This is the most common form of actinomycosis (1). The infection is generally odontogenic in origin, and evolves as a chronic or subacute painless or painful soft-tissue swelling or mass involving the submandibular or paramandibular region. However, the submental and retromandibular spaces, tempomandibullar joint and cheek can be involved. The swelling may have ligneous consistency caused by tissue fibrosis. Depending on the composition of the concomitant synergistic flora, the onset of actinomycosis may be acute, subacute, or chronic. When Staphylococcus aureus or beta-hemolytic streptococci are involved, an acute painful abscess or a phlegmatous cellulitis may be the initial manifestation. The chronic form of the disease is characterized by painless infiltration and induration that usually progress to form multiple abscesses and draining sinus tracts discharging pus that may contain sulfur granules in up to 25% of instances. Periapical infection, trismus, fever, pain, and leukocytosis may be present. The infection can extend to the carotid artery, tongue, sinuses, ears, mastoid, orbit, salivary glands, pharynx, masseter muscle, thyroid, larynx, trachea, or thorax (3). Bone (most commonly the mandible) may be invaded from the adjacent soft tissue leading to periostitis or osteomyelitis. Cervical spine or cranial bone infection may lead to subdural empyema and invasion of the CNS. The differential diagnosis includes tuberculosis (scrofula), fungal infections, nocardiosis, suppurative infections by other organisms, and neoplasm.
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