Alonso A, Roldán-Pascual N, Pérez-Mora RM, et al. International Journal of Pediatric Otorhinolaryngology. 2025.