Bezold abscess presenting as a carbuncle-like cervical lesion in an adult with destructive otomastoiditis: a case report from Malaysia

Abstract

Background Bezold abscess is a rare extracranial complication of otomastoiditis caused by spread of infection through an eroded mastoid tip into the deep cervical tissues. Its rarity and variable presentation can delay recognition, particularly when superficial cutaneous changes dominate the clinical picture.

Case presentation A 43-year-old Malaysian man presented with 2 weeks of left otalgia, purulent otorrhea, fever and progressive left lateral neck swelling. The lesion was initially referred as a neck carbuncle because of erythema, skin necrosis and multiple draining puncta. Random blood glucose was 23.4 mmol/L and previously undiagnosed diabetes mellitus was subsequently identified. Contrast-enhanced computed tomography showed destructive left otomastoiditis with mastoid air-cell erosion and an extensive intramuscular rim-enhancing collection in the left posterolateral neck measuring approximately 6.9 × 8.2 × 13.1 cm, involving the paravertebral musculature and extending across the midline at C4/C5. Emergency canal-wall-up mastoid surgery with cervical wound saucerization, debridement and drainage yielded approximately 80 mL of frank pus from the middle ear, mastoid cavity, mastoid tip and contiguous cervical tissues. Culture grew Klebsiella pneumoniae. The patient received intravenous piperacillin–tazobactam 4.5 g four times daily and metronidazole 500 mg three times daily for 1 week. After infection control and development of a healthy granulating wound bed, delayed reconstruction was performed 42 days later using a 9 × 6 cm full-thickness skin graft from the left inguinal region. No cholesteatoma was identified at second-look exploration. At 4 months, the graft and wound had healed well; pure-tone audiometry before discharge showed mild left high-frequency sensorineural hearing loss.

Conclusion Bezold abscess can present as a carbuncle-like cervical lesion. Coexisting otalgia, otorrhea, or mastoid tenderness should prompt careful ear examination and early contrast-enhanced imaging. Definitive treatment requires antimicrobial therapy and surgical source control; extensive skin and soft-tissue loss may require staged reconstruction.