Eur Arch Otorhinolaryngol (I996) 253:378-380 © Springer-Verlag 1996

T. H o s h i n o - H. A m a n o 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 en-

tity, with 24 cases reported thus far in the available English-lan-
guage 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 re-
current 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 nat-
ural 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 deteriora-
tion and a sensation of fullness. Otoscopy revealed the posterior
half of the left eardrum to be markedly bulged, but no inflam-
matory signs were seen. A small tympanic membrane perfora-
tion was seen antero-inferior to the umbo with pulsating muco-
pus 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 con-
dition 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 perfora-
tion closed 2 weeks later. Fig. 1 Sulfur granule (A) and actinomyces mycelia (B). The gran-
When drum bulging persisted, CT scans were obtained and ule (A) was aspirated through a tympanotomy orifice. Hema-
showed soft tissue shadow occupying all of the middle ear cav- toxylin and eosin staining. Bar = 0.5 ram. Grocott's staining dis-
ity. A tympanotomy was then done in August. Whitish yellow closed typical branched mycelia in the same sulfur granule (B)
granules and a thin mucus were aspirated from the mesotympa- (x 490). Bar = 10 gm
num, after which the granules were sent for pathological exami-
nation. These stained positively with Gram stain and demon- The eardrum resumed its normal contour shortly thereafter.
strated a number of branched mycelia and characteristic clubs. As the patient did not want any further procedures done, follow-
Grocott's methenamine-silver staining showed dark mycelia up was arranged at our outpatient clinic. Otoscopic checks in
(Fig. 1); the granules were not acid fast. These findings led to a November 1993 and April 1994 revealed a normal-looking
diagnosis of actinomycosis. 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,
T. Hoshino ([E~) . H. Amano the patient remained otherwise asymptomatic and refused fur-
Department of Otolaryngology, ther treatment. CT scans taken during a quiescent period (De-
Hamamatsu University School of Medicine, 3600 Handa-cho, cember 1994) showed some air space in the middle ear cavity
Hamamatsu 431-31, Japan (Fig. 3).
After 18 months without event, the patient suddenly felt a re-
K. Tanaka
Institute of Anaerobic Bacteriology, turn of symptoms in her left ear in May 1995. This was accom-
Gifu University School of Medicine, 500 Tsukasa-machi, panied by occasional stinging earaches that began in July. She
Gifu 500, Japan returned to our clinic in mid-July. A pronounced bulging of the