Bezold's abscess, an uncommon complication of otitis media and cholesteatoma: a case report.

BACKGROUND: Mastoiditis frequently occurs in children as they are more susceptible to middle ear infections, but infrequently occurs in adults. A rare complication that results from mastoiditis and an obstructing cholesteatoma is a Bezold's abscess, of which there are less than 100 reported cases in literature to date. CASE PRESENTATION: Here, we present a case of a 72-year-old Caucasian man who has had no history of prior ear infections and was found to have a cholesteatoma and advanced acute coalescent mastoiditis complicated by a Bezold's abscess. CONCLUSIONS: Bezold's abscess is a rare entity infrequently encountered in the modern era, likely owing to more prompt treatment of otitis media. Cholesteatoma poses a great risk for both the development of otitis media and further progression to mastoiditis and its associated complications, such as Bezold's abscess. Knowledge of said abscess is crucial; without prompt recognition, further spread of infection can occur with vascular or mediastinal involvement.

The Clinical Value of Cranial CT Venography for Predicting Fusobacterium necrophorum as the Causative Agent in Children with Complicated Acute Mastoiditis.

BACKGROUND AND PURPOSE: Fusobacterium necrophorum (F necrophorum) is an anaerobic bacteria that causes invasive head and neck infections in children. Several studies have demonstrated an increasing prevalence of F necrophorum as the causative agent in acute mastoiditis in children, with associated high rates of intracranial complications such as epidural abscess and sinus venous thrombosis, to name a few. F necrophorum requires a treatment protocol that differs from the empiric treatment that is tailored to more common pathogens (eg, group A streptococci, Streptococcus pneumonia), and hence expediting the diagnosis is important. For evaluating complicated acute mastoiditis in children, cranial CT venography remains the imaging study of choice in most medical centers due to its availability in emergency situations. Based on our clinical experience, our hypothesis is that children with F necrophorum-associated complicated acute mastoiditis can be differentiated from those with other etiologies using CT venography. MATERIALS AND METHODS: CT venography studies of 76 children hospitalized and treated for complicated acute mastoiditis were retrospectively reviewed. Retrieved imaging data included intracranial complications (epidural abscess, sinus venous thrombosis), cranial bone-related complications, and extracranial complications (subperiosteal abscess, temporomandibular joint abscess, and soft-tissue inflammation). The cohort was divided into children with F necrophorum-related disease (study group) and those with non-F necrophorum-related disease (control group). RESULTS: Thirty-seven children (49%) comprised the study group, and 39 children in whom the causative agents were other bacteria comprised the control group. There were significantly higher rates of complications in the study group: sinus venous thrombosis (P < .001), perisigmoid epidural abscess (P = .036), and extramastoid osteomyelitis (P < .001). Thrombosis in venous sites beyond the sigmoid sinus and jugular foramen (a pattern consistent with an otogenic variant of Lemierre syndrome) and emphysematous osteomyelitis were found only among children in the F necrophorum-related study group (32% and 22% accordingly). CONCLUSIONS: In children with complicated acute mastoiditis, CT venography findings of emphysematous osteomyelitis and/or thrombosis in venous sites beyond the sigmoid sinus and jugular foramen (a pattern consistent with the otogenic variant of Lemierre syndrome) should lead the radiologist to suggest F necrophorum-related mastoiditis.

Auritidibacter ignavus: an underestimated pathogen?

Auritidibacter ignavus is an emerging diagnosed microorganism associated with fulminant otitis, mastoiditis and recurrent otitis. Here we describe a clinical case in a little girl in La Gomera Island together with images of the bacteriological culture and whole genome sequencing.

Tuberculous mastoiditis - a case series.

SUMMARY: Tuberculous mastoiditis (TBM) is a rare form of extrapulmonary tuberculosis (TB), which may result in catastrophic complications, including mastoid and ossicle destruction, hearing loss and intracranial spread if untreated. Diagnosis is challenging due to the paucibacillary nature of extrapulmonary TB, compounded by limited theatre access for specimen retrieval, resulting in delayed diagnosis and treatment initiation. In this case series, we discuss three cases of TBM (one paediatric and two adults) who presented to the public and private healthcare sectors in the Eastern Cape in 2022, underscoring that TB does not respect socioeconomic status.

Probable fatal mastoiditis by the around 2300 year old Heidelberg's Egyptian mummy Djed-Hor.

The universal use of computed tomography (CT) has opened up new possibilities in the noninvasive examination of human mummies, and particularly the detailed study of the fine structures of the temporal bone. The aim of this study was to describe the morphological changes, as seen on CT, found in the right temporal bone of Djed-Hor, an around 2300 year old Heidelberg's Egyptian mummy, and to discuss their possible causal relation to his death. Here we showed the presence of a compress on the auricle, and of probable pus in the mastoid, middle ear, and external ear with erosion of the tegmen tympani probably related to a fatal acute mastoiditis. These typical morphological changes of such a disease were demonstrated in the same way as in living patients of today. This would be the first depiction of a compress on an auricle associated with pus in the ear of an Egyptian mummy.

Multicentric Case Series and Literature Review of Coccidioidal Otomastoiditis.

Coccidioidomycosis involving the ear, mastoid bone, or both is uncommon. We describe 5 new cases from the United States and review 4 cases reported in the literature of otomycosis and mastoiditis caused by Coccidioides. Of the 9 cases, 8 were linked to residence in or travel to California. Two patients had poorly controlled diabetes mellitus, 7 had otomastoiditis, 1 had otitis externa without mastoid involvement, and 1 had mastoiditis without otic involvement. Four patients had concurrent or prior pulmonary coccidioidomycosis. Ipsilateral facial nerve palsies developed in 2 patients. All patients received antifungal treatment for varying durations, and 8 of the 9 patients underwent surgical debridement. Clinicians should consider coccidioidomycosis as a differential diagnosis for otomastoiditis in patients with geographic risks.

Diagnosing acute mastoiditis in a Pediatric Emergency Department: a retrospective review.

Background and aim Acute mastoiditis (AM) is a common complication of acute otitis media in children. There is currently no consensus on criteria for diagnosis. Head CT is the most frequent diagnostic tool used in the ED although the increasing awareness on the use of ionized radiations in children has questioned the use of CT imaging versus solely using clinical criteria. Our research aimed to understand if CT imaging was essential in making a diagnosis of AM. Methods We retrospectively analyzed medical records from pediatric patients who accessed our Pediatric Emergency Department (ED) between January 2014 and December 2020, with a clinical suspicion of AM. We reviewed clinical symptoms upon presentation, head CT and lab values (white blood cell count or WBC, C-Reactive Protein or CRP) when done, presence of complications and discharge diagnosis. A multilogistic regression model was specified to establish the role of clinical features and of CT in the diagnosis of AM based on 77 patients. Results Otalgia (OR= 5.01; 95% CI= 1.52-16.51), protrusion of the auricle (OR= 8.42; 95% CI= 1.37-51.64) and hyperemia (OR= 4.07; 95% CI= 1.09-15.23) of the mastoid were the symptoms strongly associated with a higher probability of AM. In addition to clinical features, the adjusted OR conferred by head CT was 3.09 (95% CI = 0.92-10.34). Conclusions Clinical signs were most likely predictive of AM in our sample when compared to Head CT. Most common symptoms were protrusion of the auricle, hyperemia or swelling behind the ear and otalgia.

Application of symmetry evaluation to deep learning algorithm in detection of mastoiditis on mastoid radiographs.

As many human organs exist in pairs or have symmetric appearance and loss of symmetry may indicate pathology, symmetry evaluation on medical images is very important and has been routinely performed in diagnosis of diseases and pretreatment evaluation. Therefore, applying symmetry evaluation function to deep learning algorithms in interpreting medical images is essential, especially for the organs that have significant inter-individual variation but bilateral symmetry in a person, such as mastoid air cells. In this study, we developed a deep learning algorithm to detect bilateral mastoid abnormalities simultaneously on mastoid anterior-posterior (AP) views with symmetry evaluation. The developed algorithm showed better diagnostic performance in diagnosing mastoiditis on mastoid AP views than the algorithm trained by single-side mastoid radiographs without symmetry evaluation and similar to superior diagnostic performance to head and neck radiologists. The results of this study show the possibility of evaluating symmetry in medical images with deep learning algorithms.

Mastoiditis enmascarada: Reporte de caso en un hospital pediátrico de alta complejidad / Masked mastoiditis: case report in a high-complexity pediatric hospital

La mastoiditis enmascarada es una forma poco frecuente dentro de las complicaciones de las otitis medias, ya sean aguda o crónicas. Su principal característica es presentar poca o mínima sintomatología ótica y tener un curso larvado en el tiempo. Este diagnóstico debe ser correctamente sospechado, ya que eventualmente puede generar consecuencias otológicas graves y presentar complicaciones mayores a nivel intra o extratemporal. En este trabajo se presenta el caso clínico de una paciente pediátrica sana, a la cual se diagnostica mastoiditis enmascarada de tres meses de evolución complicada con absceso de Bezold. Se inicia desde el ingreso hospitalario esquema antibiótico bi-asociado y se realiza mastoidectomía simple, evolucionando de forma satisfactoria.

Masked mastoiditis is a rare complication of acute or chronic otitis media. Its main characteristic is to present little or minimal otic symptoms and has a slowly progressive course over time. This diagnosis must be suspected correctly because it can eventually generate serious otological consequences and present major complications at intra or extratemporal levels. We report the clinical case of a healthy pediatric patient, who was diagnosed with masked mastoiditis complicated with a Bezold's abscess. A bi-associated antibiotic scheme was started from admission and a timpanomastoidectomy was performed, with a satisfactory outcome.

Pediatric temporomandibular joint (TMJ) arthritis, an elusive complication of acute mastoiditis.

INTRODUCTION: Septic arthritis of the Temporomandibular joint (TMJ) is a rare complication of acute middle ear infection. Presentation is elusive and could be easily missed. Often diagnosis is made only with consequential development of TMJ ankylosis. This study intends to characterize patients and course of disease and suggest a diagnostic and therapeutic strategy. METHODS: Retrospective review of all children diagnosed with TMJ arthritis and/or TMJ ankylosis secondary to acute middle ear infection, treated in a tertiary pediatric medical center between the years 2005 and 2021. RESULT: Seven patients were identified with otogenic TMJ arthritis. Median age at presentation was 1.14 years (IQ range 1.1-1.5). All seven were diagnosed with acute mastoiditis. CT scans demonstrated TMJ related collections in 5/7 and intracranial complications in 3/7. Treatment included cortical mastoidectomy for 5/7. One patient had a concomitant surgical washout of the TMJ. Two patients had drainage only of subperiosteal collections. Six of the seven patients went on to develop TMJ ankylosis that presented within a median of 2.8 years (IQ range 2.6-3.9) after the episode of acute mastoiditis. All six patients presented with trismus and facial growth anomalies, and all but one required surgery to release the ankylosis. CONCLUSION: Otogenic TMJ arthritis develops mostly in young children with acute mastoiditis and intratemproal and/or intracranial suppuration. Imaging is helpful in making the diagnosis, with TMJ related collections on CT being the most common finding. TMJ ankylosis can develop within a few years and present with trismus and abnormal facial growth. Cortical mastoidectomy does not seem to prevent ankylosis. It remains unclear whether focused treatment to the TMJ or physiotherapy could be beneficial in that.

Epidemiologic, Imaging, and Clinical Issues in Bezold's Abscess: A Systematic Review.

Bezold's abscess is a deep neck abscess related to otomastoiditis. Due to the insidious clinical presentation, diagnosis can be extremely challenging, leading to delays in treatment and possible life-threatening complications. The literature currently provides a fragmented picture, presenting only single or small number of cases. The present study aims at examining our experience and the literature findings (based on PRISMA criteria) of 97 patients with Bezold's abscess, summarizing their epidemiology, pathogenesis, clinical presentation, imaging findings, and treatments. Bezold's abscess is found at any age, with overt male prevalence among adults. The clinical presentation, as well as the causative pathogens, are strikingly heterogeneous. Otomastoiditis and cholesteatoma are major risk factors. A clinical history of otitis is commonly reported (43%). CT and MRI are the main diagnostic tools, proving the erosion of the mastoid tip in 53% of patients and the presence of a concomitant cholesteatoma in 40%. Intracranial vascular (24%) or infectious (9%) complications have also been reported. Diagnosis might be easily achieved when imaging (CT) is properly applied. MRI has a limited diagnostic role, but it might be crucial whenever intracranial complications or the coexistence of cholesteatoma are suspected, helping to develop proper treatment (prompt antibiotic therapy and surgery).

The management of elevated intracranial pressure and sinus vein thrombosis associated with mastoiditis: the experience of eighteen patients.

PURPOSE: Cerebral sinus vein thrombosis (CSVT) associated with acute mastoiditis is a rare complication of acute otitis media. Elevated intracranial pressure (ICP) frequently occurs secondary to CSVT. The study aims to review the 5 years of experience of four medical centres to treat sigmoid sinus thrombosis and elevated intracranial pressure in children. METHODS: Patients with CSVT that developed secondary mastoiditis from 2016 through 2021 were evaluated in four centres from Turkey. Patients diagnosed with a preceding or synchronous mastoiditis and intracranial sinus thrombosis were included in the study. Magnetic resonance imaging (MRI), magnetic resonance venography (MRV), ICP measurements, ophthalmological examinations, thrombophilia studies and treatments for increased ICP have also been recorded. RESULTS: The study group comprises 18 children. Twelve patients were diagnosed with right-sided, six patients with left-sided sinus vein thrombosis. All of the patients had ipsilateral mastoiditis. The most common presenting symptoms were fever, ear pain, headache, visual disorders and vomiting. The most encountered neurologic findings were papilledema, strabismus and sixth cranial nerve palsy. ICP was over 20 cm H2O in eleven patients. Anticoagulant treatment, antibiotics, pressure-lowering lumbar puncture and lumboperitoneal shunt were among the treatment modalities. CONCLUSION: Elevated ICP can damage the brain and optic nerve irreversibly, without treatment. For treating elevation of ICP associated with cerebral sinus thrombosis, pressure-lowering lumbar puncture (LP), acetazolamide therapy, optic nerve sheath fenestration (ONSF) and cerebrospinal fluid (CSF)-shunting procedures are suggested in case of deteriorated vision.

IgG4-related pachymeningitis and mastoiditis, associated with cerebral venous thrombosis: A case report.

IgG4-related disease (IgG4-RD) is a multisystem fibroinflammatory condition; this can be a challenging diagnosis that requires clinico-pathologic correlation. We report a young woman, presenting with cranial nerve palsy. The work-up revealed pachymeningitis, cerebral venous thrombosis (CVT), and a destructive lesion in the mastoid. We diagnosed IgG4-RD through mastoidectomy. Thus, a biopsy of asymptomatic, infrequently affected organs, like the mastoid, can meet all histopathological criteria. In neuro-meningeal presentations, CVT may be secondary to the local inflammatory environment of pachymeningitis. Since our patient had a deep vein thrombosis one year prior, we discuss a possible higher risk of thrombosis in IgG4-RD patients.

Transmastoid and Transtemporal Drainage of Petrous Apicitis with Otitis Media.

BACKGROUND: Petrous apicitis (PA) is a serious infection involving the apical portion of the petrous temporal bone. The classic triad of purulent otorrhea, ipsilateral abducens nerve palsy and retroorbital pain is rarely seen due to early detection and widespread use of antibiotics. Medical management is the primary treatment modality with surgery reserved for cases of recalcitrant petrous apex abscess. METHODS AND RESULTS: We presented a case of PA with previously untreated otitis media. After multidisciplinary evaluation, the patient was initially treated with intravenous antibiotics followed by drainage of the abscess using a combined transmastoid and middle cranial fossa (MCF) approach. The patient recovered well with no recurrence of the infection based on imaging and symptoms. DISCUSSION: While a variety of different surgical approaches can be used in treatment of PA, we recommend the MCF approach in cases where access to the anterior petrous apex may be challenging via transcanal or transmastoid approach.

Detection of Coalescent Acute Mastoiditis on MRI in Comparison with CT.

PURPOSE: Current imaging standard for acute mastoiditis (AM) is contrast-enhanced computed tomography (CT), revealing inflammation-induced bone destruction, whereas magnetic resonance imaging (MRI) outperforms CT in detecting intracranial infection. Our aim was to compare the diagnostic performance of MRI with CT in detecting coalescent AM and see to which extent MRI alone would suffice to diagnose or rule out this condition. METHODS: The MR images of 32 patients with AM were retrospectively analyzed. Bone destruction was evaluated from T2 turbo spin echo (TSE) and T1 Gd magnetization-prepared rapid acquisition with gradient echo (MPRAGE) images. Intramastoid enhancement and diffusion restriction were evaluated subjectively and intramastoid apparent diffusion coefficient (ADC) values were measured. The MRI findings were compared with contrast-enhanced CT findings of the same patients within 48 h of the MR scan. RESULTS: Depending on the anatomical subsite, MRI detected definite bone defects with a sensitivity of 100% and a specificity of 54-82%. Exception was the inner cortical table where sensitivity was only 14% and specificity was 76%. Sensitivity for general coalescent mastoiditis remained 100% due to multiple coexisting lesions. The absence of intense enhancement and non-restricted diffusion had a high negative predictive value for coalescent mastoiditis: an intramastoid ADC above 1.2â€¯× 10-3 mm2/s excluded coalescent mastoiditis with a negative predictive value of 92%. CONCLUSION: The MRI did not miss coalescent mastoiditis but was inferior to CT in direct estimation of bone defects. When enhancement and diffusion characteristics are also considered, MRI enables dividing patients into low, intermediate and high-risk categories with respect to coalescent mastoiditis, where only the intermediate risk group is likely to benefit from additional CT.