Disclaimer: The information contained within the Grand Rounds Archive is intended for use by doctors and other health care professionals. These documents were prepared by resident physicians for presentation and discussion at a conference held at Baylor College of Medicine in Houston, Texas. No guarantees are made with respect to accuracy or timeliness of this material. This material should not be used as a basis for treatment decisions, and is not a substitute for professional consultation and/or peer-reviewed medical literature.

Actinomycosis infections of the head and neck, although fairly uncommon, represents an important entity because of its varied presentation that may mimic other more common disease, the difficulties involved in its diagnosis, and the long course of treatment necessary to eradicate the disease.

The first reported case of human infection with actinomycosis was reported by Von Langenbeck in 1845 and was attributed to a fungus. The species actinomyces bovis was further described by Bollinger in 1876 and given the name "lumpy jaw disease" because of its presentation in cattle. Harz, in 1877, named the infecting organism actinomyces, which means ray fungus, reflecting the belief at the time that the organism was a fungus. Israel and Ponfick delineated the anaerobic nature of actinomyces and isolated it from humans in 1891. In the 1960's Waksman showed that actinomyces was actually a gram positive bacteria.

Since their proper identification in the 1960's, five species have been identified: A israelli, A bovis, A naeslundii, A viscosus and A odontolyticus.These organisms are members of the family Actinomycetaceae, Stretomycetaceae and Actinoplanaceae. They are gram positive rods which are strict or faculative anaerobes. Morphologically they are filamentous and branching in nature .

Except for A bovis, all the species are normal inhabitants of the human oral cavity. Precipitating factors believed to lead to disease in the cervical facial region include carious teeth, dental manipulations and maxillofacial trauma. Its pathogenesis is related to its ability to act as a intracellular parasite and thus resist phagocytosis as well as its tendency to spread without respect for established tissue plains or anatomic barriers.

The infection is fairly rare; most reports cite an incidence of one case per year per institution. There is a slight male predominance (anywhere from 1.5:1 to 3:1). The age of the patients centers around the 4th to 6th decade of life. There are no known predisposing racial, environmental or geographic factors.

Cope, in 1938, classified actinomycosis infection into three distinct forms. The cervicofacial form that h occurred 50 % of the time, the pulmonothoracic form that occurred in 30 % of cases and the abdominopelvic presentation that was responsible for 20 % of infections. Due to the emergence of modern antimicrobial therapy and improvements in diagnosis, these last two forms are rarely seen today.

In the cervicofacial region, the infection usually presents as a mass adjacent to the mandible, which may be tender to palpation, associated with surrounding induration or erythema, and may present with fever in up to 50 % of cases. Abscess formation with secondary infection as well as lymphadenopathy can be seen as well; however, actinomyces rarely involves the lymph nodes. The classic formation of draining sinus tracts with the presence of sulfur granules is seen in approximately 40% of cases and, when present, can help make the diagnosis. However, sulfur granules may also be seen in Nocardia infections and this distinction can be made by the presence of acid fast staining seen in Nocardia.

The diagnosis of Actinomycosis based on clinical grounds is very difficult due to its varied presentation and the number of other disease which may present in a similar manner. For the diagnosis of Actinomycosis to be established, two of the following conditions must be present: positive cultures, sulfur granules, or biopsy specimens showing the organism. When draining sinuses are present, material may be sent for culture and gram stain, but the organism is very difficult to grow, with less than 50% of cultures being positive. The presence of characteristic sulfur granules may help make the diagnosis. Aspiration of an abscess, if present, may also be sent for culture as well as morphologic examination. In the past, because of these difficulties, excision and pathological examination of the specimen was the most common and easiest way to make the diagnosis as well as initiate therapy. In two past retrospective studies, the diagnosis was made prior to biopsy or excision in only 19 of 181 and 4 of 57 cases respectively. However, with the advent and widespread use of fine needle aspiration, the diagnosis has become somewhat easier and less invasive.

Fine needle aspiration not only allows morphologic identification comparable to that obtained from excisional biopsy, but can also be used as an effective means of collecting material for microbiologic identification. The typical findings include the presence of sulfur granules seen as basophilic masses with a granular center and a radiating fringe of club-shaped protrusions as well as the distinctive filamentous and beaded actinomyces. The number of sulfur granules may vary, with the average number being seven. However, even in culture positive specimens, no granules may be seen.

The CT scan findings of actinomycosis infection of the head and neck are generally nonspecific. CT scan with contrast usually demonstrates an ill-defined soft tissue mass in the neck with slightly less attenuation than muscle. However, an enhancing rim may be found when contrast is administered. The radiological differential diagnosis includes branchial cleft cyst, metastatic lymphadenopathy, inflammatory lymphadenopathy and vascular tumor.

The head and neck manifestations of actinomyces infection are numerous and varied. As mentioned earlier, they cam mimic many more common diseases and thus make the diagnosis that much more challenging. Thus, a high index of suspicion is necessary. The most common head and neck presentation is a mass in the area of the mandible, most commonly in the submandibular triangle. Involvement of the skin of the cheek is the next most common presentation. Periodontal disease as well as involvement of the mandible with osteomyelitis and bony erosion is rare, but has been reported. Bony involvement of the maxilla may also develop with the formation of bony sequestra. Other manifestations include involvement of the temporal bone and middle ear, presumably as a result of spread of infection up the eustachian tube. Actinomycosis otitis media has been reported and presents with chronic otorrhea, conductive as well as sensorineural hearing loss and yellow cheesy material or granulation tissue filling the middle ear and mastoid. This presentation and material is also consistent with cholesteatoma and highlights the importance of pathological examination of the specimen in patients with chronic ear infections. Actinomycosis infection may also present as an external otitis with chronic drainage and a soft tissue mass in the external canal . A malignancy of the external canal must be excluded in these cases. Laryngeal involvement, presenting as hoarseness with the finding of an exophytic lesion of the larynx, is a rare but important presentation because of its possible misdiagnosis as a laryngeal malignancy. Other sites of reported involvement include the tonsil, hard palate, parotid gland, lacrimal duct, tongue and orbit.

While no evidence exists that Actinomycosis infection is more prevalent in the immunocompromised population, numerous case reports of clinical infection exist in the literature. Actinomycosis of the nasal septum presenting with purulent rhinorrhea and nasal obstruction has been seen in a patient with AIDS. Given the fact that Actinomyces can behave as an intracellular organism, and thus its containment would be dependent on intact T-cell function, one could theorize that this population would be more susceptible to clinical infection. Moreover, in this population, the differential diagnosis is more extensive and would have to include more exotic infections such as blastomycosis, coccidiomycosis and nocardia, as well as generalized lymphadenopathy seen in AIDS.

In the past surgery has been used to both diagnose and treat actinomycosis; however, since the advent of antimicrobial therapy, the mainstay of therapy has been long term treatment with antibiotics. But, with the fairly recent and widespread use of fine needle aspiration, the diagnosis can frequently be made without excision. Surgery can then be reserved for those cases that present with abscess formation, when FNA is nondiagnostic or in cases unresponsive to antimicrobial therapy alone in which excision may hasten resolution by removing gross disease. Some controversy exists in that some authors still believe that surgical excision followed by long term antibiotics remains the treatment of choice.

The current recommended therapy includes 4 weeks of high dose IV Penicillin followed by a 3 to 6 month course of oral Penicillin, continuing treatment even after total resolution of symptoms. Other antimicrobials that have been found to be effective include tetracycline, erythromycin and clindamycin. These can be used in Penicillin-allergic patients with good success rates. Case reports of treatment of recalcitrant case with Ciprofloxacin have also appeared in the literature.

Complications of Actinomycosis are rare, yet may be severe and life threatening. Spread down the bronchial tree can lead to the pulmonothoracic manifestations including pneumonia, empyema and thoracic draining fistulas. Hematogenous spread may lead to widespread dissemination. Central nervous system involvement, either as a result of hematogenous spread or by direct extension, may lead to brain abscess, meningitis or subdural empyema.

Actinomycosis of the head and neck, while rare, is an important entity because of its role as the "great masquerader" of the head and neck . Proper recognition and diagnosis is important because of the long term therapy needed to successfully treat the infection. Advances in clinical pathology have made its diagnosis easier and less invasive; however, a high index of suspicion is still needed to correctly make the diagnosis, avoid unnecessary tests and institute timely and effective therapy.

Case Presentation

A 51-year-old Pakistani man presented with a 2-month history of a slowly enlarging left neck mass that was painless and not associated with any discharge initially. A 10-day course of antibiotics prescribed by a private physician was not associated with any decrease in the size of the mass. He denied any history of oral trauma or recent dental extraction, tobacco or alcohol use, or any history of exposure to tuberculosis, fever or other constitutional symptoms. Physical examination was significant for a 2 X 2 cm firm nontender mass in the left midcervical region. There was no skin breakdown or drainage associated with the mass on his initial visit. There was no fluctuance; however, there was firm induration surrounding the mass as well as slight erythema of the overlying skin. The rest of his head and neck examination was normal. A PPD was placed which was found to be nonreactive and a chest x-ray was normal. Fine needle aspirate was performed which revealed no evidence of malignancy; however, stains were positive for Actinomyces. Cultures revealed no growth. He was placed on oral penicillin resulting in a reduction in the size of the mass. On his last visit he was found to have developed skin ulceration and drainage from the site. He will continue to be treated with oral penicillin for a total of 6 months.

Allen HA, Scatarige JC, Kim MH. Actinomycosis: CT findings in six patients. Am J Radiol 1987;149:1255-1258.

Bartels LJ, Vrabec DP. Cervicofacial actinomycosis. Arch Otolaryngol 1978;104:705-708.

Bennhoff DF. Actinomycosis: diagnostic and therapeutic considerations and a review of 32 cases. Laryngoscope 1984;94:1198-1217.

Chang CJ, Lalwani AK, Lanser MJ. Actinomycosis of the external auditory canal. Otolaryngol Head Neck Surg 1993;108:73-75.

Drake DP, Holt RJ. Childhood actinomycosis: report of three cases. Arch Dis Child 1976;51:979-981.

Fradis M, Zisman D, Podoshin L, Wellisch G. Actinomycosis of the face and neck. Arch Otolaryngol 1976;102:87-89.

Harvey JC, Cantrell JR, Fisher AM. Actinomycosis: its recognition and treatment. Ann Intern Med 1957;46:868-885.

Hong IS, Mezghebe HM, Gaiter TE, Lofton J. Actinomycosis of the neck: diagnosis by fine needle aspiration biopsy. J Natl Med Assoc 1993;85:145-146.

Kingdom TT, Tami TA. Actinomycosis of the nasal septum in a patient infected with the human immunodeficiency virus. Otolaryngol Head Neck Surg 1994;111:130-133.

Kwartler JA, Limaye A. Cervicofacial actinomycosis: pathologic quiz case. Arch Otolaryngol Head Neck Surg 1989;115:524-526.

Leek JH. Actinomycosis of the tympanomastoid. Laryngoscope 1974;84:290-301.

Macfarlane DJ, Tucker LG, Kemp RJ. Treatment of recalcitrant actinomycosis with ciprofloxacin. J Infect 1993;27:177-180.

Nelson EG, Tybor AG. Actinomycosis of the larynx. Ear Nose Throat J 1992;71:356-358.

Norman JE. Cervicofacial actinomycosis. Oral Surg Oral Med Oral Pathol 1970;29:735-744.

Pollock PG, Meyers DS, Frable WJ, Valicenti JF, Koontz FP, Beavert CS. Rapid diagnosis of actinomycosis by thin-needle aspiration biopsy. Am J Clin Path 1978;70:27-30.

Rankow RM, Abraham DM. Actinomycosis: masquerader in the head and neck. Ann Otol Rhinol Laryngol 1978;87:230-237.

Shelton C, Brackman DE. Actinomycosis otitis media. Arch Otolaryngol Head Neck Surg 1988;114:88-89.

Silverman PM, Farmer JC, Korobkin M, Wolfe J. CT diagnosis of actinomycosis of the neck. J Comput Assist Tomogr 1984;8:793-794.

Smego RA. Actinomycosis of the central nervous system. Rev Infect Dis 1987;9:855-865.

Stenhouse D, MacDonald DG, MacFarlane TW. Cervico-facial and intraoral actinomycosis: a 5-year retrospective study. Br J Oral Surg 1975;13:172-182.

Stewart MG, Sulek M. Pediatric actinomycosis of the head and neck. Ear Nose Throat J 1993;72:614-619.

Vera-Alvarez J, Marigil-Gomez M, Abascal-Agorreta M. Fine needle aspiration cytology of cervicofacial actinomycosis. Acta Cytol 1993;37:109-111.

Weese WC, Smith IM. A study of 57 cases of actinomycosis over a 36- year period. Arch Intern Med 1975;135:1562-1568

Yeager BA, Hoxie J, Weisman RA, Greenberg MS, Bilaniuk LT. Actinomycosis in the acquired immunodeficiency syndrome-related complex. Arch Otolaryngol Head Neck Surg 1986;112:1293-1295.

Yenson A, DeFries HO, Deeb ZE. Actinomycotic osteomyelitis of the facial bones and mandible. Otolaryngol Head Neck Surg 1983;91:173-176.

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