CASE REPORT Actinomycosis Hard Palate: A Rare Presentation Vijeyta Dahiya 1 , Binu Raju George 2 , Kizhakkethil Ramachandran 3 , Shamej Peter 4 A BSTRACT Actinomycosis is a gradually evolving infection caused by bacteria of genus Actinomyces. Cervicofacial involvement is the most common presentation and palatal involvement is very rare. Presented below is the case report of a 79-year-old diabetic and hypertensive female who presented with nonhealing ulcer over the hard palate for 10 months, which enlarged and formed a large oroantral fstula within 4 months. Following the diagnosis of actinomycosis by histology, complete debridement and removal of necrotic tissue was done. She was treated with intravenous crystalline penicillin 6th hourly for 4 weeks and was discharged on oral amoxicillin for 12 months with regular follow-up. Only four cases of actinomycosis hard palate have been reported in English literature so far. Keywords: Actinomycosis, Hard palate, Oroantral fstula. Otorhinolaryngology Clinics: An International Journal (2019): 10.5005/jp-journals-10003-1334 I NTRODUCTION Actinomycosis is a rare infection caused by saprophytes of the genus Actinomyces, which are anaerobic or microaerophilic and nonacid fast. 1 The name was coined by Harz meaning the ray-like appearance of organism in the granules that characterize the lesion. Actinomycosis is a chronic granulomatous infection characterized by development of indurated swellings, mainly in connective tissue, suppuration, and discharge of “sulfur granules.” 2 Actinomyces israelli is the most common causative agent. In humans, it occurs in four main forms: cervicofacial, thoracic, abdominal, and pelvic. Cervicofacial mainly involves the cheek. Involvement of the hard palate is rare. Presenting below is a case report of actinomycosis involving the hard palate. C ASE D ESCRIPTION A 79-year-old female presented with ulceration of the hard palate of 10 months’ duration. For 6 months, there was nasal regurgitation and fstula at the site, which was gradually increasing in size (Fig. 1). There was no episode of bleeding from the ulcer. She was diabetic and hypertensive for 20 years on medications. She also gave history of carcinoma of breast detected 1½ years back treated with wide excision under general anesthesia with postoperative renal failure needing dialysis. The biopsy report came out to be an invasive papillary carcinoma. The patient has been on follow-up since then and there had been no recurrence so far. She also had history of extensive oropharyngeal and esophageal candidiasis 1 year back, which subsided with medications. On examination of the oral cavity, there was a large 2 × 2 cm ulcer with bone erosion involving anterior half of midline of the hard palate more on the right side with oroantral and oronasal communications. It was covered with slough at the edges and blackish necrotic tissue was present in the surrounding areas (Fig. 1). Dental caries was present and orodental hygiene was poor. Rest of the examination did not reveal any signifcant fndings. Orthopantamogram was taken, which revealed bone erosions involving the hard palate (Fig. 2). Contrast-enhanced CT paranasal sinuses (Figs 3 and 4) including maxillae and palate showed extensive bone erosion and destruction of the hard palate, inferior and inferolateral walls of both maxillary sinuses, adjacent margins of upper alveolus, and anteroinferior margin of the right pterygoid bone reaching up to the left posterior ethmoid sinus and margins of sphenoid sinus. Blood investigations were normal except for ESR, which was 50 mm/hour. Her blood sugar was controlled and renal parameters were normal. Incision biopsy was taken from the lesion, which confrmed the diagnosis of actinomycosis. It showed the presence of sulfur granules with basophilic center surrounded by neutrophils (Fig. 5). Thereafter, the lesion was curetted all around with removal of 1–4 Department of ENT, Government Medical College, Kozhikode, Kerala, India Corresponding Author: Vijeyta Dahiya, Department of ENT, Government Medical College, Kozhikode, Kerala, India, Phone: +917293206954, e-mail: dr.vijeyta@gmail.com How to cite this article: Dahiya V, George BR, Ramachandran K, et al. Actinomycosis Hard Palate: A Rare Presentation. Int J Otorhinolaryngol Clin 2019;11(3):73–75. Source of support: Nil Confict of interest: None © Jaypee Brothers Medical Publishers. 2019 Open Access This article is distributed under the terms of the Creative Commons Attribution 4.0 International License (https://creativecommons.org/licenses/by-nc/4.0/), which permits unrestricted use, distribution, and non-commercial reproduction in any medium, provided you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons license, and indicate if changes were made. The Creative Commons Public Domain Dedication waiver (http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated. Fig. 1: Erosion of hard palate and oroantral fstula