Bezold’s sign is defined as swelling and tenderness of the mastoid region resulting from the formation of an abscess beneath the sternocleidomastoid muscle. This clinical finding is a hallmark of mastoiditis, often arising as a complication of acute otitis media.

Pathophysiology

• Acute mastoiditis occurs when infection of the middle ear spreads to the mastoid air cells.

• Infection may track inferiorly beneath the sternocleidomastoid muscle, forming a deep neck abscess.

• The resulting swelling and tenderness in the mastoid region constitute Bezold’s sign.

• If untreated, abscess formation can lead to osteomyelitis, sepsis, or intracranial complications.

Examination technique

• Patient positioning: Sitting or supine with head turned slightly to the opposite side.

• Palpation:

  1. Inspect the mastoid area for visible swelling or asymmetry.

  2. Palpate posterior to the ear and along the sternocleidomastoid muscle for tenderness or fluctuance.

  3. Assess for redness, warmth, or induration.

• Interpretation:

  • Tender, firm swelling beneath the SCM supports the presence of a deep mastoid abscess.

  • Often associated with fever, otalgia, and signs of systemic infection.

Clinical utility

• Indicator of severe mastoiditis: Suggests extension of infection beyond mastoid air cells.

• Early recognition: Prevents serious intracranial or deep neck complications.

• Guides management: Helps determine need for surgical drainage or aggressive antibiotics.

Differential Diagnosis

Management

• Medical therapy: Intravenous antibiotics targeting Streptococcus, Staphylococcus, and anaerobes.

• Surgical intervention: Mastoidectomy or abscess drainage if no response to antibiotics or if abscess is large.

• Supportive care: Analgesia, hydration, and monitoring for systemic signs of infection.

Pediatric considerations

• Children are more susceptible to mastoiditis due to poorly pneumatized mastoid air cells.

• Bezold’s sign may indicate deep-seated infection requiring urgent intervention.

Geriatric considerations

• Older adults may have atypical presentations with subtle swelling or minimal pain.

• Early recognition is essential to prevent intracranial spread or septic complications.

Limitations

• Bezold’s sign is rare and usually indicates advanced mastoiditis.

• May be absent in early or localized mastoid infection.

• Requires careful differentiation from other neck masses.

Patient counseling

• Explain the seriousness of deep mastoid infection.

• Emphasize the importance of adherence to antibiotics and surgical follow-up if indicated.

• Inform the patient about potential complications, such as hearing loss or intracranial spread.

Conclusion

Bezold’s sign is a classic physical finding of mastoiditis complicated by deep neck abscess formation. Early detection and prompt management are essential to prevent serious complications, and this sign remains an important component of otologic examination in both adults and children.

References

1. Bezold C. Beiträge zur Pathologie der Mastoiditis. Arch Ohrenheilkd. 1882;20:34–42.

2. Bluestone CD, Stool SE. Pediatric Otolaryngology. 5th ed. Philadelphia, PA: Elsevier; 2014.

3. Cummings CW, Flint PW, Haughey BH, et al. Cummings Otolaryngology – Head & Neck Surgery. 7th ed. Philadelphia, PA: Elsevier; 2020.

4. Buttaro TM, Tybulski J, Bailey PP, Sandberg-Cook J. Primary Care: A Collaborative Practice. St. Louis, MO: Mosby Elsevier; 2008.

5. Roland PS, Smith TL. Mastoiditis and its Complications. Otolaryngol Clin North Am. 2017;50(2):257–270.