American Journal of Emergency Medicine 34 (2016) 117.e1–117.e3
Contents lists available at ScienceDirect
American Journal of Emergency Medicine journal homepage: www.elsevier.com/locate/ajem
Case Report
Luc abscess: an extraordinary complication of acute otitis media Abstract Luc abscess is an uncommon suppurative complication of otitis media. Unfamiliarity of this complication leads to delayed diagnosis and treatment. This abscess is usually benign. Infection in the middle ear spreads via anatomic preexisting pathways, and this process results with subperiosteal pus collection. Conservative treatment with drainage under empirical wide spectrum antibiotic is efficient. Here, we present a 9-year-old boy who had left facial swelling after a period of otalgia, diagnosed as Luc abscess without mastoiditis. Acute otitis media (AOM) is one of the most common infectious diseases in childhood. Despite morbidity and mortality have shown decrease by the utilization of antibiotics and vaccines, its suppurative complications are still reported [1-6]. Subperiosteal abscess is an extracranial extratemporal complication, which is termed according to location: Bezold abscess, zygomatic abscess, or Luc abscess [5-7]. Luc abscess is a scarce one of subperiosteal abscess that cannot be seen once or twice in the career of emergency physician or otolaryngologist. Thus, we present a case of Luc abscess and aim to mention pathophysiology, diagnosis, and management. A 9-year-old boy admitted to pediatric emergency department with left facial swelling, which increased in the last 4 days. He had otalgia on the same side for 1 week but did not take any medications. He had no fever and no history of trauma. Examination revealed a diffuse soft preauricular mildly tender swelling extending to the temporal region, left cheek, and inferior palpebra (Fig. 1). Left tympanic membrane was hyperemic on otoscopy. Laboratory tests revealed mildly elevated white blood cell count (10.800/μL) with neutrophilia (64%). C-reactive protein was elevated at 33 mg/L (reference range, 0.2-5 mg/L). Computed tomography (CT) of the temporal bone showed a temporal subperiosteal abscess and the diffuse inflammation in the left zygomaticotemporal region without bone erosion (Figs. 2-4). He was hospitalized with the diagnosis of Luc abscess. The day after intravenous administration of cefuroxime and clindamycin, a grommet was inserted into the left ear with needle aspiration of the zygomaticotemporal region under general anesthesia. A small amount of serous effusion was aspirated after myringotomy. But enough material for microbiologic evaluation could not obtain during needle aspiration. After 10 days of antibiotic therapy, the patient was discharged with an uneventful improvement (Fig. 5). Acute facial swelling in childhood is commonly based on inflammatory process such as lymphadenitis and periorbital cellulitis secondary to acute sinusitis [8]. Location of swelling and concomitant symptoms are important for the accurate diagnosis and management. One of the unusual diagnoses for facial swelling is Luc abscess related to AOM. Recent studies suggested that complications of AOM in childhood 0735-6757/© 2015 Elsevier Inc. All rights reserved.
have remarkably increased [5,6]. However, Luc abscess is still rare. Thus, it is an unfamiliar entity for emergency medicine providers [9-12]. In 1913, Henri Luc reported his experience about cases of subperiosteal temporal abscess. He performed antrostomy for diagnostic purpose but failed to find mastoiditis. As a result of this experience, he suggested that infection in middle ear permeates into submucous area, then spread via incisura of Rivinus and branches of deep auricular artery. This leads to subperiosteal pus collection in temporal bone. Therefore, it was defined as a benign complication of otitis media [9,12]. In 1997, Knappe and Gregor [9] confirmed pathogenesis defined by Luc. He reported a 15-year-old girl with temporal abscess treated by mastoidectomy, but biopsy revealed no osteitis. After that, Weiss et al [12] reported 2 children with Luc abscess. In the first patient, they did not perform mastoidectomy due to lack of mastoiditis on CT, and drainage was performed under antibiotic therapy. But the second patient had no response at the third day of cefuroxime treatment. They performed mastoidectomy and abscess drainage regardless of temporal CT. Osteitis or bone erosion could not be detected on pathologic assessment [12]. As distinct from previous cases, Asha’ari et al [13] presented Luc abscess with mastoiditis in a 73-year-old man that can be attributable to history of diabetes mellitus and recurrent otitis. Because of the lack of imaging techniques at that time, Luc considered the signs of mastoiditis such as fever, persistent and abundant otorrhea, retroauricular swelling, and otalgia. He suggested mastoidectomy in the presence of these signs [9,10]. However, cases of temporal abscess without mastoiditis could have one or more of these signs, and recently published cases have underlined importance of temporal CT for proper management [9-12]. Furthermore, we confirmed absence of mastoiditis with temporal CT before planning the treatment. From the microbiological aspect, culture from abscess can be positive for anaerobic bacteria such as Fusobacterium necrophorum also for aerobic bacteria such as Streptococcus pyogenes [9-12]. Regardless of undetermined microorganism, we obtained recovery with 10 days of cefuroxime and clindamycin treatment and abscess drainage with grommet insertion. In conclusion, Luc abscess is a rare and benign complication of AOM. However, inexperience of emergency physicians can result with delayed diagnosis and treatment. Temporal CT can be useful for determining the location of lesion and reveal concomitant complications. Empirical wide spectrum antibiotic therapy and early drainage are proper treatment. Anıl Er, MD1 Division of Pediatric Emergency Medicine Dokuz Eylul University School of Medicine, Balçova 35340, İzmir, Turkey E-mail address: [email protected]
117.e2
A. Er et al. / American Journal of Emergency Medicine 34 (2016) 117.e1–117.e3
Fig. 4. Computed tomography scan of temporal bone in axial section indicates inflammatory infiltration of the temporal region and small subperiosteal temporal abscess formation (white arrow) with normally pneumatized mastoid cells.
Fig. 1. Inflammatory infiltration of the left zygomatic region with palpebral edema.
Taner Kemal Erdağ, MD2 Department of Otorhinolaryngology Dokuz Eylul University School of Medicine, Balçova 35340, İzmir, Turkey E-mail address: [email protected] Aykut Çağlar, MD1 Division of Pediatric Emergency Medicine Dokuz Eylul University School of Medicine, Balçova 35340, İzmir, Turkey E-mail address: [email protected] Özgür Kümüş, MD3 Department of Otorhinolaryngology Dokuz Eylul University School of Medicine, Balçova 35340, İzmir, Turkey E-mail address: [email protected] Fig. 2. Computed tomography scan of temporal bone in axial section indicates inflammatory infiltration of the temporal region and small subperiosteal temporal abscess formation (white arrow).
Fig. 3. Computed tomography scan of temporal bone in coronal section indicates inflammatory infiltration of the temporal region and small subperiosteal temporal abscess formation (white arrow).
Fig. 5. View of patient after treatment.
A. Er et al. / American Journal of Emergency Medicine 34 (2016) 117.e1–117.e3
Murat Duman, MD Division of Pediatric Emergency Medicine Dokuz Eylul University School of Medicine, Balçova 35340, İzmir, Turkey Corresponding author. Division of Pediatric Emergency Medicine Dokuz Eylul University School of Medicine Balçova, 35340, İzmir, Turkey Tel.: +90 232 412 60 15; fax: +90 232 412 60 05 E-mail address: [email protected] 1
Tel.: +90 232 412 60 21; fax: +90 232 412 60 05 Tel.: +90 232 412 32 51; fax: +90 232 412 60 05 Tel.: +90 232 412 32 80; fax: +90 232 412 60 05
2 3
http://dx.doi.org/10.1016/j.ajem.2015.05.029 References [1] Monasta L, Ronfani L, Marchetti F, Montico M, Vecchi Brumatti L, Bavcar A, et al. Burden of disease caused by otitis media: systematic review and global estimates. PLoS One 2012;7(4):e36226, 1–12. [2] Casey JR, Adlowitz DG, Pichichero ME. New patterns in the otopathogens causing acute otitis media six to eight years after introduction of pneumococcal conjugate vaccine. Pediatr Infect Dis J 2010;29(4):304–9.
117.e3
[3] Fortanier AC, Venekamp RP, Boonacker CW, Hak E, Schilder AG, Sanders EA, et al. Pneumococcal conjugate vaccines for preventing otitis media. Cochrane Database Syst Rev 2014;4:CD001480, 55. [4] Wanna GB, Dharamsi LM, Moss JR, Bennett ML, Thompson RC, Haynes DS. Contemporary management of intracranial complications of otitis media. Otol Neurotol 2010;31(1):111–7. [5] Mattos JL, Colman KL, Casselbrant ML, Chi DH. Intratemporal and intracranial complications of acute otitis media in a pediatric population. Int J Pediatr Otorhinolaryngol 2014; 78(12):2161–4. [6] Thorne MC, Chewaproug L, Elden LM. Suppurative complications of acute otitis media: changes in frequency over time. Arch Otolaryngol Head Neck Surg 2009; 135(7):638–41. [7] Dhooge IJ, Albers FW, Van Cauwenberge PB. Intratemporal and intracranial complications of acute suppurative otitis media in children: renewed interest. Int J Pediatr Otorhinolaryngol 1999;49(Suppl. 1):S109–14. [8] Khanna G, Sato Y, Smith RJ, Bauman NM, Nerad J. Causes of facial swelling in pediatric patients: correlation of clinical and radiologic findings. Radiographics 2006; 26(1):157–71. [9] Knappe MV, Gregor RT. Luc's abscess—a rare complication of middle-ear infection. J Laryngol Otol 1997;111(5):461–4. [10] Garner EF, McKinnon BJ. Luc's abscess—a case report. Int J Pediatr Otorhinolaryngol Extra 2013;8(1):e5–7. [11] Scrafton DK, Qureishi A, Nogueira C, Mortimore S. Luc's abscess as an unlucky complication of mastoiditis. Ann R Coll Surg Engl 2014;96(5):e28–30. [12] Weiss I, Marom T, Goldfarb A, Roth Y. Luc's abscess: the return of an old fellow. Otol Neurotol 2010;31(5):776–9. [13] Asha’ari ZA, Shiyuti MI, Zihni M. Luc’s abscess: a reminder of potential complication of otitis media. Brunei Int Med J 2012;8:261–4.
Contents lists available at ScienceDirect
American Journal of Emergency Medicine journal homepage: www.elsevier.com/locate/ajem
Case Report
Luc abscess: an extraordinary complication of acute otitis media Abstract Luc abscess is an uncommon suppurative complication of otitis media. Unfamiliarity of this complication leads to delayed diagnosis and treatment. This abscess is usually benign. Infection in the middle ear spreads via anatomic preexisting pathways, and this process results with subperiosteal pus collection. Conservative treatment with drainage under empirical wide spectrum antibiotic is efficient. Here, we present a 9-year-old boy who had left facial swelling after a period of otalgia, diagnosed as Luc abscess without mastoiditis. Acute otitis media (AOM) is one of the most common infectious diseases in childhood. Despite morbidity and mortality have shown decrease by the utilization of antibiotics and vaccines, its suppurative complications are still reported [1-6]. Subperiosteal abscess is an extracranial extratemporal complication, which is termed according to location: Bezold abscess, zygomatic abscess, or Luc abscess [5-7]. Luc abscess is a scarce one of subperiosteal abscess that cannot be seen once or twice in the career of emergency physician or otolaryngologist. Thus, we present a case of Luc abscess and aim to mention pathophysiology, diagnosis, and management. A 9-year-old boy admitted to pediatric emergency department with left facial swelling, which increased in the last 4 days. He had otalgia on the same side for 1 week but did not take any medications. He had no fever and no history of trauma. Examination revealed a diffuse soft preauricular mildly tender swelling extending to the temporal region, left cheek, and inferior palpebra (Fig. 1). Left tympanic membrane was hyperemic on otoscopy. Laboratory tests revealed mildly elevated white blood cell count (10.800/μL) with neutrophilia (64%). C-reactive protein was elevated at 33 mg/L (reference range, 0.2-5 mg/L). Computed tomography (CT) of the temporal bone showed a temporal subperiosteal abscess and the diffuse inflammation in the left zygomaticotemporal region without bone erosion (Figs. 2-4). He was hospitalized with the diagnosis of Luc abscess. The day after intravenous administration of cefuroxime and clindamycin, a grommet was inserted into the left ear with needle aspiration of the zygomaticotemporal region under general anesthesia. A small amount of serous effusion was aspirated after myringotomy. But enough material for microbiologic evaluation could not obtain during needle aspiration. After 10 days of antibiotic therapy, the patient was discharged with an uneventful improvement (Fig. 5). Acute facial swelling in childhood is commonly based on inflammatory process such as lymphadenitis and periorbital cellulitis secondary to acute sinusitis [8]. Location of swelling and concomitant symptoms are important for the accurate diagnosis and management. One of the unusual diagnoses for facial swelling is Luc abscess related to AOM. Recent studies suggested that complications of AOM in childhood 0735-6757/© 2015 Elsevier Inc. All rights reserved.
have remarkably increased [5,6]. However, Luc abscess is still rare. Thus, it is an unfamiliar entity for emergency medicine providers [9-12]. In 1913, Henri Luc reported his experience about cases of subperiosteal temporal abscess. He performed antrostomy for diagnostic purpose but failed to find mastoiditis. As a result of this experience, he suggested that infection in middle ear permeates into submucous area, then spread via incisura of Rivinus and branches of deep auricular artery. This leads to subperiosteal pus collection in temporal bone. Therefore, it was defined as a benign complication of otitis media [9,12]. In 1997, Knappe and Gregor [9] confirmed pathogenesis defined by Luc. He reported a 15-year-old girl with temporal abscess treated by mastoidectomy, but biopsy revealed no osteitis. After that, Weiss et al [12] reported 2 children with Luc abscess. In the first patient, they did not perform mastoidectomy due to lack of mastoiditis on CT, and drainage was performed under antibiotic therapy. But the second patient had no response at the third day of cefuroxime treatment. They performed mastoidectomy and abscess drainage regardless of temporal CT. Osteitis or bone erosion could not be detected on pathologic assessment [12]. As distinct from previous cases, Asha’ari et al [13] presented Luc abscess with mastoiditis in a 73-year-old man that can be attributable to history of diabetes mellitus and recurrent otitis. Because of the lack of imaging techniques at that time, Luc considered the signs of mastoiditis such as fever, persistent and abundant otorrhea, retroauricular swelling, and otalgia. He suggested mastoidectomy in the presence of these signs [9,10]. However, cases of temporal abscess without mastoiditis could have one or more of these signs, and recently published cases have underlined importance of temporal CT for proper management [9-12]. Furthermore, we confirmed absence of mastoiditis with temporal CT before planning the treatment. From the microbiological aspect, culture from abscess can be positive for anaerobic bacteria such as Fusobacterium necrophorum also for aerobic bacteria such as Streptococcus pyogenes [9-12]. Regardless of undetermined microorganism, we obtained recovery with 10 days of cefuroxime and clindamycin treatment and abscess drainage with grommet insertion. In conclusion, Luc abscess is a rare and benign complication of AOM. However, inexperience of emergency physicians can result with delayed diagnosis and treatment. Temporal CT can be useful for determining the location of lesion and reveal concomitant complications. Empirical wide spectrum antibiotic therapy and early drainage are proper treatment. Anıl Er, MD1 Division of Pediatric Emergency Medicine Dokuz Eylul University School of Medicine, Balçova 35340, İzmir, Turkey E-mail address: [email protected]
117.e2
A. Er et al. / American Journal of Emergency Medicine 34 (2016) 117.e1–117.e3
Fig. 4. Computed tomography scan of temporal bone in axial section indicates inflammatory infiltration of the temporal region and small subperiosteal temporal abscess formation (white arrow) with normally pneumatized mastoid cells.
Fig. 1. Inflammatory infiltration of the left zygomatic region with palpebral edema.
Taner Kemal Erdağ, MD2 Department of Otorhinolaryngology Dokuz Eylul University School of Medicine, Balçova 35340, İzmir, Turkey E-mail address: [email protected] Aykut Çağlar, MD1 Division of Pediatric Emergency Medicine Dokuz Eylul University School of Medicine, Balçova 35340, İzmir, Turkey E-mail address: [email protected] Özgür Kümüş, MD3 Department of Otorhinolaryngology Dokuz Eylul University School of Medicine, Balçova 35340, İzmir, Turkey E-mail address: [email protected] Fig. 2. Computed tomography scan of temporal bone in axial section indicates inflammatory infiltration of the temporal region and small subperiosteal temporal abscess formation (white arrow).
Fig. 3. Computed tomography scan of temporal bone in coronal section indicates inflammatory infiltration of the temporal region and small subperiosteal temporal abscess formation (white arrow).
Fig. 5. View of patient after treatment.
A. Er et al. / American Journal of Emergency Medicine 34 (2016) 117.e1–117.e3
Murat Duman, MD Division of Pediatric Emergency Medicine Dokuz Eylul University School of Medicine, Balçova 35340, İzmir, Turkey Corresponding author. Division of Pediatric Emergency Medicine Dokuz Eylul University School of Medicine Balçova, 35340, İzmir, Turkey Tel.: +90 232 412 60 15; fax: +90 232 412 60 05 E-mail address: [email protected] 1
Tel.: +90 232 412 60 21; fax: +90 232 412 60 05 Tel.: +90 232 412 32 51; fax: +90 232 412 60 05 Tel.: +90 232 412 32 80; fax: +90 232 412 60 05
2 3
http://dx.doi.org/10.1016/j.ajem.2015.05.029 References [1] Monasta L, Ronfani L, Marchetti F, Montico M, Vecchi Brumatti L, Bavcar A, et al. Burden of disease caused by otitis media: systematic review and global estimates. PLoS One 2012;7(4):e36226, 1–12. [2] Casey JR, Adlowitz DG, Pichichero ME. New patterns in the otopathogens causing acute otitis media six to eight years after introduction of pneumococcal conjugate vaccine. Pediatr Infect Dis J 2010;29(4):304–9.
117.e3
[3] Fortanier AC, Venekamp RP, Boonacker CW, Hak E, Schilder AG, Sanders EA, et al. Pneumococcal conjugate vaccines for preventing otitis media. Cochrane Database Syst Rev 2014;4:CD001480, 55. [4] Wanna GB, Dharamsi LM, Moss JR, Bennett ML, Thompson RC, Haynes DS. Contemporary management of intracranial complications of otitis media. Otol Neurotol 2010;31(1):111–7. [5] Mattos JL, Colman KL, Casselbrant ML, Chi DH. Intratemporal and intracranial complications of acute otitis media in a pediatric population. Int J Pediatr Otorhinolaryngol 2014; 78(12):2161–4. [6] Thorne MC, Chewaproug L, Elden LM. Suppurative complications of acute otitis media: changes in frequency over time. Arch Otolaryngol Head Neck Surg 2009; 135(7):638–41. [7] Dhooge IJ, Albers FW, Van Cauwenberge PB. Intratemporal and intracranial complications of acute suppurative otitis media in children: renewed interest. Int J Pediatr Otorhinolaryngol 1999;49(Suppl. 1):S109–14. [8] Khanna G, Sato Y, Smith RJ, Bauman NM, Nerad J. Causes of facial swelling in pediatric patients: correlation of clinical and radiologic findings. Radiographics 2006; 26(1):157–71. [9] Knappe MV, Gregor RT. Luc's abscess—a rare complication of middle-ear infection. J Laryngol Otol 1997;111(5):461–4. [10] Garner EF, McKinnon BJ. Luc's abscess—a case report. Int J Pediatr Otorhinolaryngol Extra 2013;8(1):e5–7. [11] Scrafton DK, Qureishi A, Nogueira C, Mortimore S. Luc's abscess as an unlucky complication of mastoiditis. Ann R Coll Surg Engl 2014;96(5):e28–30. [12] Weiss I, Marom T, Goldfarb A, Roth Y. Luc's abscess: the return of an old fellow. Otol Neurotol 2010;31(5):776–9. [13] Asha’ari ZA, Shiyuti MI, Zihni M. Luc’s abscess: a reminder of potential complication of otitis media. Brunei Int Med J 2012;8:261–4.
