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Luc's Abscess: The Return of an Old Fellow

Article  in  Otology & neurotology: official publication of the American Otological Society, American Neurotology Society [and] European Academy of Otology
and Neurotology · July 2010
DOI: 10.1097/MAO.0b013e3181e40a5d · Source: PubMed

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Otology & Neurotology
00:00Y00 Ó 2010, Otology & Neurotology, Inc.

Luc’s Abscess: The Return of an Old Fellow

*Inbal Weiss, *Tal Marom, *Abraham Goldfarb, and *†Yehudah Roth

*Department of OtolaryngologyYHead and Neck Surgery, Edith Wolfson Medical Center, Tel-Aviv University
Sackler School of Medicine, Holon, Israel; and ÞDalla Lana School of Public Health,
University of Toronto, Ontario, Canada

Objective: Mastoiditis, subperiosteal abscess and sigmoid vein Main Outcome Measure(s): Clinical improvement, resolution
thrombosis are the most common suppurative complications of of symptoms.
acute otitis media (AOM). Luc’s abscess, a subperiosteal tem- Results: Both patients recovered shortly following the surgical
poral collection, is an infrequent complication with a particu- drainage. Mastoidectomy was poor in findings and was con-
larly benign course. cluded as redundant.
Patients: Two children, aged 5 years, presented with AOM Conclusion: Luc’s abscess is associated with relatively little
complicated by an atypical abscess deep to the temporalis muscle, morbidity and requires a more limited surgical intervention.
with no evidence for mastoid or zygomatic arch involvement. Computed tomographic scan is of great value to evaluate the
Intervention(s): Computed tomographic scan was performed extent of the disease and prevent needless mastoidectomy.
in only 1 child. In both children, treatment included antibiotic Key Words: Acute otitis mediaVComplicationVComputed
therapy, grommet insertion, and local surgical drainage of the tomographic scanVTemporalis muscleVZygomatic arch.
temporalis abscess. In addition, a cortical mastoidectomy was
performed in the patient who did not undergo computed tomog-
raphy, based on clinical assessment. Otol Neurotol 00:00Y00, 2010.

Acute otitis media (AOM) is a common disease in the CASE PRESENTATIONS


pediatric population, which is usually treated with anti-
biotics, with or without myringotomy (1). When compared Case I
with the pre-antibiotic era, suppurative complications of A 5-year-old boy presented with a 2-day onset of a
AOM are rare. Mastoiditis, subperiosteal abscess, and right temporal region swelling. Medical history was
sigmoid vein thrombosis are the most common suppurative remarkable for recurrent otitis media. A week before
complications of AOM (2), whereas other suppurative admission to our department, he was diagnosed elsewhere
complications, such as Bezold’s abscess or zygomatic arch with right AOM and was treated with oral amoxicillin for
abscess, are even less frequent. Luc’s abscess is another 5 days. A day before admission, he was examined
rare, yet benign, complication of AOM, which reflects a because of a right temporomandibular joint (TMJ) pain
purulent collection deep to the temporalis muscle. This and periauricular swelling. Otoscopy demonstrated mid-
report describes 2 children who presented with an abscess dle ear effusion (MEE); the auricle did not protrude, and
deep to the temporalis muscle as a complication of AOM. there was a mild TMJ swelling, without fluctuation or
We discuss the possible pathophysiology for the evolve- tenderness. He was diagnosed with a TMJ inflammation,
ment of this abscess, the recommended management, and and treatment was switched to ibuprofen. A day later, on
treatment options. admission, he presented with a worsening of the swelling
of right temporal region, a downward protrusion of the
auricle, a retro-auricular erythema, and an ipsilateral cer-
vical lymphadenopathy. Otoscopy demonstrated remnants
of MEE. There was a mild protrusion of the anterosupe-
Address correspondence and reprint requests to Tal Marom, M.D.,
Department of OtolaryngologyYHead and Neck Surgery, Edith Wolfson
rior external canal skin, without trismus or facial nerve
Medical Center, P.O. Box 5, 58100 Holon, Israel; E-mail: maromtal@ involvement. Body temperature was 37.7-C. Laboratory
013.net.il workup revealed leukocytosis (26,200) with neutrophilia

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2 I. WEISS ET AL.

(77%), mild thrombocytosis (495,000), and an elevated periosteum, whereas the underlying temporal bone was
C-reactive protein level (3.71 mg/dL; normal, G0.5). uninvolved. Culture from the abscess was positive for
Temporal bone computed tomography demonstrated Streptococcus pyogenes. Intravenous antibiotic treatment
an opacification of pneumatic cells of the right mastoid was switched to cefamizine, according to culture sensi-
and middle ear, with a collection within the soft tissues tivities, in addition to the local administration of cipro-
near the right auricle, predominantly in the anterior floxacin aural drops. Postoperatively, there was a gradual
temporal region, adjacent to the squamous part of the reduction of the temporal swelling, and otorrhea even-
temporal bone, and deep to the temporalis muscle. The tually ceased after 4 days. One year of follow-up was
collection extended from the roof of the external ear canal uneventful.
superiorly, without bony involvement. There were no
aerated cells in the right zygomatic arch (Fig. 1). Case 2
Despite 24 hours of intravenous cefuroxime treatment A previously healthy 5-year-old boy presented with
after admission, the patient was still febrile, and there a 1-day onset of fever and left otalgia, with a pro-
was an increase in the local tenderness. Consequently, he truding auricle. On examination, the patient was febrile
was rushed to the operating room and underwent myr- (38.8-C); there was no retroauricular or mastoid ery-
ingotomy, insertion of a grommet, and drainage of the thema or fluctuation. The external ear canal appear-
temporal region abscess via an external incision. Upon ance was normal. Otoscopy demonstrated AOM. Upon
myringotomy, small effusion was drained with no evi- myringotomy, pus from the middle ear was sent for cul-
dence of pus in the middle ear. During abscess drainage, ture. Laboratory workup revealed leukocytosis (20,500)
the normal-appearing temporal muscle was bluntly dis- with neutrophilia (75%) and elevated C-reactive protein
sected. A purulent collection was drained deep to the (13.86 mg/dL; normal, G0.5). Treatment with intravenous

FIG. 1. Luc’s abscess, axial CT scans of Case I. A, Contrast-enhanced collection deep to the temporalis muscle, adjacent to the right
squamous temporal bone (arrow). B, Evidence of bilateral sclerotic mastoid cavity (arrows). Note the opacified right antrum. C, The col-
lection extends laterally and superiorly to the right external ear canal (arrow). D, Absence of aerated right zygomatic arch cells (arrow).

Otology & Neurotology, Vol. 00, No. 00, 2010

Copyright @ 2010 Otology & Neurotology, Inc. Unauthorized reproduction of this article is prohibited.
LUC’S ABSCESS 3

cefuroxime and aural ciprofloxacin drops was initiated. periosteally to reach the temporal fossa, deep to the tem-
After 3 days of intravenous antibiotic therapy, there was poralis muscle.
no clinical improvement, which manifested as a worsening Since the widespread use of antibiotic therapy for
of the periauricular swelling, spiky fever, and ongoing AOM, only a few reports have described patients with
otorrhea. The clinical presentation suggested the diagnosis Luc’s abscess, which may raise the possibility of an
of acute mastoiditis with a subperiosteal abscess. The unfamiliar or a misdiagnosed entity among otolaryngol-
patient was rushed to the operating room without obtain- ogists and pediatricians. These patients were reported
ing a computed tomographic (CT) scan. He underwent with only a few or no signs of an acute systemic illness,
myringotomy, insertion of a grommet, drainage of the sometimes with an intermittent otorrhea, and were treated
temporal abscess via a retroauricular incision, and cortical conservatively (5Y10).
mastoidectomy. Surgical findings were notable for a loca- This report describes 2 children presenting with
lized pus collection deep to the temporalis muscle; the AOM, complicated by an abscess deep to the temporalis
cortical mastoid bone showed no erosion with mostly muscle. They presented with moderate signs of infec-
sclerotic mastoid cells and only mild granulation tissue in tion and inflammation (local fluctuation, fever, leukocy-
the attic. There was no pus or signs of osteitis. Culture from tosis, thrombocytosis, and elevated C-reactive protein).
the abscess was positive for Fusobacterium necrophurum. The management of the first patient included medical
Therapy was switched to clindamycin according to culture therapy (systemic and local antibiotic therapy), imaging,
sensitivities. Postoperatively, the temporal swelling gra- and local surgical drainage, guided by the findings in the
dually resolved. The patient was discharged 4 days later, CT scan, whereas the management of the second patient
without further sequelae. included medical therapy, which was followed by a more
extensive surgery, without performing any imaging stu-
DISCUSSION dies, owing to the clinical impression of mastoiditis/sub-
periosteal abscess. The abscess deep to the temporalis
The most common suppurative complication of AOM muscle was externally addressed in both patients and also
is acute mastoiditis. It can progress to a subperiosteal included a cortical mastoidectomy in the second patient,
abscess, which usually requires surgical drainage by some which was poor in findings. The difference stems from
form of a mastoidectomy. It is assumed that pus collec- the imaging studies, which were performed only in the
tion is a consequence of intraosseous suppuration caus- first patient. The route of infection progression and pus
ing osteitis, most commonly in the mastoid cavity, which collection deep to the temporalis muscle was probably
finally ends in the destruction of the mastoid cortex over- direct from the middle ear to the external aspect of the
lying the affected air cells. Pus then spreads between the temporal bone via a subperiosteal plain, along the external
cortical bone and the periosteum. In addition, an inflam- meatus. Had CT scans been performed in the second
mation of the mastoid air cells can spread, via the cells patient, an unnecessary mastoidectomy would have been
in the root of the zygomatic arch, to the soft tissues of avoided.
the malar area, or via the incisura temporalis to the neck There is a trend of increase in the incidence of otitis
(Bezold’s abscess). media in all age groups, despite the administration of 7-
A subperiosteal temporal abscess as a complication of valent pneumococcal conjugate vaccines, especially in
AOM was first described by Henri Luc in 1900 but was infants in the more developed countries (11,12); thus, it is
acknowledged in the English literature only more than a anticipated that the incidence of rare complications of
decade later (3). Luc described a previously healthy 9- AOM, such as Luc’s abscess, also may increase. How-
year-old girl with a diffuse swelling of the temporal ever, in our view, Luc’s presentation is associated with
region, as a complication of AOM. A combined local anatomic variations that may allow pus collection deep to
drainage followed by 3 weeks of local dressings led to the the temporalis muscle rather than the virulence or pre-
full recovery of the patient. Presumed pathophysiology valence of pathogens.
was attributed to bacteria penetration to the mucosa in the To conclude, Luc’s abscess is associated with relatively
middle ear, with further spread via submucosal tissue little morbidity and requires a more limited surgical inter-
plains, that is, the incisure of Rivinus and along the vention. Temporal bone CT scan studies are of great value
branches of the deep auricular artery, to the subperiosteal in these patients, to evaluate the extent of the disease and
space in the external ear canal, ultimately resulting in pus to avoid unnecessary mastoid surgery. Limited local drai-
collection deep to the temporalis muscle. At that time, nage via a retroauricular incision or via the external ear
imaging studies were unavailable, and he performed cor- canal, combined with myringotomy and grommet inser-
tical mastoidectomy, which revealed no mastoid pathol- tion, is the proper surgical therapy.
ogy in this and several other similar pediatric cases, thus
he concluded that mastoidectomy was unnecessary. Luc Acknowledgments: The authors thank Dr. Sagit Shoushan,
also emphasized the Bparticularly benign[ nature of this for assistance, and Dr. Mario Orozco, for linguistic assistance.
complication. Several comparable cases have been repor-
ted by other European authors at the beginning of the 20th REFERENCES
century (4). These authors also concluded that pus was 1. Powers JH. Diagnosis and treatment of acute otitis media: evalu-
formed in the middle ear and subsequently tracked sub- ating the evidence. Infect Dis Clin North Am 2007;21:409Y26.

Otology & Neurotology, Vol. 00, No. 00, 2010

Copyright @ 2010 Otology & Neurotology, Inc. Unauthorized reproduction of this article is prohibited.
4 I. WEISS ET AL.

2. Thorne MC, Chewaproug L, Elden LM. Suppurative complications 8. Moisa II, Danziger EJ, Brauer RJ. Subperiosteal and Bezold’s
of acute otitis media: changes in frequency over time. Arch Oto- abscesses complicating cholesteatoma: a case report. Otolaryngol
laryngol Head Neck Surg 2009;135:638Y41. Head Neck Surg 1987;97:399Y402.
3. Luc H. The sub-periosteal temporal abscess of otic origin without 9. Knappe MV, Gregor RT. Luc’s abscessVa rare complication of
intraosseous suppuration. Laryngoscope 1913;23:999Y1003. middle-ear infection. J Laryngol Otol 1997;3:461Y4.
4. Marc’Hadour L, Chauveau L. Contribution a l’etude des periostites 10. Takes RP, Langeveld AP, Baatenburg de Jong RJ. Abscess for-
du conduit auditif externe au cours des otitis suppurees. Annal mation in the temporomandibular joint as a complication of otitis
Malad de L’Oreille et du Larynx 1910;7:1Y13. media. J Laryngol Otol 2000;114:373Y5.
5. Kafka MM. Mortality of mastoiditis and cerebral complications 11. Van Zuijlen DA, Schilder AG, Van Balen FA, Hoes AW. National
with review of 3,225 cases of mastoiditis, with complications. differences in incidence of acute mastoiditis: relationship to pre-
Laryngoscope 1935;45:790Y822. scribing patterns of antibiotics for acute otitis media. Pediatr Infect
6. Hawkins DB, Dru D. Mastoid subperiosteal abscess. Arch Otolar- Dis J 2001;20:1012Y3.
yngol 1983;109:369Y71. 12. Jansen AG, Hak E, Veenhoven RH, Damoiseaux RA, Schilder
7. Rosen AV, Ophir D, Marshak G. Acute mastoiditis: a review of 69 AG, Sanders EA. Pneumococcal conjugate vaccines for prevent-
cases. Ann Otol Rhinol Laryngol 1986;95:222Y4. ing otitis media. Cochrane Database Syst Rev 2009;15:CD001480.

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