Atypical presentation of Bezold's and Citelli's abscesses, with recollection following an incomplete postoperative course of antibiotics

Background

Bezold's and Citelli's abscesses are rare complications of acute suppurative otitis media and mastoiditis, in which infection erodes through the mastoid bone and extends into the neck. A Bezold's abscess extends into the sheath of the sternocleidomastoid muscle, while a Citelli's abscess extends into the digastric fossa. Their rarity makes identification on clinical signs difficult. 1

Acute mastoiditis is often treated without surgery, if there is a good initial response to antibiotics. However, treatment of a neck abscess usually requires, in addition to appropriate antibiotic therapy, surgical drainage of the abscess, 2 3 with earlier surgery associated with better outcome. 1

In this presented case, our patient, initially diagnosed with mastoiditis which responded to medical treatment, was found to have Bezold's and Citelli's abscesses on a CT scan, necessitating surgical treatment. The appearance of both these rare complications illustrates the need to look for uncommon but serious complications of otitis media even when the patient's condition is improving with medical treatment. This case also highlights the significance of communication, as had the patient understood the discharge plan, re-admission and further surgery could have been avoided.

Case presentation

A 44-year-old man of Eastern European ascent presented to the Assessment Unit with fever and mild right otalgia of a few hours' duration. There was no neck pain, nor restriction of movement. He had no difficulty breathing or swallowing, and had no change in his voice. The patient had suffered recurrent otitis media over the last year, but had no previous ear discharge. He was otherwise well, and not immunocompromised; he was on no regular medications, and had no allergies. On examination, there was tenderness and a small swelling over the right mastoid process, while the tympanic membrane appeared retracted. The chest was clear and the oropharynx appeared to be normal. The patient was apyrexial and haemodynamically stable.

Investigations

Serum white cell count (reference range: 4.0x10⁹ -11.0x10⁹ /L): On initial admission: 12.2x10⁹ /L

On re-admission: 22.1x10⁹ /L

First CT scan of internal auditory meati: Right mastoiditis with bony erosion anterior to the sigmoid venous...