Luc’s abscess: The zygomatic route of infection from cholesteatoma

@#Luc’s abscess is an uncommon complication of otitis media wherein a subperiosteal abscess develops into the temporalis muscle and follows the route of a pneumatized zygoma.1 In uncomplicated cases, surgical drainage and antibiotics are adequate management with mastoidectomy reserved for severe or complicated cases. We report a case of complicated Luc’s abscess presenting with many complications that required multiple surgical interventions.

Zygomatic root abscess: A rare entity not to be forgotten!

Zygomatic root abscess is a rare extracranial extratemporal complication of otitis media. To the best of our knowledge, there are only a few scattered cases of zygomatic root abscesses reported in the literature. We present an unusual case of a zygomatic root abscess in a 24 years old adult. He presented with one month duration of right zygomatic swelling. Otoscopic examination revealed superior and posterior external auditory canal wall sagging with an intact tympanic membrane. High Resolution Computed Tomography (HRCT) temporal bone revealed a rim enhancing lesion lateral to the zygomatic process with fluid filled mastoid air cells. He was managed with antibiotics and staged surgical interventions. He recovered well. Our case serves to shed light on the pathways of infection, clinical manifestations and timely staged surgical intervention in this rare pathology.

Clinical features and management of Luc's abscess: Case report and systematic review of the literature.

OBJECTIVES: Luc's abscess is a rare complication of acute otitis media, with a challenging diagnosis and a controversial surgical treatment. The aim of the present study was to review the published literature in order to clarify the clinical features and the surgical management of those patients. METHODS: A systematic review of the literature was carried out for published reports or case series in English language, describing a temporo-zygomatic (or Luc's) abscess which complicated an acute or chronic otitis media and/or mastoiditis, confirmed through CT scan or MRI of the petrous bone. The collected clinical and radiological data were merged and critically appraised. RESULTS: Eighteen reports of Luc's abscess were included. Adding our case report, a total of 21 cases were included in the analysis. Abscess drainage plus myringotomy alone vs. abscess drainage plus myringotomy and mastoidectomy were the two surgical management approaches described in the literature. Patients undergoing first line mastoidectomy were successfully treated in all cases, while among those undergoing a more conservative approach, one failure required subsequent mastoidectomy. CONCLUSIONS: The clinical features of Luc's abscess are rather constant and help in rising the suspicion before the radiological diagnosis. Although cases with associated intra-cranic complications have been reported, the limited existing data do not permit to advocate the mastoidectomy over a more conservative surgical approach. However, the decision to avoid mastoidectomy as the first line surgical treatment should be based on the clinical and radiologic assessment, after an accurate counseling, particularly in the case of a pediatric patient.

Atypical presentation of aural tuberculosis with complication.

Tuberculosis involving mastoid and ear is an uncommon entity presenting with myriads of non-specific features and difficult to diagnose, being a paucibacillary condition. The involvement of otomastoid compartment is hypothesised to be of haematogenous origin. Rarely it can spread directly via tympanic membrane perforation or via reflux through eustachian tube. The usual picture of presentation tends to be one of indolent ear infection not responsive to usual antibiotic treatment and symptomatology being out of proportion to examination findings. We present a case of aural tuberculosis presenting with zygomatic and Bezold abscess without other symptoms, and the usefulness of GeneXpert test in mycobacterial detection in such paucibacillary conditions.

Zygomatic Mastoiditis with Extracranial Complications: An Extremely Rare Cause of Cheek Swelling / 대한이비인후과학회지

Zygomatic mastoiditis is an extremely rare cause of an inflamed, swollen cheek. We encountered a 10-year-old girl with left preauricular swelling, pain, and mild trismus. Temporal bone computed tomography revealed a zygomatic root abscess with bone defects and a scanty amount of soft tissue lesion in Prussak's space. After antibiotic therapy for 2 weeks, her pain subsided, but the swelling persisted. All inflamed air cells, including the lesion in the zygomatic root, were eradicated. The swelling subsided after the surgery. The patient has not experienced any postoperative complications or shown any evidence of relapse for more than 1 year.

Posttraumatic Intracranial Tuberculous Subdural Empyema in a Patient with Skull Fracture

Intracranial tuberculous subdural empyema (ITSE) is extremely rare. To our knowledge, only four cases of microbiologically confirmed ITSE have been reported in the English literature to date. Most cases have arisen in patients with pulmonary tuberculosis regardless of trauma. A 46-year-old man presented to the emergency department after a fall. On arrival, he complained of pain in his head, face, chest and left arm. He was alert and oriented. An initial neurological examination was normal. Radiologic evaluation revealed multiple fractures of his skull, ribs, left scapula and radius. Though he had suffered extensive skull fractures of his cranium, maxilla, zygoma and orbital wall, the sustained cerebral contusion and hemorrhage were mild. Eighteen days later, he suddenly experienced a general tonic-clonic seizure. Radiologic evaluation revealed a subdural empyema in the left occipital area that was not present on admission. We performed a craniotomy, and the empyema was completely removed. Microbiological examination identified Mycobacterium tuberculosis (M. tuberculosis). After eighteen months of anti-tuberculous treatment, the empyema disappeared completely. This case demonstrates that tuberculosis can induce empyema in patients with skull fractures. Thus, we recommend that M. tuberculosis should be considered as the probable pathogen in cases with posttraumatic empyema.

[A case of infratemporal fossa abscess cause by facial acupuncture].

The infratemporal fossa abscess is an irregularly shaped cavity, situated below and media to the zygomatic arch. It consists of masseter and nervus vascularis, etc. Comparatively speaking, the low position of the infratemporal fossa has almost freed the patient from dental, nasal,ocular and aural source of pain. So facial acupuncture is more likely to cause the infection. But it is also possible that the patient get cryptogenic infection of maxillofacial cavity, the treatment of which needs further study.

A Case of Infratemporal Fossa Abscess Caused by Acute Sinusitis / 대한이비인후과학회지

Infratemporal fossa abscess caused by acute sinusitis, without other predisposing factors, is very rarely reported. We present such a case in a 78-year-old woman who was treated successfully with surgical drainage and antibiotics. She presented with a 10-day history of swelling and pain on the right side of her face. Physical examination revealed swelling on the right mandible area up to the zygomatic arch and the presence of mucopurulent rhinorrhea in the right nasal cavity without abnormal dental findings. Computed tomography revealed a right infratemporal fossa abscess and ipsilateral maxillary sinusitis connected through a defect on the posterior wall of the maxillary sinus. Drainage procedure was performed by navigation-guided endoscopic sinus surgery and intravenous antibiotics were administered. During a four months follow-up period, there was no sign of recurrence. Infratemporal fossa abscess can develop from acute sinusitis without predisposing factors, including dental infection. Surgical drainage along with intravenous antibiotics can lead to successful treatment in such cases.

A case of infratemporal fossa abscess cause by facial acupuncture / 临床耳鼻咽喉头颈外科杂志

The infratemporal fossa abscess is an irregularly shaped cavity, situated below and media to the zygomatic arch. It consists of masseter and nervus vascularis, etc. Comparatively speaking, the low position of the infratemporal fossa has almost freed the patient from dental, nasal,ocular and aural source of pain. So facial acupuncture is more likely to cause the infection. But it is also possible that the patient get cryptogenic infection of maxillofacial cavity, the treatment of which needs further study.

A very rare complication of acute sinusitis: subgaleal abscess.

A 12-year-old girl presented with a swollen right eye with three days of pain and a diffused swollen frontal region and head lasting for one day. On the computed tomography with contrast, diffused collection was detected in the subgaleal regions and subperiosteal of the right orbita. It was observed that she had bilateral maxillary, ethmoidal, and frontal sinusitis and an infected bilateral middle concha bullosa in the right side. No symptoms of intracranial complication and osteomyelitis in the frontal or other calvarial bones were determined. This case presentation is thought to be the first one in literature that is an acute sinusitis without an intracranial complication and osteomyelitis, but with a diffused subgaleal abscess resulting from a subperiosteal abscess.

Zygomatic abscess with temporal myositis - a rare extracranial complication of acute otitis media.

Acute mastoiditis is the most common complication of acute otitis media (AOM) and its early recognition and management still poses a challenge due to potentially serious consequences. The incidences of extracranial and intracranial suppurative complications of AOM in children have decreased significantly, yet they remain a serious clinical problem, especially when caused by bacteria resistant to antibiotics. The authors presented a case of rare AOM complication - zygomatic abscess with temporal myositis. A 6-year-old boy was admitted to the ENT Department with 4 weeks of ear pain, treated for AOM with cefuroxime axetyl and amoxicilline, with acute mastoiditis and subsequent abscess formation in zygomatic and preauricular region. The inflammatory process spread through anterior air cells to the zygomatic cells leading to a fistula formation in the zygomatic bone and breakthrough into the temporal muscle. The surgical procedures applied were: myringotomy with drainage, cortical mastoidectomy and revision of zygomatic area and treatment with antibiotics (ceftriaxon). Enterococcus faecalis and Streptococcus viridans were found in the culture of middle ear and mastoid effusion. After half a year of follow-up the child had a normal hearing. Severe complications of AOM are rare today. An early diagnosis in order to promote adequate management and prevent inherently suppurative complications is essential.

[Abscess of the skull base--therapy and reconstruction after zygoma resection]. / Der Abszess an der Schädelbasis--Therapie und Rekonstruktion nach Jochbogenresektion.

Abscesses of the base of skull, if not correctly managed, can lead to the intracranial spread of infection - a life-threatening complication. Infection can spread from the upper and lower molar teeth through the retromaxillary area or the parapharyngeal space to reach the temporal, infratemporal or pterygopalatine fossa. Our recommended treatment of abscesses in these fossae is wide abscess incision together with resection of the midsection of the zygomatic arch ("Partsch method"). Two case reports are included. The first report is of a patient with cerebral abscess caused by an oral infection. The second report is of a case in which zygomatic arch reconstruction was necessary after its partial resection for abscess treatment. A new alloplastic bone-substitute material made from coral was used in the reconstruction.

A swollen cheek, an unusual course of acute mastoiditis.

An acute mastoiditis can occasionally present as a swelling in front of the ear. An inflammation of the air cells of the mastoid cavity can spread, via the cells in the root of the zygomatic arch, to the soft tissues of the cheek. Unfamiliarity with this underlying cause of a swollen cheek can lead to delay of proper treatment with potential harm to the patient. This case presents such an uncommon form of mastoiditis in a 3-year-old boy; the failure to recognize the disease initially led to extensive osteomyelitis of the temporal bone. CT scanning was important in establishing the cause of the persistently severe condition of the boy, in spite of bilateral myringotomies and mastoidectomy on the right side. Destruction of bone from the zygomatic arch to the suture between temporal and occipital bone was shown. Extensive removal of diseased bone was achieved neurosurgically, thus leading to uneventful recovery.

Job's syndrome.

Job's syndrome is characterized by the clinical features of fair skin, red hair, recurrent cold staphylococcal skin abscesses with concurrent other bacterial infections and skin lesions. This case report chronicles a classic presentation of Job's syndrome. A brief review of the otolaryngological presentations of immune deficiencies is presented. Other than its relationship to the manifestations of other immunological defects, Job's syndrome is of interest to the otolaryngologist because of the head and neck infections represented in its clinical expression. Familiarity with phenotypic and laboratory manifestations of such diseases will enable earlier recognition and treatment of this syndrome.