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 of the Head and Neck History Von Langenbeck noted the first case of human actinomycosis in 1845, and attributed it to a fungus. Bollinger described the organism Actinomyces bovis and its ability to cause "lumpy jaw" in cattle. The word Actinomyces means "ray fungus," and reflects the general belief at the time that the organism was a fungus. The organism was first isolated from humans in 1891, when Wolff and Israel reported culturing it anaerobically growing only at body temperature. In the 1960s, Waksman concluded that Actinomyces was actually a gram-positive bacteria. Bacteriology The organisms that cause Actinomycosis are members of the families Actinomycetaceae, Streptomycetaceae, and Actinoplanaceae. The organisms are gram-positive, branching, nonspore-forming bacilli. They are anaerobic or microaerophilic. They are very difficult to grow in culture, and the culture-recovery rate from active infection is only approximately 30%. The organisms responsible for infection in man are thought to be Actinomyces israelii, naeslundii, viscosus, and odontolyticus; of these israelii is most common. Actinomyces bovis has not been isolated in man, and is felt to be the organism responsible for "lumpy jaw" in cattle. Incidence The incidence of symptomatic actinomycosis infection is quite low. Most reviews report approximately one case per year in major medical centers. The infection involves the head and neck in approximately 50% of cases, the chest and lungs in approximately 30% and the abdominal viscera in 20%. Pathogenesis Actinomyces organisms are normal inhabitants of the oral cavity of normal hosts. Actinomyces can be cultured from 10 to 15% of normal tonsils, and several investigators have been able to culture Actinomyces from teeth. Apparently, in the normal host, the organism can live as a symbiont in the oral cavity. The etiology of Actinomyces infection is probably related to local mucosal trauma, or dental manipulation. In infection, the organism can function as a facultative intracellular parasite which spreads into adjacent soft tissues without regard for tissue planes or lymphatic drainage. Actinomycosis seldom involves lymph nodes. Clinical Presentation Clinically, cervicofacial actinomycosis usually presents as a palpable mass, sometimes painful or recurrent, that may be associated with a draining sinus tract. Fever is present in 50 to 80% of cases. This may be associated with a draining sinus tract in approximately 40% of cases. Regional lymphadenopathy is noted in some patients. The surrounding tissue is often described as "woody induration." The skin over the mass may be a characteristic purple-red. The CT findings of actinomycosis are non-specific. Usually, it appears as an irregular mass in the soft tissue of the neck, with lower attenuation than muscle. If drainage from a sinus tract is present, this can be sent for culture and gram stain, which may identify the organism. However, specimens from a draining sinus seldom are suitable for culture. If possible, aspiration of material from a fluctuant abscess cavity is preferable. Also, the characteristic sulfur granules can occasionally be seen on fine-needle aspiration histology. Diagnosis Actinomycosis is notoriously hard to diagnose at presentation. Actinomycosis has been named the "masquerader"of the head and neck, and the differential diagnosis for its presentation is extensive. Radiographic findings are non-specific, and even after biopsy or excision, the diagnosis can be difficult because the organism is very difficult to grow in culture, and the characteristic pathologic findings are not always present. Pathology Microscopically, there is an outer zone of purulence surrounding characteristic sulfur granules which contain branching, pleomorphic gram-positive rods. There are varying numbers of granules present. In the Armed Forces Pathology series, the average number present was seven (7), although 56% of cases had only one to three granules, and there were seven (7) cases which were culture-positive and no granules were seen histologically. Sulfur granules are not pathognomonic of actinomycosis. Demographics The age range is from childhood to age 90, but most reviews report a mean age in the 40s. There is a three (3) or four (4) to one (1) ratio of males to females, and no racial predilection. There are no occupations at increased risk. The disease has been reported from all parts of the world. Head and Neck Actinomycotic infection has been reported from virtually every site of the head and neck. Although it is a normal inhabitant of the oral cavity, Actinomyces can be a pathogen there also. Periapical actinomycosis is reported usually in association with previous trauma to a tooth, or a dental procedure. Actinomycosis of the teeth usually presents with a painful local swelling. Actinomycosis of the tongue is very rare. It usually presents as a painful firm nodule involving the lateral portion of the mobile tongue, and is often mistaken for malignancy. The submandibular space is the most common site of cervicofacial actinomycosis. Presumably, infection here begins from periodontal disease, or intra-oral mucosal trauma. Fistulization usually occurs to the skin of the submandibular triangle. Involvement of the mandible itself with osteomyelitis is very rare, but has been reported. The next most common site of involvement is the cheek. These probably arise from maxillary teeth or mucosal injuries. The bony maxilla itself, the premaxillary space, and the maxillary sinus may be involved. The soft tissues of the neck and face can also be involved. Although rare, there are 21 reported cases of actinomycosis of the temporal bone. The mechanism is thought to be direct spread up the Eustachian tube, and the clinical course is similar to chronic otitis media, except that the infection is resistant to conventional courses of antibiotic therapy. Also rare, but reported, are actinomycosis of the lacrimal canaliculus, and involvement of the orbit, usually through an involved maxillary sinus. Treatment Because the diagnosis is difficult to make, surgery becomes important as both diagnosis and treatment of actinomycosis. Recurrence following surgery alone, however, is very common, and antibiotic therapy is a necessary part of treatment. The course of treatment is two to four weeks of high-dose intravenous antibiotics, followed by three to six months of oral antibiotics. The mainstay of therapy for years has been penicillin. The semi-synthetic penicillins such as Nafcillin and Dicloxacillin are less effective. In penicillin allergy, tetracycline is used. Erythromycin is effective, and is recommended in rare cases of penicillin and tetracycline allergy. Clindamycin is also effective, and if co-infection with other anaerobic bacteria or Staphylococcus is suspected, treatment with clindamycin is recommended. The cure rate with appropriate antibiotic therapy is over 90%. Case Presentation An 11-year-old African-American male, previously in good health, presented with a two week history of an enlarging right submandibular mass. He denied fever or other constitutional symptoms. His past medical history is entirely unremarkable. There were no unusual animal exposures, or recent travel. Physical exam revealed a very hard right submandibular mass measuring 8 X 5 cm, which was tender to palpation, and felt partially fixed to the mandible. The intra-oral exam and the remainder of the head and neck exam were unremarkable. The patient was afebrile, and there was no other lymphadenopathy or organomegaly. Panorex and mandible series were normal. Chest x-ray and PPD were normal. The laboratory evaluation was entirely normal. The patient was admitted to the Pediatric service, placed on IV Nafcillin and Clindamycin, and the Otolaryngology service was consulted. The mass was unchanged on exam after five days of IV antibiotics, and the patient underwent surgical excision of the right submandibular gland in continuity with a mass of matted submandibular lymph nodes. Pathology revealed acute and chronic inflammation of the submandibular gland, and an abscess containing Actinomycosis. The antibiotic was changed to IV penicillin, and the patient was discharged home to complete a four week course of IV penicillin followed by a six month course of oral penicillin. The final cultures showed no growth at six weeks. Bibliography Allen HA, Scatarige JC, Kim MH: Actinomycosis: CT findings in six patients. AJR 149:1255-58, 1987. Bartels LJ, Vrabec DP: Cervicofacial actinomycosis: A variable disorder. Arch Otolaryngol 104:705-08, 1978. Bartlett JG, Gorbach SL: Anaerobic infections of the head and neck. Otolaryngol Clin North Am 9:655-78, 1976. Brown JR: Human actinomycosis: A study of 181 subjects. Hum Pathol 4:319-30, 1973. Carpenter JL, Artenstein MS: Use of diagnostic microbiologic facilities in the diagnosis of head and neck infections. Otolaryngol Clin North Am 9:611-29, 1976. del Rosario N, Rickman L: Cervicofacial actinomycosis. Arch Otolaryngol 113:777-78, 1987. Drake DP, Holt RJ: Childhood actinomycosis: Report of three recent cases. Arch Dis Child 51:979-81, 1976. Fradis M, et al: Actinomycosis of the face and neck. Arch Otolaryngol 102:87-89, 1976. Freeman LR, Zimmerman EE, Ferrillo PJ: Conservative treatment of periapical actinomycosis. Oral Surg 51:205-08, 1981. Har-El G, et al: Actinomycotic granuloma masquerading as an infraorbital nerve neoplasm. Head Neck Surg 12:261-63, 1990. Harvey JC, Cantrell JR, Fisher AM: Actinomycosis: Its recognitiona and treatment. Ann Intern Med 46:868-85, 1957. Kaplan RJ: Neurologic complications of infections of the head and neck. Otolaryngol Clin North Am 9:729-49, 1976. Kuepper RC, Harrigan WF: Actinomycosis of the tongue: Report of a case. J Oral Maxillofac Surg 37:123-25, 1979. Kwartler JA, Limaye A: Cervicofacial actinomycosis: Pathologic quiz case. Arch Otolaryngol 115:524-26, 1989. Lane RJ, Keane WM, Potsic WP: Pediatric infectious cervical lymphadenitis. Otolaryngol Head Neck Surg 88:332-35, 1980. Leek JH: Actinomycosis of the typmpanomastoid. Laryngoscope 84:290-301, 1974. Leigh RJ, Good EF, Rudy RP: Ophthalmoplegia due to actinomycosis. J Clin Neuro Ophthalmol 6:157-59, 1986. Norman JE: Cervicofacial actinomycosis. Oral Surg 29:735-45, 1970. Pollock PG, et al: Cervicofacial actinomycosis: Rapid diagnosis by thin-needle aspiration. Arch Otolaryngol 104:491-94, 1978. Rankow M, Abraham DM: Actinomycosis: Masquerader in the head and neck. Ann Otol Rhinol Laryngol 87:230-37, 1978. Richtsmeier WJ, Johns ME: Actinomycosis of the head and neck. CRC Crit Rev Clin Lab Sci 11:175-202, 1979. Shelton C, Brackmann DE: Actinomycosis otitis media. Arch Otolaryngol 114:88-89, 1988. Silverman PM, et al: CT diagnosis of actinomycosis of the neck. J Comput Assist Tomogr 8:793-94, 1984. Smego RA: Actinomycosis of the central nervous system. Rev Infect Dis 9:855-65, 1987. Smith LR, Heaton CL: Actinomycosis presenting as Wegener's granulomatosis. JAMA 240:247-8, 1978. Stenhouse D, MacDonald DG, MacFarlane TW: Cervicofacial and intra-oral actinomycosis: A five year retrospective study. Br J Oral Surg 13:1972-82, 1975. Weese WC, Smith IM: A study of 57 cases of actinomycosis over a 36 year period: A diagnostic `failure' with good prognosis after treatment. Arch Int Med 135:1562-68, 1975. Weir JC, Buck WH: Periapical actinomycosis: Report of a case and review of the literature. Oral Surg 54:336-40, 1982. Yakata H, et al: Actinomycotic osteomyelitis of the mandible: Report of a case. J Oral Maxillofac Surg 36:720-24, 1978. Yeager BA, et al: Actinomycosis in the acquired immunodeficiency syndrome-related complex. Arch Otolaryngol 112:1293-95, 1986. Yenson A, DeFries HO, Deeb ZE: Actinomycotic osteomyelitis of the facial bones and mandible. Otolaryngol Head Neck Surg 91:173-76, 1983. Grand Rounds Archive | Department Home page BCM Public | BCM Intranet | Privacy Notices | Contact BCM | BCM Site Map | ©2001-2006 Baylor College of Medicine
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