Article Type : Case Report
Authors : Tanthry D and Poojitha S
Keywords : Pediatrics; Post-auricular swelling; Otitis media; Luc’s abscess; Mastoiditis
One of the rare but important
complications of acute otitis media (AOM) is Luc’s abscess, whereby infection
spreads from the middle ear, resulting in a subperiosteal collection beneath
the temporalis muscle. Unlike other subperiosteal abscesses relating to otitis
media, infection may not be associated with mastoid bone involvement. Whereas
here in this case, we present a case of a 4 months old infant presenting with a
post-auricular swelling, how we diagnosed it as Luc’s abscess with mastoid
involvement and the further management of the same. This case report directs
the fellow clinicians that this is a rare, but curable complication of a very
common disease.
Acute otitis media
(AOM) is a common self-limiting childhood illness usually managed medically.
The condition is associated with a number of complications due to proximity of
the middle ear to the intracranial and intratemporal compartments. One less frequently
encountered extracranial complication is the subperiosteal temporal abscess
known as Luc’s abscess. Unlike other extracranial abscesses of otitic origin
that develop following intraosseus suppuration, osteitis, cortical destruction
and pus collection under the periosteum, Luc’s abscess develops after spread of
infection directly along a subperiosteal route from the middle ear along the
external meatus to reach the temporal region [1]. This condition presents typically in patients
without mastoid involvement, therefore, it is defined as a benign complication
of otitis media. However, its rare occurrence plus its much rarer involvement
of mastoid bone, poses it as a clinical challenge for early diagnosis and
treatment.
Parents of a four month old female baby, brought the infant to the out-patient department with complaints of swelling behind the Right ear since 3 days- insidious in onset, gradually progressed in size to current size, associated with pain over the swelling (Figure 1). No history of any ear discharge, or prior upper respiratory tract infection. On examination, right post auricular swelling measuring 2 x 1 x 1cm with local rise of temperature and tenderness noted. Right external auditory canal was normal, whereas Right tympanic membrane was congested, with right mastoid tenderness.
Figure
1:
Right post-auricular swelling.
In the early 20th
century, Henry Luc, a French clinician described a subperiosteal abscess
located deep to the temporalis muscle as a complication of acute otitis media
in a nine year-old girl. According to Luc, the disease differs from other
subperiosteal abscesses in that it develops without the mastoid bone
involvement and that the infection spreads through the notch of Rivinus and
branches of the deep auricular arteries located between the roof of the middle
ear and the external ear canal, and the subperiosteal area [2]. Through publication,
Luc hoped that in a pre-antibiotic era he could spare patients the unnecessary
and dangerous destructive bone operations of the time. In 2013 Garner and
McKinnon described a case of a five-month-old male infant presenting with AOM
complicated by Luc’s abscess and mastoiditis managed surgically and in 2014,
Scrafton et al. discussed a case of 4 year old boy with acute otitis media with
mastoiditis, which was treated surgically as well [3,4]. These related studies
are in concurrence with our case report indicating that there could be mastoid
involvement in cases of subperiosteal abscesses, which has to be diagnosed
early for ideal surgical management. Both aerobic and anaerobic bacteria have
been found as the causative agents in the abscess cultures. Therefore, broad
spectrum antibiotics should be used for the empirical treatment until the final
aspirate culture and microbiological advice reports return [5].
In conclusion, although Luc’s abscess is one of the
otic origin abscesses following a benign course, one should always remember to
rule out the bony extension, mastoid- in specific, which would necessitate a
surgical approach of management. Imaging techniques are a helping aid to
diagnose the same and serve as a vital factor in the critical decision of the
need for surgery.