Actinomycosis of the temporal bone: a report of a case.Abstract
Actinomycosis actinomycosis (ăk'tənōmīkō`sĭs), chronic suppurative infection that occurs around the face and neck. The disease is characterized by the formation of abscesses, or pus-filled cavities, below the surface of the skin. is a chronic suppurative suppurative
pertaining to or emanating from suppuration; pus in e.g. suppurative arthritis, bronchopneumonia. infection of the cervicofacial region caused by Actinomyces Actinomyces /Ac·ti·no·my·ces/ (-mi´sez) a genus of bacteria (family Actinomycetaceae).
Actinomyces israe´lii species, which are anaerobic anaerobic /an·aer·o·bic/ (an?ah-ro´bik)
1. lacking molecular oxygen.
2. growing, living, or occurring in the absence of molecular oxygen; pertaining to an anaerobe. , gram-positive filamentous bacteria. Although actinomycosis has a propensity for involving the oral cavity, rare cases of actinomycosis involving the temporal bone have been published. We report the case of a 14-year-old girl who presented with clinical, audiometric au·di·om·e·ter
An instrument for measuring hearing activity for pure tones of normally audible frequencies. Also called sonometer.
au , and radiologic findings consistent with right chronic suppurative otitis media that persisted despite tympanomastoidectomy. Findings on histologic evaluation of a specimen obtained during revision surgery were consistent with a diagnosis of actinomycosis. Although actinomycosis of the temporal bone is rare, it should be considered in the differential diagnosis of chronic suppurative temporal bone infections that are resistant to standard therapy.
Actinomycosis is a chronic suppurative infection caused by an anaerobic, gram-positive, nonacid-fast, filamentous bacterium. (1) Actinomyces israelii is the most common pathogenic species of this bacteria found in humans. (2) Although Actinomyces is part of the normal flora of the oral cavity, it has been known to cause chronic suppurative infections of the oral cavity region, usually after minor trauma resulting in mucosal breaks. (1,2) Patients with such an infection classically present with a chronically draining wound that has a "woody" consistency and purulent pu·ru·lent
Containing, discharging, or causing the production of pus.
Consisting of or containing pus
Mentioned in: Lacrimal Duct Obstruction
containing or forming pus. discharge draining from multiple sinus tracts.
The most common sites of Actinomyces infection are the cervicofacial region (~55% of cases), (3) the abdomen, and the thorax. (4) In rare cases, actinomycosis involves the temporal bone region. (4-10) In this article, we report a new case of actinomycosis of the temporal bone.
A 14-year-old girl presented with a long-standing history of right aural fullness, otalgia otalgia /otal·gia/ (o-tal´jah) pain in the ear; earache.
Pain in the ear; earache.
o·tal , hearing loss, and recurrent otorrhea that had been unresponsive to multiple courses of oral and topical antibiotics. Because cholesteatoma had been suspected during a previous evaluation, she had undergone a right intact canal wall tympanomastoidectomy; however, this procedure failed to alleviate her symptoms.
Physical examination of the right ear revealed the presence of a thick, foul-smelling, yellow drainage; the tympanic membrane was intact. Findings on examination of the left ear and the rest of her head and neck were unremarkable. Audiometry revealed that she had a 40-dB, flat, conductive hearing loss Conductive hearing loss
A type of medically treatable hearing loss in which the inner ear is usually normal, but there are specific problems in the middle or outer ears that prevent sound from getting to the inner ear in a normal way. on the right side. Computed tomography (CT) demonstrated a complete opacification of the right middle ear and mastoid mastoid /mas·toid/ (mas´toid)
2. mastoid process.
3. pertaining to the mastoid process.
The mastoid process. (figure 1).
[FIGURE 1 OMITTED]
The patient underwent a right revision intact canal wall tympanomastoidectomy and placement of a myringotomy myringotomy /my·rin·got·o·my/ (mi-ring-got´ah-me) tympanotomy; creation of a hole in the tympanic membrane, as for tympanocentesis.
n. tube. The tympanic membrane and ossicles Ossicles
The three small bones of the middle ear: the malleus (hammer), the incus (anvil) and the stapes (stirrup). These bones help carry sound from the eardrum to the inner ear.
Mentioned in: Otitis Media, Stapedectomy were normal, but the middle ear and mastoid were filled with granulation tissue. Histopathologic evaluation demonstrated fragments of respiratory mucosa with marked acute and chronic inflammatory cells and sulfur granules Granules
Small packets of reactive chemicals stored within cells.
Mentioned in: Allergic Rhinitis, Allergies , findings that are consistent with actinomycosis (figure 2). Postoperatively, the patient was placed on oral penicillin for 6 months, and she remained asymptomatic at the 2year follow-up.
[FIGURE 2 OMITTED]
Actinomyces, a commensal commensal /com·men·sal/ (kom-men´sil)
1. living on or within another organism, and deriving benefit without harming or benefiting the host.
2. a parasite that causes no harm to the host. organism of the oral cavity, is often found in the tonsillar crypts, where it exists asymptomatically. (4) Risk factors for the development of a cervicofacial infection include poor dental hygiene, dental manipulations, and maxillofacial trauma, which enable the organism to breach the mucosa. (2) Once in the submucosal submucosal /sub·mu·co·sal/ (-mu-ko´sal)
1. pertaining to the submucosa.
2. beneath a mucous membrane. tissues, the organism causes a chronic, suppurative infectious process that has a characteristic clinical course.
Clinically, actinomycosis presents as an insidious-on set, chronic suppurating wound that is characterized by multiple draining sinus tracts. Pain is often not a significant feature at presentation, but low-grade fever is documented in approximately 50% of cases. (2) Prolonged infection results in extensive fibrosis, which imparts a firm, woody consistency to the involved tissues. Spread of the infection occurs by direct extension, and it can progress to involve adjacent bone, resulting in osteomyelitis osteomyelitis (ŏs'tēōmī'əlī`tĭs), infection of the bone and bone marrow. Direct infection of bone usually occurs through open fractures, penetrating wounds, or surgical operations. . (2)
A diagnosis of actinomycosis is often suggested by the presence of pale-yellow clusters of sulfur granules, which are made up of tangled filaments of Actinomyces organ isms, seen in discharge fluid or on microscopic evaluation of infected tissue. (1) Demonstration of the organism itself on histopathology his·to·pa·thol·o·gy
The science concerned with the cytologic and histologic structure of abnormal or diseased tissue.
The study of diseased tissues at a minute (microscopic) level. can be facilitated by using special staining techniques. In light of the typical lack of preoperative suspicion and the fastidious nature of this organism, Actinomyces is difficult to culture. Cultures are negative in more than 70% of cases, even in patients whose clinical features meet other diagnostic criteria. (2) Whenever actinomycosis is suspected, acid-fast testing should be performed to differentiate between Actinomyces and Nocardia species. Nocardia species are acid-fast--staining, whereas Actinomyces are not. (2) Diagnostic aids, including CT, are nonspecific and useful only in defining the extent of the disease process in the involved region. (2)
The management of cervicofacial actinomycosis en tails surgical debridement and long-term antibiotic therapy. Prolonged courses of antibiotic therapy are necessary in order to minimize the risk of recurrence. Penicillin is the agent of choice; the route and duration of therapy depend on the severity of the infection. For minor infections, 2 months of oral penicillin V may be sufficient. (1) More severe infections should be treated with 4 to 6 weeks of parenteral penicillin G followed by 6 to 12 months of oral penicillin V. (1) Patients who are allergic to penicillin can be adequately treated with a number of other antibiotics, including tetracycline tetracycline (tĕ'trəsī`klēn), any of a group of antibiotics produced by bacteria of the genus Streptomyces. They are effective against a wide range of Gram positive and Gram negative bacteria, interfering with protein , erythromycin erythromycin (ĭrĭth'rōmī`sĭn), any of several related antibiotic drugs produced by bacteria of the genus Streptomyces (see antibiotic). , clindamycin, and chloramphenicol chloramphenicol (klōr'ămfĕn`əkŏl'), antibiotic effective against a wide range of gram-negative and gram-positive bacteria (see Gram's stain). It was originally isolated from a species of Streptomyces bacteria. . (1)
Fewer than 30 cases of actinomycosis involving the temporal bone have been reported in the literature. Temporal bone infection is believed to be caused by the spread of the organism from the pharynx pharynx (fâr`ĭngks), area of the gastrointestinal and respiratory tracts which lies between the mouth and the esophagus. In humans, the pharynx is a cone-shaped tube about 4 1-2 in. (11.43 cm) long. to the middle ear via the eustachian tube. (8,10) Once present in the temporal bone region, the infection spreads through breaks in the mucosa, which allow it to travel between tissue planes. (9) Although actinomycosis involving the temporal bone is rare, it should be considered in the differential diagnosis of chronic suppurative temporal bone infections that are resistant to standard therapy.
The presentations of most patients with temporal bone actinomycosis have been similar to those of patients with chronic suppurative otitis media--that is, these infections were characterized by a prolonged, indolent course and were refractory to conservative treatment. (4-9) During the preantibiotic era, actinomycosis of the temporal bone was almost always fatal, usually as a result of intracranial spread of infection. (10) According to reports of these early cases, most patients died suddenly after being relatively symptom-free. The diagnosis in these cases was often made at autopsy.
During surgery, granulation tissue and a yellow, cheesy discharge are often seen in the middle ear and mastoid The diagnosis of temporal bone actinomycosis is usually based on histopathologic examination of biopsy specimens obtained during surgery. (5,7,9) Our patient presented with a history and physical examination typical of chronic suppurative otitis media; we based our diagnosis solely on the histopathologic findings.
Once the diagnosis of actinomycosis otomastoiditis has been made, the infection should be treated in the same way one would treat a typical cervicofacial Actinomyces infection, with surgical debridement and a prolonged course of a systemic antibiotic. Most authors report successful resolution of the infection with a combination of tympanomastoidectomy followed by a 3- to 6-month course of penicillin. (5,7) Shelton and Brackmann have also advocated aerating the infected site to create an aerobic environment in order to hinder Actinomyces survival. (5) Having been managed in this fashion, our patient remained free of disease at the 2-year follow-up.
(1.) Smego RA, Jr., Foglia G. Actinomycosis. Clin Infect Dis 1998; 26:1255-61.
(2.) Belmont MJ, Behar PM, Wax MK. Atypical presentations of actinomycosis. Head Neck 1999;21:264-8.
(3.) Bennhoff DF. Actinomycosis: Diagnostic and therapeutic considerations and a review of 32 cases. Laryngoscope 1984;94:11981217.
(4.) Ajal M, Turner J, Fagan P, Walker P. Actinomycosis oto-mastoiditis. J Laryngol Otol 1997;111:1069-71.
(5.) Shelton C, Brackmann DE. Actinomycosis otitis media. Arch Otolaryngol Head Neck Surg 1988;114:88-9.
(6.) Boor A, Jurkovic I, Friedmann I, et al. Actinomycosis of the middle ear. J Laryngol Otol 1998;112:800-1.
(7.) Olson TS, Seid AB, Pransky SM. Actinomycosis of the middle ear. Int J Pediatr Otorhinolaryngol 1989; 17:51-5.
(8.) Leek JH. Actinomycosis of the tympanomastoid. Laryngoscope 1974;84:290-301.
(9.) Tarabichi M, Schloss M. Actinomycosis otomastoiditis. Arch Otolaryngol Head Neck Surg 1993;119:561-2.
(10.) Risch OC. Actinomycosis of the ear. Arch Otolaryngol Head Neck Surg 1939;29:235-51.
From the Division of Otolaryngology, Department of Surgery, The Children's Hospital of Philadelphia The Children's Hospital of Philadelphia is one of the largest and oldest children's hospitals in the world. "CHOP" has been ranked as the best children's hospital in the United States by U.S. News & World Report and Child Magazine in recent years. , and the Department of Otorhinolaryngology--Head and Neck Surgery, University of Pennsylvania School of Medicine The University of Pennsylvania's School of Medicine, presently located in the University City section of Philadelphia, Pennsylvania, was the United States's first school of medicine, founded at the College of Philadelphia, as the University was then called. , Philadelphia.
Reprint requests: Ralph F. Wetmore, MD, Division of Otolaryngology, Department of Surgery, The Children's Hospital of Philadelphia, Richard D. Wood Richard D. Wood is an American molecular biologist specializing in research on DNA repair and mutation.
Dr. Wood received his B.S. in from Westminster College, Salt Lake City Utah (1975), his Ph.D. Center, 1st Floor, 34th and Civic Center Blvd., Philadelphia, PA 19104-4399. Phone:(215) 590-1582;fax:(215) 590-3986; e-mail: firstname.lastname@example.org
Originally presented at the annual meeting of the Society for Ear, Nose, and Throat Advances in Children; Dec. 6, 2002; Atlanta.