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Actinomycosis of the parotid gland
Oral medicine
Actinomycosis Report
of
of the parotid gland
five
cases
Leon Sazama,* M.D., C.&k., Hradec CHARLES
UNIVERSITY
SCHOOL
OF
Krhlove’,
Czechoslovakia
MEDICINE
A
ctinomycosis is not a common disease, but it does occur from time to time. Although the cervicofacial form is usually loca.lized in the vicinity of the major salivary glands, direct involvement of these glands is rare. Lenormant? reports that in 1903 Miiller saw, among forty-nine patients with actinomycosis, four cases in u-hich the parotid gland was affected and two cases in which the suhmandibular gland was affected. Lenormant found a total of nine cases of actinomycosis of the parotid gland reported in the literature. SGderlung,12 in 1913, noted two cases of actinomycosis of the sublingual gland and four cases involving the submandibular gland. ChiariG reported one case of actinomycosis of the submandibular gland. In 1922 Beck” reported another case of actinomycosis of the parotid gland. RauchlO considers actinomycosis of the parotid gland to be a very rare disprder. Specific actinomycotic inflammation of the parotid gland occurs as either a primary or secondary infection, and it is difficult to distinguish between these two forms. Hetzar” states that primary actinomycosis of the parotid gland is an ascending canalicular inflammation which occurs when the infection penetrates from the mouth into the gland and affects it entirely. Our experience shows, however, that even a primary actinomycotic process may be limited to a certain portion of the gland (for example, around a foreign body which penetrated into the gland through the duct or even entered from the outside through the skin). Secondary actinomycotic parotitis occurs when actinomycosis is transferred *Head
of Department
of Stomatology,
Charles
University
School
of
Medicine. 197
Tht? clinical picture of actiuomyc~otic parotitis is similar to that of the> usll;lI forms of ccrvicofacial act.inomyczosis. i\t, the beginning th(arc is a non(~haractc~ristic inflammatory swelling of thr parotideomasseteric region which causes moderate pain and does not subside aftcr routine therapy. It develops into a chronic, hard, nodular induration with formation of multiple fistulas which dischar$c pus with yellowish sulfur granules. In the parotidcomasscteric region, howcvchr, one ma.y also observe hard, nodular indurations which arc more or 1~s painful hut which may be of the most va.ried inflamma,tory or tumorous origin. There is also a series of parotideomegalics, rccent,ly classified by Rauch as sialoscs. often of unknown origin. The biochemical, hematologic, bacteriologic, serologic., and pathologico-anatomic signs, the bncterioscopic findings in the pus, md the &lographic findings are of major practical importance. The finding of gram-positive granulated branching threads on microscopic examination of the yellowish, gritty “sulfur granules” or of the pus confirms the diagnosis, even if the result of bacteriologic culture is negative. Growt.11 of tha organism on artificial rncdia is difficult, especially now when WC see patients suffering from artinomycosis which has been previously treated with antibiotics. The diagnosis may also ‘rw confirmed by the histologic finding of actinomycctcs in the granulomatous tissues.
An affection of the parotid gland always causes changes in the sialogram. The gland fills irregularly. In some portions there are defects in filling of the ducts which are evidently compressed by an interstitial induration. At the site of the defect one can usually observe larger or smaller, often multiple, shadows of cysts of irregular shapes. This findin, v in the sialogram corresponds to t,hta focal descending form of inflammation with colliquation. Whole portions of the gland fill regularly and are evidently not, affected. This finding rules out a diagnosis of ascending parotitis, where the changes in the filling of the salivary glands are quite different. Sulfur granules in the saliva coming from Stensen.‘s duct were observed in onl)- one of our patients. Redness and induration of the orifice of Stensen’s duct occur as a rule, however. CASE REPORTS From 1916 to the end of 1962 a total of forty-five patients with proved a~tinomycosis of the maxillofscial region were treated in the Department of Stomatology at Hradec Krklovk. Among them were five cases of actinomycotic parotitis. CASE History
1
Three months earlier he had experienced difficulty The patient was a 2%year-old soldier. with the eruption of an impacted third molar. A pericoronal abscess was incised and drained, After the extraction a hard induration drand after a few days the tooth was removed. veloped which did not yield to the usual conservative treatment. The patient was treated for 8 weeks in two successive hospitals. Repeated extraoral and int,raoral incisions were made
Volume Sumber
zlctinomycosis
19 3
Pig. 1. Case I. Actinomyeotic gland. Ventral portion of gland at the site of the induration; was administered locally. As the Stomatology Department.
osteomyelitis of mandible did not fill, except for small
of parotid
and actinomycosis irregular cavities
glnnd
199
of parotid (arrows).
penicillin and Chloromycetin were given orally, and tyrothricin the condition did not improve, the patient was transferred
to
Examination
In the left parotideomasseteric region there was an extensive smelling which was strikThere were several scars from ingly hard and relatively insensitive to pain on compression. the various incisions. In one of them there was a fistula discharging a sanguinolent fluid. On pressure, several yellowish granules no larger than a pinhead appeared. In the mouth the orifice of Stensen’s duct on the left side was reddish in color and, on compression, discharged some saliva which was markedly turbid with pus. At the site of the third molar extraction there was an unhealed wound with purulent secretion. A roentgenogram revealed an osteolytic focus in the ramus of the jaw, into which the shadow of an irregular sequestrum projected. A sialogram showed a filling defect in the ventral half of the left parotid gland. The ducts were filled quite insufficiently, irregularly, and with interruptions; several small cysts could be observed. All these findings were in the vicinity of the translucent area in the ramus. The dorsal portion of the gland filled normally (Fig. 1). Microscopic examination showed multiple gram-positive granulated and lnamhing thr(lads in the pus. DiGgnosis: Actinomycotic osteomyelitis of the left ramus and ac*tinomycosis of tlm parotid gland. TREATMENT
A sequestrotomy was performed, and antibiotics were given. The patient received a total of 7,800,OOO units of penicillin and 18 gr. of streptomycin. Histologic examination revealed numerous actinomycotic sulfur granules in the granulation tissues. The patient recovered and was dismissed after 4 weeks. When seen for followup examinations 3 and 10 months later, he was free of complaints. CASE
2
A 7%year-old A stomatologist
pensioner extracted
stated a third
that 5 weeks molar, which
earlier his right cheek had suddenly had not caused any pain and which
swelled. vvas not
Fig.
1.
Case
2. Irregular
rarity
diseased. Following the extracrion, wound WLS irrigated, and rrlwn Stomatology Department.
( arrow)
tlw
in eccondar~
actinornycotic
parotitis.
the swelling inrreawl an11 psiti set in. The extraction condition did not change the patient was sent to the
Examination
An extensive swelling of the right cheek was seen to cxtcnd as far as the ear, lifting the lobulus. The skin was brown-red in color. The swelling was stiff and not very sensitive to pressure. The lymph nodes were not palpable. The parotid papilla on the right side was indurated. There was no spontaneous secretion from the orifice of the duct, but after compression a little bit of saliva mixed with pus was discharged. A roentgenogram disclosed the presence of a third molar root in t,he alveolus; the surrounding bone was normal. A sialogram of the right, parotid gland showrd the entire gland to be filled; the filling was partly parenchymatous. In the anterior lower quadrant a cavity of irregular shape could b’e seen; t.he largest diameter of its shadow measured 8 mm. (Fig. 2). Extraction of the third molar root was followed by excochlcation of the granulations. When the extraoral incision was made, a system of small abscess cavities discharging pus with numerous yellow granules ww ap1~roachetl. Bacteriologic culture of the pus yielded a mixed flora. Microscopic examination rwealetl numerous gram-positive granulatetl and branching threads typical of actinomycosis. Histologic cxaminat,ion also revealed numerous actinomycot,ic~ granules. Biugsosis : CervicofaeisJ and right lrwotiil gland actinomycosis. Treatment
A total of 3,200,OOO units of penicillin, 19 gr. of streptomycin, and 1.35 gr. of neomycin were administered over a period of 36 days. In addition, the patient was given stimulation therapy and supporting treatment. At dismissal, the patient was cured of the disease. When seen for control examinations for up to 1 year, he was free of complaints. CASE
3 A
in the
22.year-old soldier was seen with a gradually increasing swelling of 3 weeks’ duration left parotideomasseteric region. He had been treated with compresses and analgesics.
Examination
The red and
mouth appeared normal indurated and discharged
except for a whitish
the orifice of the left Stensen’s duct, which turbid saliva with isolated yellow granules.
WV
Acfinovlycosis
with
Pig. 3. Cast actinomyeosis.
3. Sytcm
of irregular
cavities
in inferior
portion
of pnroticl
of parotid
glnnd
gland
201
affectctl
An excision biopsy at the site of the induration revealed chronic inflammation and isolat,ed actinomycotic threads. Examination of a smear of the yellow granules from the excreted fibrin, and many gram-positive actinomyeotic threads. saliva showed numerous leukocytes, A sialogram of the left parotid gland showed that Stensen’s duct was not changed. The filling of the gland was good, but in the anterior lower quadrant there was a system of middle-sized, irregularly shaped filling defects which extended as far as the lower and csternal margins of the gland (Fig. 3). Uiagnosis : Actinomycosis of the left parotid gland. Treatment
Treatment in the Stomatology Department lasted 42 days. The patient was given 11,350,OOO units of penicillin and irradiation totaling 520 r. At dismissal he was normal. Control examinations up to 12 months later showed that there had been no relapse. 4 The patient was a 34year-old foreman in a st,ovo-manufacturing plant. Twelve years earlier his left ear had been operated on twice. Five days before the patient’s admission to the Stomatology Department a welling had appeared in the left parotideomassetoric region and was increasing in size every day. The district practitioner recommended that the patient see a stomatologist, and the latter suggested admission to our department, CASE
Examination
On admission, the patient had no fever and the general condition was normal, but the erythrocytc sedimentation reaction was slightly accelerated (15 and 35 during 1 and 2 hours). A stiff induration was conspicuous in the left parotideomasseteric region, hut it did not cause great pain. In the mouth only the orifice of the left Strnscn’s duet was red and indurated ; purulently turbid saliva was discharged on compression. A sialogram showed that Lipiodol had penetrated the entire gland, the canals of which appeared delicate. In the periphery of the anterior upper quadrant there mere two irregular, rather extensive lobulated cavities; in lateral projection their outlines almost merged, but in anteroposterior projection they were distant from each other so that. one of them was situated deeper in the tissue (Fig. 4). In the pus obtained by puncture, numerous actinomycotic granules with typical bacteriologic findings were observed. Dia,gnosis : Actinomycosis of the left parotid gland.
U.S..
0.M.
B 0.1’.
F’rI)ru:trp,
Fig. 4. Case 4. I~rltc,ropo~t(,rior actinomycotic
focus,
afYel:ting
(ranin
pro,i(‘ct,ion of sialopram showing an11 central portion of glancl.
two
larger
1965
cavities
in
Treatment
Treatment, administration phenicol, and local instillations Following CASE
which lasted 51 days, inc~luded puncture and extraoral incisions for drainage, of a total of 4% gr. of Elkosin, 19.5 gr. of st,reptomycin, 9 gr. of chloramirradiation with 400 r. The antibiolics were applied both generally and by into the fistula and Stcnsm’s duct. dismissal, the patient was examined repeatedly and found to be in good health.
5
A
37-year-old laborer was first admitted to the Stomatology Department on Aug. 18, 1961. He stated that one year earlier a swelling had appeared about the left mandibular angle and that there had been a L’discharge of pus through the ear,” after which the eondition had improved. Two months before the present admission the swelling reappeared. The and the condition improved, but a week patient’s district practitioner prescribed penicillin, later the swelling recurred. Penicillin was again administered, and after 4 wrtks the patient was referred to our department. Examination
On admission, general examination findings were within normal limits except for the crythrocyte sedimentation reaction, which was 22 and 45 during 1 and 2 hours. On the left side, from the mandibular angle to the parotideomasseteric region, there was a stiff induration which caused moderate pain. The skin over the induration was normal. Opening of the mouth was limited. A diagnosis of actinomycosis of the parotid gland was made on the basis of clinical signs, sialograms, and the pathologist’s finding of actinomyeotic granules in the excochleated granulomatous tissues. Treatment
After surgical intervention, the patient was given, over a period of 67 240 gr. of PAS, and 6,100,OOO units of penicillin, 17 gr. of Aureomycin, 320 r. The penicillin was given both systemically and locally by instillations fistula. On surgical intervention, a small abscess cavity was found in the parotid yellow round corpuscles mere found in the pus as well as in the granulations. A portion of the Sialography through Stensen’s duct was not possible.
days, a total of irradiation with through the gland.
Numerous
gland
was
filled,
Volume Number
fiatula
dctinomycosis
19 2
B’i$+ 5. C!asr 5. A portion of gland In case of primary a.etinomycotic
however, cavities patient
through could be probably around a foreign
filled after parotitis.
instillation
of parotid gland
of
c*ontrast
oil
through
203
skin
the fistula which had developed in the cheek. Several orifices and irregular seen (Fig. 5). From the operative findings, it can be concluded that this had a primary form of actinomycosis of the parotid gland which developed body.
DISCUSSION
The study and treatment of these five patients with proved actinomycotic parotitis did not reveal any characteristic signs which would make it possible to diagnose this diseasewith greater accuracy. In addition to the common findings suggestive of actinomycosis, there are the reddening and induration of the pasotid papilla and the purulent turbidity of t.he saliva discharged from the parotid gland. Actinomycotic granules are found less commonly in the saliva than in pus discharged from a fistula. Clinica.lly, actinomycotic parotitis is not greatly different from the usual form of ccrvicofacial actinomycosis, but it. often lasts longer and is more refractory to t.reatment. Sialography always shows the typical picture of a focal descending affection of the gland with orifices compressed by an interstitial infiltrate and colliquation at. several spots. The pictturc differs from conditions seen in sialolithiasis. Our findings, therefore, did not confirm the opinion of HetzaF that sialoadenitis accompanying sialolithiasis is generally of actinomycotic origin, although Naeslund’s works concerning the importance of actinomyrotic threads for the development of sialolithiasis are well known to us. In sialolithiasis t,he clinical picture is different, and the disease can be easily controlled. The instillation of iodized contrast oil, such as Lipiodol, into the parot.id gland also has therapeutic value because of the direct introduction of iodine into the focus. Local instillation of antibiotics through the salivary duct also has beneficial effects.
204
SaSama.
CONCLUSION
Regular sialographic examination of ccrvicofacial forms 01’ ;rc.tillutll!-c,osis showed that t,he parotid gland was involved in 1I. I per cent oi’ casts. Ir~still;ltion of iodized oils in actinomycotic parotitis is useful for both diagnosis and therapy. The filling of the glanrl can bc achieved, in most cases, through Stenseen’sduct; in other cases the medium may 1~ injcctcd through ;I fistula. Thcb sialogram presents t~ypical signs of a descending affection of the gland. SUMMARY
Among forty-five patients treated for actinomycosis of the maxillofacial region in the Department of Stomatology at Hradec Kralovk, there were five cases of actinomycotic parot,itis. In one of these the disease was found to bc primary; in the others it was secondary. Characteristic signs of this disease are described. Sialographic roentgenologic examination should be tarried out, as it is of both diagnostic and therapeutic importance. REFERENCES
1. 2. 3. 4. :i. 6. 7. 8. 9. 10. 11. 12.
hutalovskb. 2.: Prakt. l@ka? 37: X56. 195i. Antalovski, Z.: LBka?skb zpr$y 2: 51, 19.57. Rwk, K.: Ztxchr. Hals-, IYawnu. Ohrenh. 2: 270, 1922. Bethmann, TV.: Tropenerfahm~l~ell in plastischer Gexichts untl Kieferchirurgie, 1960, VEB Verlag. Hetzar. WT.: Die Sialoaraphie, Leiuzin. 19J2. Geora Thieve. Chiari.‘O.: Wien. klin:‘W>hnschr. i5f’i562. i912. chir. i. Grekova 6: 64, 1962. Kabagov, B. Il., and Klementov, A. T.: i’ctnnik T,enormant. Ch.: Presae m&l. 21: 254. 1913. Lentze. F. ‘A.: Zentralbl. Bakt. 141: 51. 19X Rauch,‘R.: Die Speieheldriisen den Me&hen, Stuttgart, 1959, Georg Thieme. Sazama, L.: Cesk. stomatol. 60: 91, 1960. Siidcrlund, G. : I)rutwhc nwtl. \V~lrnschr. 39: 1632, 1913.
Berlin,
Actinomycosis Report
of
of the parotid gland
five
cases
Leon Sazama,* M.D., C.&k., Hradec CHARLES
UNIVERSITY
SCHOOL
OF
Krhlove’,
Czechoslovakia
MEDICINE
A
ctinomycosis is not a common disease, but it does occur from time to time. Although the cervicofacial form is usually loca.lized in the vicinity of the major salivary glands, direct involvement of these glands is rare. Lenormant? reports that in 1903 Miiller saw, among forty-nine patients with actinomycosis, four cases in u-hich the parotid gland was affected and two cases in which the suhmandibular gland was affected. Lenormant found a total of nine cases of actinomycosis of the parotid gland reported in the literature. SGderlung,12 in 1913, noted two cases of actinomycosis of the sublingual gland and four cases involving the submandibular gland. ChiariG reported one case of actinomycosis of the submandibular gland. In 1922 Beck” reported another case of actinomycosis of the parotid gland. RauchlO considers actinomycosis of the parotid gland to be a very rare disprder. Specific actinomycotic inflammation of the parotid gland occurs as either a primary or secondary infection, and it is difficult to distinguish between these two forms. Hetzar” states that primary actinomycosis of the parotid gland is an ascending canalicular inflammation which occurs when the infection penetrates from the mouth into the gland and affects it entirely. Our experience shows, however, that even a primary actinomycotic process may be limited to a certain portion of the gland (for example, around a foreign body which penetrated into the gland through the duct or even entered from the outside through the skin). Secondary actinomycotic parotitis occurs when actinomycosis is transferred *Head
of Department
of Stomatology,
Charles
University
School
of
Medicine. 197
Tht? clinical picture of actiuomyc~otic parotitis is similar to that of the> usll;lI forms of ccrvicofacial act.inomyczosis. i\t, the beginning th(arc is a non(~haractc~ristic inflammatory swelling of thr parotideomasseteric region which causes moderate pain and does not subside aftcr routine therapy. It develops into a chronic, hard, nodular induration with formation of multiple fistulas which dischar$c pus with yellowish sulfur granules. In the parotidcomasscteric region, howcvchr, one ma.y also observe hard, nodular indurations which arc more or 1~s painful hut which may be of the most va.ried inflamma,tory or tumorous origin. There is also a series of parotideomegalics, rccent,ly classified by Rauch as sialoscs. often of unknown origin. The biochemical, hematologic, bacteriologic, serologic., and pathologico-anatomic signs, the bncterioscopic findings in the pus, md the &lographic findings are of major practical importance. The finding of gram-positive granulated branching threads on microscopic examination of the yellowish, gritty “sulfur granules” or of the pus confirms the diagnosis, even if the result of bacteriologic culture is negative. Growt.11 of tha organism on artificial rncdia is difficult, especially now when WC see patients suffering from artinomycosis which has been previously treated with antibiotics. The diagnosis may also ‘rw confirmed by the histologic finding of actinomycctcs in the granulomatous tissues.
An affection of the parotid gland always causes changes in the sialogram. The gland fills irregularly. In some portions there are defects in filling of the ducts which are evidently compressed by an interstitial induration. At the site of the defect one can usually observe larger or smaller, often multiple, shadows of cysts of irregular shapes. This findin, v in the sialogram corresponds to t,hta focal descending form of inflammation with colliquation. Whole portions of the gland fill regularly and are evidently not, affected. This finding rules out a diagnosis of ascending parotitis, where the changes in the filling of the salivary glands are quite different. Sulfur granules in the saliva coming from Stensen.‘s duct were observed in onl)- one of our patients. Redness and induration of the orifice of Stensen’s duct occur as a rule, however. CASE REPORTS From 1916 to the end of 1962 a total of forty-five patients with proved a~tinomycosis of the maxillofscial region were treated in the Department of Stomatology at Hradec Krklovk. Among them were five cases of actinomycotic parotitis. CASE History
1
Three months earlier he had experienced difficulty The patient was a 2%year-old soldier. with the eruption of an impacted third molar. A pericoronal abscess was incised and drained, After the extraction a hard induration drand after a few days the tooth was removed. veloped which did not yield to the usual conservative treatment. The patient was treated for 8 weeks in two successive hospitals. Repeated extraoral and int,raoral incisions were made
Volume Sumber
zlctinomycosis
19 3
Pig. 1. Case I. Actinomyeotic gland. Ventral portion of gland at the site of the induration; was administered locally. As the Stomatology Department.
osteomyelitis of mandible did not fill, except for small
of parotid
and actinomycosis irregular cavities
glnnd
199
of parotid (arrows).
penicillin and Chloromycetin were given orally, and tyrothricin the condition did not improve, the patient was transferred
to
Examination
In the left parotideomasseteric region there was an extensive smelling which was strikThere were several scars from ingly hard and relatively insensitive to pain on compression. the various incisions. In one of them there was a fistula discharging a sanguinolent fluid. On pressure, several yellowish granules no larger than a pinhead appeared. In the mouth the orifice of Stensen’s duct on the left side was reddish in color and, on compression, discharged some saliva which was markedly turbid with pus. At the site of the third molar extraction there was an unhealed wound with purulent secretion. A roentgenogram revealed an osteolytic focus in the ramus of the jaw, into which the shadow of an irregular sequestrum projected. A sialogram showed a filling defect in the ventral half of the left parotid gland. The ducts were filled quite insufficiently, irregularly, and with interruptions; several small cysts could be observed. All these findings were in the vicinity of the translucent area in the ramus. The dorsal portion of the gland filled normally (Fig. 1). Microscopic examination showed multiple gram-positive granulated and lnamhing thr(lads in the pus. DiGgnosis: Actinomycotic osteomyelitis of the left ramus and ac*tinomycosis of tlm parotid gland. TREATMENT
A sequestrotomy was performed, and antibiotics were given. The patient received a total of 7,800,OOO units of penicillin and 18 gr. of streptomycin. Histologic examination revealed numerous actinomycotic sulfur granules in the granulation tissues. The patient recovered and was dismissed after 4 weeks. When seen for followup examinations 3 and 10 months later, he was free of complaints. CASE
2
A 7%year-old A stomatologist
pensioner extracted
stated a third
that 5 weeks molar, which
earlier his right cheek had suddenly had not caused any pain and which
swelled. vvas not
Fig.
1.
Case
2. Irregular
rarity
diseased. Following the extracrion, wound WLS irrigated, and rrlwn Stomatology Department.
( arrow)
tlw
in eccondar~
actinornycotic
parotitis.
the swelling inrreawl an11 psiti set in. The extraction condition did not change the patient was sent to the
Examination
An extensive swelling of the right cheek was seen to cxtcnd as far as the ear, lifting the lobulus. The skin was brown-red in color. The swelling was stiff and not very sensitive to pressure. The lymph nodes were not palpable. The parotid papilla on the right side was indurated. There was no spontaneous secretion from the orifice of the duct, but after compression a little bit of saliva mixed with pus was discharged. A roentgenogram disclosed the presence of a third molar root in t,he alveolus; the surrounding bone was normal. A sialogram of the right, parotid gland showrd the entire gland to be filled; the filling was partly parenchymatous. In the anterior lower quadrant a cavity of irregular shape could b’e seen; t.he largest diameter of its shadow measured 8 mm. (Fig. 2). Extraction of the third molar root was followed by excochlcation of the granulations. When the extraoral incision was made, a system of small abscess cavities discharging pus with numerous yellow granules ww ap1~roachetl. Bacteriologic culture of the pus yielded a mixed flora. Microscopic examination rwealetl numerous gram-positive granulatetl and branching threads typical of actinomycosis. Histologic cxaminat,ion also revealed numerous actinomycot,ic~ granules. Biugsosis : CervicofaeisJ and right lrwotiil gland actinomycosis. Treatment
A total of 3,200,OOO units of penicillin, 19 gr. of streptomycin, and 1.35 gr. of neomycin were administered over a period of 36 days. In addition, the patient was given stimulation therapy and supporting treatment. At dismissal, the patient was cured of the disease. When seen for control examinations for up to 1 year, he was free of complaints. CASE
3 A
in the
22.year-old soldier was seen with a gradually increasing swelling of 3 weeks’ duration left parotideomasseteric region. He had been treated with compresses and analgesics.
Examination
The red and
mouth appeared normal indurated and discharged
except for a whitish
the orifice of the left Stensen’s duct, which turbid saliva with isolated yellow granules.
WV
Acfinovlycosis
with
Pig. 3. Cast actinomyeosis.
3. Sytcm
of irregular
cavities
in inferior
portion
of pnroticl
of parotid
glnnd
gland
201
affectctl
An excision biopsy at the site of the induration revealed chronic inflammation and isolat,ed actinomycotic threads. Examination of a smear of the yellow granules from the excreted fibrin, and many gram-positive actinomyeotic threads. saliva showed numerous leukocytes, A sialogram of the left parotid gland showed that Stensen’s duct was not changed. The filling of the gland was good, but in the anterior lower quadrant there was a system of middle-sized, irregularly shaped filling defects which extended as far as the lower and csternal margins of the gland (Fig. 3). Uiagnosis : Actinomycosis of the left parotid gland. Treatment
Treatment in the Stomatology Department lasted 42 days. The patient was given 11,350,OOO units of penicillin and irradiation totaling 520 r. At dismissal he was normal. Control examinations up to 12 months later showed that there had been no relapse. 4 The patient was a 34year-old foreman in a st,ovo-manufacturing plant. Twelve years earlier his left ear had been operated on twice. Five days before the patient’s admission to the Stomatology Department a welling had appeared in the left parotideomassetoric region and was increasing in size every day. The district practitioner recommended that the patient see a stomatologist, and the latter suggested admission to our department, CASE
Examination
On admission, the patient had no fever and the general condition was normal, but the erythrocytc sedimentation reaction was slightly accelerated (15 and 35 during 1 and 2 hours). A stiff induration was conspicuous in the left parotideomasseteric region, hut it did not cause great pain. In the mouth only the orifice of the left Strnscn’s duet was red and indurated ; purulently turbid saliva was discharged on compression. A sialogram showed that Lipiodol had penetrated the entire gland, the canals of which appeared delicate. In the periphery of the anterior upper quadrant there mere two irregular, rather extensive lobulated cavities; in lateral projection their outlines almost merged, but in anteroposterior projection they were distant from each other so that. one of them was situated deeper in the tissue (Fig. 4). In the pus obtained by puncture, numerous actinomycotic granules with typical bacteriologic findings were observed. Dia,gnosis : Actinomycosis of the left parotid gland.
U.S..
0.M.
B 0.1’.
F’rI)ru:trp,
Fig. 4. Case 4. I~rltc,ropo~t(,rior actinomycotic
focus,
afYel:ting
(ranin
pro,i(‘ct,ion of sialopram showing an11 central portion of glancl.
two
larger
1965
cavities
in
Treatment
Treatment, administration phenicol, and local instillations Following CASE
which lasted 51 days, inc~luded puncture and extraoral incisions for drainage, of a total of 4% gr. of Elkosin, 19.5 gr. of st,reptomycin, 9 gr. of chloramirradiation with 400 r. The antibiolics were applied both generally and by into the fistula and Stcnsm’s duct. dismissal, the patient was examined repeatedly and found to be in good health.
5
A
37-year-old laborer was first admitted to the Stomatology Department on Aug. 18, 1961. He stated that one year earlier a swelling had appeared about the left mandibular angle and that there had been a L’discharge of pus through the ear,” after which the eondition had improved. Two months before the present admission the swelling reappeared. The and the condition improved, but a week patient’s district practitioner prescribed penicillin, later the swelling recurred. Penicillin was again administered, and after 4 wrtks the patient was referred to our department. Examination
On admission, general examination findings were within normal limits except for the crythrocyte sedimentation reaction, which was 22 and 45 during 1 and 2 hours. On the left side, from the mandibular angle to the parotideomasseteric region, there was a stiff induration which caused moderate pain. The skin over the induration was normal. Opening of the mouth was limited. A diagnosis of actinomycosis of the parotid gland was made on the basis of clinical signs, sialograms, and the pathologist’s finding of actinomyeotic granules in the excochleated granulomatous tissues. Treatment
After surgical intervention, the patient was given, over a period of 67 240 gr. of PAS, and 6,100,OOO units of penicillin, 17 gr. of Aureomycin, 320 r. The penicillin was given both systemically and locally by instillations fistula. On surgical intervention, a small abscess cavity was found in the parotid yellow round corpuscles mere found in the pus as well as in the granulations. A portion of the Sialography through Stensen’s duct was not possible.
days, a total of irradiation with through the gland.
Numerous
gland
was
filled,
Volume Number
fiatula
dctinomycosis
19 2
B’i$+ 5. C!asr 5. A portion of gland In case of primary a.etinomycotic
however, cavities patient
through could be probably around a foreign
filled after parotitis.
instillation
of parotid gland
of
c*ontrast
oil
through
203
skin
the fistula which had developed in the cheek. Several orifices and irregular seen (Fig. 5). From the operative findings, it can be concluded that this had a primary form of actinomycosis of the parotid gland which developed body.
DISCUSSION
The study and treatment of these five patients with proved actinomycotic parotitis did not reveal any characteristic signs which would make it possible to diagnose this diseasewith greater accuracy. In addition to the common findings suggestive of actinomycosis, there are the reddening and induration of the pasotid papilla and the purulent turbidity of t.he saliva discharged from the parotid gland. Actinomycotic granules are found less commonly in the saliva than in pus discharged from a fistula. Clinica.lly, actinomycotic parotitis is not greatly different from the usual form of ccrvicofacial actinomycosis, but it. often lasts longer and is more refractory to t.reatment. Sialography always shows the typical picture of a focal descending affection of the gland with orifices compressed by an interstitial infiltrate and colliquation at. several spots. The pictturc differs from conditions seen in sialolithiasis. Our findings, therefore, did not confirm the opinion of HetzaF that sialoadenitis accompanying sialolithiasis is generally of actinomycotic origin, although Naeslund’s works concerning the importance of actinomyrotic threads for the development of sialolithiasis are well known to us. In sialolithiasis t,he clinical picture is different, and the disease can be easily controlled. The instillation of iodized contrast oil, such as Lipiodol, into the parot.id gland also has therapeutic value because of the direct introduction of iodine into the focus. Local instillation of antibiotics through the salivary duct also has beneficial effects.
204
SaSama.
CONCLUSION
Regular sialographic examination of ccrvicofacial forms 01’ ;rc.tillutll!-c,osis showed that t,he parotid gland was involved in 1I. I per cent oi’ casts. Ir~still;ltion of iodized oils in actinomycotic parotitis is useful for both diagnosis and therapy. The filling of the glanrl can bc achieved, in most cases, through Stenseen’sduct; in other cases the medium may 1~ injcctcd through ;I fistula. Thcb sialogram presents t~ypical signs of a descending affection of the gland. SUMMARY
Among forty-five patients treated for actinomycosis of the maxillofacial region in the Department of Stomatology at Hradec Kralovk, there were five cases of actinomycotic parot,itis. In one of these the disease was found to bc primary; in the others it was secondary. Characteristic signs of this disease are described. Sialographic roentgenologic examination should be tarried out, as it is of both diagnostic and therapeutic importance. REFERENCES
1. 2. 3. 4. :i. 6. 7. 8. 9. 10. 11. 12.
hutalovskb. 2.: Prakt. l@ka? 37: X56. 195i. Antalovski, Z.: LBka?skb zpr$y 2: 51, 19.57. Rwk, K.: Ztxchr. Hals-, IYawnu. Ohrenh. 2: 270, 1922. Bethmann, TV.: Tropenerfahm~l~ell in plastischer Gexichts untl Kieferchirurgie, 1960, VEB Verlag. Hetzar. WT.: Die Sialoaraphie, Leiuzin. 19J2. Geora Thieve. Chiari.‘O.: Wien. klin:‘W>hnschr. i5f’i562. i912. chir. i. Grekova 6: 64, 1962. Kabagov, B. Il., and Klementov, A. T.: i’ctnnik T,enormant. Ch.: Presae m&l. 21: 254. 1913. Lentze. F. ‘A.: Zentralbl. Bakt. 141: 51. 19X Rauch,‘R.: Die Speieheldriisen den Me&hen, Stuttgart, 1959, Georg Thieme. Sazama, L.: Cesk. stomatol. 60: 91, 1960. Siidcrlund, G. : I)rutwhc nwtl. \V~lrnschr. 39: 1632, 1913.
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