Actinomycosis of the larynx: a case report

Abstracts

We report a case of a patient with actinomycosis of the larynx mimicking a neoplasm. A literature review, clinical features, pathology and imaging findings is also presented. This paper reports a rare disease occurring in an atypical location, simulating larynx neoplasm. To our knowledge, there is no report of this disease and locations evaluated with computed tomography.

Actinomycosis; Computed tomography; Cancer

Relatamos um caso de actinomicose laríngea mimetizando neoplasia, com revisão da literatura a respeito dos aspectos clínicos, patológicos e de imagens. Utilizamos tomografia computadorizada, exame loco-regional, nasofibroscopia e estudo anatomopatológico. A importância do estudo se deve à raridade da enfermidade, localização atípica e particularmente ao diagnóstico diferencial com neoplasia de laringe. Não identificamos, na literatura, casos com avaliação por meio de tomografia computadorizada.

Actinomicose; Tomografia computadorizada; Câncer

CASE REPORT

Actinomycosis of the larynx: a case report^*

Marcelo Carneiro Menezes^I; Olger de Souza Tornin^II; Renato Assayag Botelho^III; Joel Pinheiro de Brito Júnior^III; Daniel Knabben Ortellado^IV; Lucas Rios Torres^V; Sandro Caldeira Ferreira Júnior^V; José Francisco Sales Chagas^VI; Oswaldo Luiz Pinto^VII; Ricardo Pires de Souza^VIII

^IMaster Degree Student in Sciences of Health at Hospital Heliópolis, Professionalizing Practice in Computed Tomography at Universidade de São Paulo

^IIMaster Degree Student in Sciences of Health at Hospital Heliópolis, Professionalizing Practice in Magnetic Resonance Imaging at Universidade de São Paulo

^IIIMaster Degree Students in Sciences of Health at Hospital Heliópolis

^IVMaster in Sciences of Health by Hospital Heliópolis

^VMD, Residents in Diagnostic Imaging at Hospital Heliópolis

^VITeacher at Course of Post-Graduation at Hospital Heliópolis, Doctor in Medicine, Universidade Federal de São Paulo-Escola Paulista de Medicina

^VIIMD, Surgeon

^VIIITeacher at Course of Post-Graduation at Hospital Heliópolis, Doctor in Radiology, Universidade de São Paulo

^{Mailing address}

ABSTRACT

We report a case of a patient presenting actinomycosis of the larynx mimicking a neoplasm, with a literature review including clinical, pathological and imaging findings. Computed tomography, loco-regional examination, nasofibroscopy and anatomopathological studies were performed. The relevance of the present study is related to the rarity, atypical location of the disease and particularly the differential diagnosis with larynx neoplasm. We could not identify in the literature any case evaluated with computed tomography.

Keywords: Actinomycosis; Computed tomography; Cancer.

INTRODUCTION

Actinomycosis of the larynx is a rare disease caused by Actinomyces israelii — a saprophyte commensal of the native microbiota of the oral cavity. This gram-positive microorganism develops in anaerobic or microaerophilic environment, forming elongated unicellular mycelium.

Actinomycosis was first described by Israel for more than a hundred years⁽¹⁾. Although the majority of cases occur in the region of head & neck, laryngeal involvement is fairly uncommon, with few cases reported in the literature, and as far as we are concerned there is no case report regarding evaluation of this disease by means of computed tomography.

Infectious diseases should always be taken into consideration in the differential diagnosis of larynx lesions. Such diseases, especially the granulomatous ones, have been increasingly gaining importance, since they are directly related to the increase in life expectancy, decrease in immunity and a greater rate of populational displacement⁽²⁾. Differential diagnosis of infectious and inflammatory diseases with larynx neoplasms is indispensable, considering the significant difference in the form of treatment. The definite diagnosis is achieved by means of biopsy and computed tomography is employed particularly to evaluate the disease extent.

The objective of the present study is to describe a case of endolaryngeal actinomycosis mimicking neoplasm, evaluated by computed tomography.

CASE REPORT

Male, 77-year old, caucasian patient, admitted into Service of Head & Neck Surgery at Hospital Heliópolis, complaining of hoarseness.

The patient reported mild throat pain for about a year. In the last two years the pain had worsened in association with progressive hoarseness and non-quantified weight loss. The patient was a smoker (30 cigarettes/day), alcoholic (distilled consumption) for 47 years and did not present dysphagia, dyspnea or otalgia.

At loco-regional examination a vegetating, lobulated mass was found, with an ulcerative component, measuring 2.0 cm in diameter, located in the left aryepiglottic fold, anteriorly distant 0.5 cm from epiglottis and posteriorly compromising the interarytenoid space; laterally not reaching the left piriform recess; medially, under a vegetating form, compromised the vestibular fold. Vocal folds mobility was normal.

Nasofibrolaryngoscopy with biopsy and computed tomography (CT) were requested.

Nasofibrolaryngoscopy and CT confirmed the lesion limits and biopsy presented actinomyces granules in an inflammatory infiltrate with neutrophils, plasmocytes and histiocytes, therefore confirming the etiologic diagnosis. Tomographic findings were: a dense, lobulated mass reducing the piriform sinus lumen and involving aryepiglottic and left ventricular folds, apparently obliterating the ipsilateral paraglottic space (Figures 1, 2 and 3).

The conduct adopted was admission of the patient for treatment with antibiotics for 21 days. The patient presented a good evolution and the antibiotic therapy was maintained for 6 months.

DISCUSSION

Infectious diseases of the larynx are relatively uncommon, but should be always taken into consideration in cases of vegetating laryngeal lesions. Despite its remarkable similarity with neoplasm, the clinical conduct is completely different between both entities.

Actinomyces israelii is a saprophyte commensal naturally found in the oral cavity. It may be found in the crypts of palatine tonsils in about 15% of amygdalectomies⁽³⁾. For the microorganism to grow it needs to break through the mucosal barrier and access an anaerobic environment. Typically, this occurs as a result of oral traumas like dental manipulations or endo-oral surgeries⁽⁴⁾.

Actinomycosis is directly related to factors which reduce the host´s immunological capacity like diabetes mellitus, malignant neoplasms, chemotherapy and radiotherapy or even HIV infection⁽¹⁾. Cases of actinomycosis in patients who underwent radiotherapy in the region of larynx are particularly significant probably as a result of local immunological defense alterations in larynx and pharynx mucosas. In the present case, the patient did not present comorbidity relating to immunological deficiency.

Actinomycosis of head and neck affects particularly the region of mandible following dental treatments. Endolarynx involvement is fairly rare⁽⁵⁾. In the referred literature, we have found only few studies relating to this subject and none of them describe computed tomography findings.

Actinomycosis is characterized as a subacute granulomatous disease. In the region of head and neck it may present as an abscess with fever, leukocytosis, pain and obstructive symptoms, or a more indolent progression as a painful, indurated mass in the neck. The growth of the lesion not restricted to fascial compartments, anatomical or lymphatic barriers is typical of actinomycosis⁽⁶⁾.

In the larynx, actinomycosis may be characterized by dyspnea, hoarseness, dyphagia and nocturnal laryngeal stridor of long evolution, differently from larynx neoplasms which present a somewhat more acute clinical picture.

The diagnosis is made by means of the lesion biopsy that identifies the actinomyces granules also called sulphur granules due its yellowish color and characteristic friability. Normally there is an inflammatory reaction or necrosis surrounding this actinomyces mycelium.

Treatment consists of surgical draining of the larger lesions and antibiotic therapy over an extended period.

REFERENCESS

• 1. Hughes RA, Paonessa DF, Conway WF. Actinomycosis of the larynx. Ann Otol 1984;93:520524.
• 2. Donegan JO, Wood MD. Histoplasmosis of the larynx. Laringoscope 1983;94:206209.
• 3. Vrabec DP. Fungal infections of the larynx. Otolaryngol Clin North Am 1993;26:10911114.
• 4. Everts EC. Cervicofacial actinamycosis. Arch Otolaryngol 1970;92:468474.
• 5. Nelson EG, Tybor AG. Actinomycosis of the larynx. Ear Nose Throat J 1992;71:356358.
• 6. Brandenburg JH, Finch WW, Kirkham WR. Actinomycosis of the larynx and pharynx. Otolaryngol Head Neck Surg 1978;86:739742.

*

Study developed in the Service of Diagnostic Imaging at Hospital Heliópolis, São Paulo, SP, Brazil.

Publication Dates

• Publication in this collection
  26 Sept 2006
• Date of issue
  Aug 2006