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Year : 2022  |  Volume : 28  |  Issue : 4  |  Page : 320-321

Middle ear actinomycosis

Department of ENT, Al-Nahdha Hospital, Muscat, Oman

Date of Submission15-Jul-2021
Date of Acceptance12-Oct-2021
Date of Web Publication29-Dec-2022

Correspondence Address:
Dr. Zaina Khalfan Al Dhahli
Department of ENT, Al-Nahdha Hospital, Muscat
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/indianjotol.indianjotol_111_21

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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

How to cite this article:
Al Dhahli ZK, Naik JZ, Al Saidi Y. Middle ear actinomycosis. Indian J Otol 2022;28:320-1

How to cite this URL:
Al Dhahli ZK, Naik JZ, Al Saidi Y. Middle ear actinomycosis. Indian J Otol [serial online] 2022 [cited 2023 Feb 5];28:320-1. Available from: https://www.indianjotol.org/text.asp?2022/28/4/320/365953

  Introduction Top

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 Report Top

A 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 ear

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She 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.

  Discussion Top

Actinomycosis 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.

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Conflicts of interest

There are no conflicts of interest.

  References Top

Sheikh MA, Alenzi S, Ahmadi AA, Mashragi A, Alsayid H, Abdullah A. Actinomycosis of the middle ear and mastoid. Med Arch 2018;72:295-6.  Back to cited text no. 1
Kakuta R, Hidaka H, Yano H, Miyazaki H, Suzaki H, Nakamura Y, et al. Identification of Actinomyces meyeri actinomycosis in middle ear and mastoid by 16S rRNA analysis. J Med Microbiol 2013;62:1245-8.  Back to cited text no. 2
Kullar PJ, Yates P. Actinomycosis of the middle ear. J Laryngol Otol 2013;127:712-5.  Back to cited text no. 3
Lezcano C, Simons JP, Colman KL, Cohen MS, Lin PL, Reyes-Múgica M. Actinomycotic mastoiditis complicated by sigmoid sinus thrombosis and labyrinthine fistula. Pediatr Dev Pathol 2014;17:478-81.  Back to cited text no. 4
Shishegar M, Hossein S, Hosseini D, Varedi P, Varedi P, Mahmoodi S, et al. Actinomycosis of the middle ear. Otology & Neurotology, 2009, 30.5: 686-687.  Back to cited text no. 5
Böör A, Jurkovic I, Friedmann I, Benický M, Dudriková K, Krajcár R. Actinomycosis of the middle ear. J Laryngol Otol 1998;112:800-1.  Back to cited text no. 6
Olson TS, Seid AB, Pransky SM. Actinomycosis of the middle ear. Int J Pediatr Otorhinolaryngol 1989;17:51-5.  Back to cited text no. 7
Shelton C, Brackmann DE. Actinomycosis otitis media. Arch Otolaryngol Head Neck Surg 1988;114:88-9.  Back to cited text no. 8
Hoshino T, Amano H, Tanaka K. Actinomycosis of the middle ear and mastoid. Eur Arch Otorhinolaryngol 1996;253:378-80.  Back to cited text no. 9
Fletcher R, Rafael S. A rare case of chronic otorrhea with intracranial complications. The Laryngoscope, 1956:66:702-10.  Back to cited text no. 10
Leek JH. Actinomycosis of tympanomastoid. Laryngoscope J 1974; 84:290-301.  Back to cited text no. 11


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