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CASE REPORT
Year : 2022 | Volume
: 28
| Issue : 4 | Page : 320-321
Middle ear actinomycosis
Zaina Khalfan Al Dhahli, Jagdish Zoivont Naik, Yousuf Al Saidi
Department of ENT, Al-Nahdha Hospital, Muscat, Oman
Correspondence Address:
Dr. Zaina Khalfan Al Dhahli
Department of ENT, Al-Nahdha Hospital, Muscat
Oman
Source of Support: None, Conflict of Interest: None
CheckDOI: 10.4103/indianjotol.indianjotol_111_21
Actinomycosis subacute to chronic infection caused by actinomyces. Actinomyces is filamentous, Gram-positive, anaerobic, nonacid-fast microaerophilic bacteria. Although it is considered as normal flora it is rarely colonize middle ear. The aim is to report the case of middle ear actinomycosis. We present 35-year-old female complain of recurrent left ear discharge. The whole tympanic membrane was bulging (due to granulation tissue behind it) with tiny hole that are discharging. Underwent tympano-mastoidectomy surgery with surgery finding of whitish material and granulation tissue in the middle ear. Histopathology of that material reported as the colony of actinomyces. Middle ear actinomycosis although is rare infection but should be done as one of differential diagnoses for recurrent otorrhea. Both surgical treatment and antibiotics are recommended as treatment for middle ear actinomycosis.
Keywords: Actinomyces, Actinomycosis, middle ear actinomycosis
Actinomycosis is rare subacute to chronic disease caused by actinomyces. Actinomyces is filamentous, Gram-positive, anaerobic, nonacid-fast microaerophilic bacteria. These bacteria generally colonize the human mouth, urogenital tract, and gastrointestinal tract but very rarely found in the middle ear. To date, around 47 cases of middle ear actinomycosis are reported in the literature.[1],[2],[3],[4],[5],[6],[7],[8],[9],[10],[11] Here, we are reporting the case of middle ear actinomycosis presented as chronic otitis media.
Case ReportA 35-year-old female presented to our otology clinic with complain of recurrent left ear discharge and pain for 4 years. There are no associated hearing loss, vertigo, or tinnitus. She had the previous tympanoplasty done on the same side in 2007. Examination showed bulge in the inferior part of the tympanic membrane with pinhole perforation. Pulsatile mucopurulent discharge was coming from the perforation. Audiological investigation showed mild conductive hearing loss in the left ear. Computed tomographic scan [Figure 1] showed opacification in the middle ear and mastoid cells with normal ossicles and inner ear.
Figure 1: Computed tomography temporal bone show opacification in the left middle earShe underwent tympano-mastoidectomy surgery. During operation found to have whitish soft material in the anterior part of mesotympanum and granulation tissue in the middle ear cleft. Granulation tissue with whitish material sent to histopathology examination and culture and sensitivity. There was no growth of bacteria in the culture and sensitivity, but histopathology showed colony of nonacid-fast bacterial colonies surrounded by inflammatory cells, which are consistent with actinomyces.
After discussion with the microbiologist, the patient started on amoxicillin 1 g and clindamycin 450 mg over 6 weeks. On follow-up, there was no complaint and the tympanic membrane was intact.
DiscussionActinomycosis is subacute or chronic infection caused by actinomyces.[1],[2] They are Gram-positive filamentous nonacid fast anaerobic microaerophilic bacteria that typically colonize the human mouth, urogenital tract, and gastrointestinal tract. Israeli and Wlfeand first described this organism in 1878.[3] There are different species, but the majority of infections are due to either Actinomyces israelii or Actinomyces gerencseriae.[2]
Middle ear actinomycosis is rare infection and about 47 cases reported in the literature.[1],[2],[3],[4],[5],[6],[7],[8],[9],[10],[11] It is believed that the infection enters to middle from the nasopharynx via the Eustachian tube. Some authors also suggest hematogeneous and direct spread from the external auditory canal. The most reported symptoms are otorrhea and otolagia. In case of severe infection, it may present as acute mastoiditis or jugular vein thrombosis.[4] Our case presented with chronic otorrhea and no neurological symptoms.
Although actinomycosis can accurately diagnosed by isolating actinomyces species in tissue culture, around 70% of tissue culture came negative as in our case.[2] This is because of it is the fastidious organism and difficult to be cultured. The diagnosis can be made by the presence of granules of actinomycosis in histological examination. Recently, 16S rRNA gene sequence analysis as reported by Kakuta et al. also can be used for diagnosis.[2]
As actinomycosis infection in other part of the body other than temporal bone, the treatment is the combination of surgical debridement and antibiotic. Combine tympanoplasty with intact canal mastoidectomy is the most surgical management in reported cases. Prolong antibiotic is recommended. Duration of therapy is vary from 6 weeks to 1 year depended on the severity of the cases. Several antibiotic drugs can eliminate actinomycosis including: Penicillin, clindamycin, streptomycin, tetracycline, erythromycin, imipenem, cephalosporin, and chloramphenicol.[1] Close and prolonged follow-up is needed to detect recurrence.
Declaration of patient consent
The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.
Financial support and sponsorship
Nil.
Conflicts of interest
There are no conflicts of interest.
References
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