GARG,ONLINE EXCLUSIVE
SCHALCH, PEPPER, NGUYEN
Osteomyelitis of the hard palate
secondary to actinomycosis:
A case report
Rohit Garg, MD; Paul Schalch, MD; Jon-Paul Pepper, MD; Quoc A. Nguyen, MD
Abstract
Osteomyelitis of the hard palate is a rare and difficult-to-
eradicate sequela of actinomycosis. In this case report, we
illustrate the necessity of aggressive surgical management of
actinomycotic infection of the hard palate. The patient was
initially treated with multiple local debridements supple-
mented with oral and then parenteral antibiotics, but his
disease progressively worsened. His condition eventually
resolved only after a partial palatectomy was performed
to remove all the necrotic bone, followed by a prolonged
course of intravenous and oral antibiotic treatment.
Introduction
Despite the universal presence of Actinomyces species
in the oral cavity,1 which commonly manifests as a cer-
vicofacial actinomycotic infection,2 very few cases of
actinomycosis of the hard palate have been described in
the literature. In this article, we present a case of advanced
disease, and we review the diagnostic and therapeutic
management of palatal actinomycosis.
Case report
A 49-year-old man with a history of maxillary dental
extractions presented to an oral surgeon with postopera-
tive pain and bleeding, a foul-smelling oral discharge, and
swelling of the right side of his face and jaw. A radiologic
From the Department of Otolaryngology–Head and Neck Surgery, Uni-
versity of California Irvine Medical Center, Orange, Calif.
Corresponding author: Rohit Garg, MD, Department of Otolaryngology–
Head and Neck Surgery, University of California Irvine Medical
Center, 101 The City Drive South, Bldg. 56, Room 500, Orange, CA
92868-3201. E-mail: rgarg@uci.edu
Previous presentation: The information in this article has been updated
from its original presentation as a poster at the Western Section
Meeting of the Triological Society; Jan. 31-Feb. 2, 2003; Indian
Wells, Calif.
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examination detected a soft-tissue density in the right
maxillary sinus and a partial bony erosion of the hard
palate. The patient was referred to an otolaryngologist,
who performed an endoscopic maxillary antrostomy,
a partial ethmoidectomy, and limited debridement
of the involved palate. Pathologic examination at that
time revealed the presence of Actinomyces israelii in the
resected specimen. However, the patient’s symptoms
did not improve, and he eventually underwent multiple
in-office oral debridements in addition to intravenous
penicillin therapy. When his condition still failed to
resolve after 1 month of parenteral antibiotic therapy,
he was referred to our ENT Department.
Examination at our institution revealed a 4 × 3-cm area
of exposed necrotic right palatal bone (figure). In view
of the osteomyelitis, we performed a partial palatectomy
with wide local debridement until healthy bleeding bone
was encountered. The palatal defect was reconstructed
with a fashioned obturator. Postoperatively, the patient
was prescribed 4 months of parenteral penicillin therapy
followed by 2 months of oral penicillin as recommended
by the consulting infectious disease service. The patient
remained free of disease during more than 4 years of
follow-up before he died of renal disease.
Discussion
The natural history of actinomycosis follows a progressive
course, starting with an acute localized inflammation and
moving to a chronic phase that is characterized by the
formation of granulomatous suppurative abscesses with
draining sinuses.3,4 Actinomyces are non-spore–forming
gram-positive rods that are either strict or facultative
anaerobes. The infection can spread in any direction,
as it does not necessarily follow lymphatic drainage
patterns or fascial planes.3 In the head and neck region,
actinomycosis most commonly involves the mandible,
presenting as either a chronic soft-tissue swelling, an
ENT-Ear, Nose & Throat Journal ■ March 2011
 OSTEOMYELITIS OF THE HARD PALATE SECONDARY TO ACTINOMYCOSIS: A CASE REPORT
Figure. Preoperative photograph shows the extent of exposed ne-
crotic palatal bone.
abscess, or a mass near the angle of the mandible. In
many cases, these infections are believed to arise from
odontogenic sources via intraosseous extension or at
recent surgery sites.2
An accurate diagnosis is notoriously difficult to make.
The diagnosis is generally based on either (1) the pres-
ence of an isolated bacterium in culture or in a histologic
preparation or (2) the presence of sulfur granules in
the tissue aspirate. In our case, the diagnosis was made
histologically, as both Actinomyces species and sulfur
granules were found in the resected material.
Radiologic findings are generally nonspecific for soft-
tissue disease. When the palate or maxilla is involved,
radiologic (computed tomography or plain film) find-
ings range from a minor subperiosteal reaction to lytic
destruction, often without osteogenesis.4
The therapeutic approach to actinomycotic infection
has remained essentially unchanged over the past several
decades.4-7 Depending on the severity of the disease, the
standard initial treatment for acute cervicofacial actino-
mycosis is parenteral antibiotics. The drug of choice is
penicillin G, although the organism is susceptible to a
variety of other antibiotics. High-dose (2 to 20 million
U/day) intravenous therapy for weeks to months is often
followed by oral penicillin V for as long as 6 weeks after
the lesion has resolved.3,4,7 Erythromycin and tetracycline
are useful alternatives in penicillin-allergic patients.8
The response to treatment is usually excellent when
the disease is confined to the soft tissue and when it is
treated before dense fibrous capsules and sinus tracts
form or osteomyelitis develops.1,3 When the disease has
advanced to these later stages, surgical intervention is
required for a complete resolution.
Surgical options include incision and drainage, exci-
Volume 90, Number 3
sion and curettage of devitalized bony sequestra, and
wide local debridement.1,2,4,5 When osseous tissue is
involved, the first operation needs to be definitive. This
is especially true when the infection affects the hard
palate; given the minimal soft tissue in this location,
actinomycotic infection here will almost invariably
infiltrate the underlying bone. When surgery is limited
to sequestrectomies, a high incidence of local recur-
rence has been reported.4 Aggressive debridement to
healthy bleeding bone is always required. When a bed
of healthy, well-vascularized bone is present, antibiotics
can penetrate adequately to control the infection. When
managed appropriately with intravenous antibiotics
and surgical therapy, actinomycosis can be cured in
nearly 90% of cases.9
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