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Eur Arch Otorhinolaryngol (I996) 253:378-380
T. H o s h i n o - H. A m a n o
© Springer-Verlag 1996
K. T a n a k a
Actinomycosis of the middle ear and mastoid
Received: 29 November / Accepted: 23 January 1996
Sirs: Actinomycosis of the middle ear and mastoid is a rare entity, with 24 cases reported thus far in the available English-language literature. Although deaths occurred in earlier cases [6], recent articles comment on the indolent nature of the disease [2, 3, 5]. We now report our experiences with a patient who had recurrent episodes of otorrhea for 18 months, but who refused surgery or long-term antibiotic administration after a diagnosis of actinomycosis was established. The signs and symptoms noted in this case appear to be typical and may indicate the natural history of actinomycosis of the middle ear. A 24-year-old Japanese female was seen in our ENT clinic in May 1993, complaining of left otorrhea of 1 week's duration. Symptoms included a slight itching sensation, hearing deterioration and a sensation of fullness. Otoscopy revealed the posterior half of the left eardrum to be markedly bulged, but no inflammatory signs were seen. A small tympanic membrane perforation was seen antero-inferior to the umbo with pulsating mucopus running out of it. The threshold for sound perception in the left ear was 43 dB, compared to 17 dB in the right ear. The condition was diagnosed as purulent otitis media, and lomefloxacin and oral steroids (prednisolone 30 mg) were given for 7 days: Routine bacteriological study revealed a Staphylococcus species. The otorrhea healed after 1 week of treatment, and the perforation closed 2 weeks later. When drum bulging persisted, CT scans were obtained and showed soft tissue shadow occupying all of the middle ear cavity. A tympanotomy was then done in August. Whitish yellow granules and a thin mucus were aspirated from the mesotympanum, after which the granules were sent for pathological examination. These stained positively with Gram stain and demonstrated a number of branched mycelia and characteristic clubs. Grocott's methenamine-silver staining showed dark mycelia (Fig. 1); the granules were not acid fast. These findings led to a diagnosis of actinomycosis.
T. Hoshino ([E~) . H. Amano Department of Otolaryngology, Hamamatsu University School of Medicine, 3600 Handa-cho, Hamamatsu 431-31, Japan K. Tanaka Institute of Anaerobic Bacteriology, Gifu University School of Medicine, 500 Tsukasa-machi, Gifu 500, Japan
Fig. 1 Sulfur granule (A) and actinomyces mycelia (B). The granule (A) was aspirated through a tympanotomy orifice. Hematoxylin and eosin staining. Bar = 0.5 ram. Grocott's staining disclosed typical branched mycelia in the same sulfur granule (B) (x 490). Bar = 10 gm The eardrum resumed its normal contour shortly thereafter. As the patient did not want any further procedures done, followup was arranged at our outpatient clinic. Otoscopic checks in November 1993 and April 1994 revealed a normal-looking eardrum with type A tympanogram but a 45 dB hearing loss. A gradual change in tympanogram tpye was noted from type A to type B in October 1994, and increasing bulging of the posterior part of the eardrum was seen at this time (Fig.2A). However, the patient remained otherwise asymptomatic and refused further treatment. CT scans taken during a quiescent period (December 1994) showed some air space in the middle ear cavity (Fig. 3). After 18 months without event, the patient suddenly felt a return of symptoms in her left ear in May 1995. This was accompanied by occasional stinging earaches that began in July. She returned to our clinic in mid-July. A pronounced bulging of the
T. H o s h i n o - H. A m a n o
© Springer-Verlag 1996
K. T a n a k a
Actinomycosis of the middle ear and mastoid
Received: 29 November / Accepted: 23 January 1996
Sirs: Actinomycosis of the middle ear and mastoid is a rare entity, with 24 cases reported thus far in the available English-language literature. Although deaths occurred in earlier cases [6], recent articles comment on the indolent nature of the disease [2, 3, 5]. We now report our experiences with a patient who had recurrent episodes of otorrhea for 18 months, but who refused surgery or long-term antibiotic administration after a diagnosis of actinomycosis was established. The signs and symptoms noted in this case appear to be typical and may indicate the natural history of actinomycosis of the middle ear. A 24-year-old Japanese female was seen in our ENT clinic in May 1993, complaining of left otorrhea of 1 week's duration. Symptoms included a slight itching sensation, hearing deterioration and a sensation of fullness. Otoscopy revealed the posterior half of the left eardrum to be markedly bulged, but no inflammatory signs were seen. A small tympanic membrane perforation was seen antero-inferior to the umbo with pulsating mucopus running out of it. The threshold for sound perception in the left ear was 43 dB, compared to 17 dB in the right ear. The condition was diagnosed as purulent otitis media, and lomefloxacin and oral steroids (prednisolone 30 mg) were given for 7 days: Routine bacteriological study revealed a Staphylococcus species. The otorrhea healed after 1 week of treatment, and the perforation closed 2 weeks later. When drum bulging persisted, CT scans were obtained and showed soft tissue shadow occupying all of the middle ear cavity. A tympanotomy was then done in August. Whitish yellow granules and a thin mucus were aspirated from the mesotympanum, after which the granules were sent for pathological examination. These stained positively with Gram stain and demonstrated a number of branched mycelia and characteristic clubs. Grocott's methenamine-silver staining showed dark mycelia (Fig. 1); the granules were not acid fast. These findings led to a diagnosis of actinomycosis.
T. Hoshino ([E~) . H. Amano Department of Otolaryngology, Hamamatsu University School of Medicine, 3600 Handa-cho, Hamamatsu 431-31, Japan K. Tanaka Institute of Anaerobic Bacteriology, Gifu University School of Medicine, 500 Tsukasa-machi, Gifu 500, Japan
Fig. 1 Sulfur granule (A) and actinomyces mycelia (B). The granule (A) was aspirated through a tympanotomy orifice. Hematoxylin and eosin staining. Bar = 0.5 ram. Grocott's staining disclosed typical branched mycelia in the same sulfur granule (B) (x 490). Bar = 10 gm The eardrum resumed its normal contour shortly thereafter. As the patient did not want any further procedures done, followup was arranged at our outpatient clinic. Otoscopic checks in November 1993 and April 1994 revealed a normal-looking eardrum with type A tympanogram but a 45 dB hearing loss. A gradual change in tympanogram tpye was noted from type A to type B in October 1994, and increasing bulging of the posterior part of the eardrum was seen at this time (Fig.2A). However, the patient remained otherwise asymptomatic and refused further treatment. CT scans taken during a quiescent period (December 1994) showed some air space in the middle ear cavity (Fig. 3). After 18 months without event, the patient suddenly felt a return of symptoms in her left ear in May 1995. This was accompanied by occasional stinging earaches that began in July. She returned to our clinic in mid-July. A pronounced bulging of the
