Abscesses in relation to Mastoid

🦻 Abscesses in Relation to the Mastoid

Complications of Chronic Suppurative Otitis Media (CSOM) can include various abscesses in relation to the mastoid.

This topic is important for viva questions, NEET-PG MCQs, and clinical practice.

📋 Types of Abscess related to Mastoid

There are six important abscesses in relation to the mastoid:

1. Postauricular abscess – behind the pinna

2. Zygomatic abscess – in front and above the pinna at root of zygoma

3. Bezold abscess – upper part of the neck

4. Luc’s abscess (Meatal abscess) – in the external auditory canal

5. Citelli’s abscess – occipital/retromastoid area

6. Parapharyngeal / Retropharyngeal abscess

Which is the most common abscess occuring as a result of mastoiditis?

1️⃣ 🦻 Postauricular Abscess

Definition: Collection of pus in the postauricular region, usually as a complication of acute mastoiditis.

🧬 Etiopathogenesis

• Usually follows acute mastoiditis

• Spread of infection from middle ear → mastoid air cells → breakdown of mastoid cortex → pus tracks into postauricular soft tissue.

🩺 Clinical Features

General:

• Irritability, flushed face, mild fever, ↑ pulse rate

Local:

• Pinna displaced forwards, outwards, downwards
• Swelling, redness, warmth behind ear
• Obliteration of postauricular groove
• Ironed-out appearance of mastoid (loss of bony ridges due to periostitis)
• Tenderness over mastoid tip
• Fluctuant skin; may rupture spontaneously

Ear Examination:

• Mucopurulent discharge
• Severe EAC edema with sagging posterior-superior canal wall
• TM congested with central perforation
• Tuning fork test → conductive hearing loss

🧪 Investigations

• CBC: ↑ total & differential count
• Pus culture & sensitivity
• X-ray mastoid (Law’s / Schüller’s view)
• HRCT temporal bone
• MRI if intracranial complication suspected
• PTA → conductive hearing loss

💊 Treatment

• Immediate hospitalization

• IV antibiotics

Which is the Drug of choice in Post auricular abscess?

• Analgesics

• Daily ear toileting

• Incision & drainage

• Myringotomy ± grommet

• Cortical mastoidectomy

What are the indications of Cortical mastoidectomy in Postauricular abscess?

2️⃣ 😮‍💨 Zygomatic Abscess

Definition: Collection of pus in the temporal fossa over the zygomatic arch due to spread from mastoid through root of zygoma.

Common in children, especially when zygomatic cells are pneumatized.

🩺 Clinical Features

• Swelling above & in front of pinna

• Upper half of pinna displaced

• Possible edema of upper eyelid

• Painful trismus

• Common ear findings: mucopurulent discharge, congested Tympanic membrane with central perforation

When does trismus develop in Zygomatic abscess?

🧪 Investigations

• CBC: ↑ counts

• Pus C&S

• HRCT → mastoiditis with extension into zygomatic root, soft tissue swelling

• PTA → conductive hearing loss

💊 Treatment

• Hospitalization

• IV antibiotics, analgesics

• Daily ear toileting

• Incision & drainage

• Cortical mastoidectomy to remove infected mastoid & zygomatic cells

What is the differential diagnosis of Zygomatic abscess?

3️⃣ 🫱 Bezold Abscess

Definition: Deep neck abscess from pus eroding medial aspect of mastoid tip and tracking along sternocleidomastoid muscle.

🧬 Spread Pathways

1. Deep to sternocleidomastoid (SCM)
2. Along posterior belly of digastric
3. Upper posterior triangle
4. Parapharyngeal space
5. Along carotid vessels

What is the most common pathway of spread for Bezold's abscess?

🩺 Clinical Features

• Sudden painful, tender swelling in upper neck (deep to sternocleidomastoid)
• Torticollis
• Fever, purulent otorrhea
• Ear findings: congested Tympanic membrane, central perforation

🧪 Investigations

• CBC: ↑ counts
• Pus C&S
• CT temporal bone & neck → mastoid erosion + deep neck abscess

💊 Treatment

• Hospitalization, IV antibiotics, analgesics
• Drainage via separate incision + dependent drain
• Cortical mastoidectomy exploring mastoid tip for fistula

What is the differential diagnosis of Bezold abscess?

4️⃣ 👂 Luc’s Abscess (Meatal Abscess)

Definition: Subperiosteal abscess in EAC wall without bony destruction of mastoid cortex.

🧬 Etiology

• Acute Otitis Media or acute mastoiditis
• Pus breaks through wall between antrum & bony EAC

🩺 Clinical Features

• Localized swelling in posterior-superior EAC wall
• Tenderness, otalgia, otorrhea, blocked ear
• No postauricular swelling or pinna displacement

🧪 Investigations

• Clinical diagnosis on otoscopy
• CT temporal bone → normal mastoid cortex, no bony erosion

💊 Treatment

• IV antibiotics
• I&D of abscess
• Mastoidectomy only if mastoiditis develops

5️⃣ 🌀 Citelli’s Abscess

Definition: Deep neck abscess from posterior spread of pus in acute mastoiditis via posterior digastric groove & Citelli’s tract to occipital/retromastoid area.

🩺 Clinical Features

• Swelling & tenderness below & behind mastoid → may extend to occipital region
• Symptoms of acute mastoiditis

🧪 Investigations

• Clinical diagnosis
• CT temporal bone & neck → confirms posterior pus tracking

💊 Treatment

• IV antibiotics
• Incision & drainage via posterior neck/occipital approach
• Cortical mastoidectomy

6️⃣ 🗣 Parapharyngeal / Retropharyngeal Abscess

Result from infection of peritubal cells in acute coalescent mastoiditis.

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