Cooking with actinomyces; would hippocrates have a bite?

doi:10.15406/joentr.2019.11.00409

Journal of

eISSN: 2379-6359

Otolaryngology-ENT Research

Opinion Volume 11 Issue 1

Cooking with actinomyces; would hippocrates have a bite?

Alexios Vardouniotis,

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Ioannis Papadakis, Emmanuel Fountoulakis, Eleftherios Margaritis, Kanela Karampela, Chrysoula Vasilokonstantaki

Athinaiki Clinic, Greece

Correspondence: Alexios Vardouniotis, ENT Consultant, Kyprou 1, Tripoli, Arkadia, Greece, Tel 0030 6937458227

Received: January 28, 2019 | Published: January 30, 2019

Citation: Vardouniotis A, Papadakis I, Fountoulakis E, et al. Cooking with Actinomyces; would Hippocrates have a bite? J Otolaryngol ENT Res. 2019;11(1):54. DOI: 10.15406/joentr.2019.11.00409

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Opinion

A case of a 46 year old male who presented to ENT outpatient clinics with intermittent complaints of sore throat, fever, painful deglutition and bilateral tonsillar enlargement. He gave a history of similar complaints on different occasions over the past one and half years, for which he was treated with antibiotics and analgesics by different local practitioners for the symptoms only for the symptoms to flare up again. On examination of the oropharynx he had bilateral enlargement of the palatine tonsils that were inflamed and showed surface exudate. General and systemic examinations were unremarkable and the patient was a smoker and occasional drinker.

Even though not fitting strictly into the current practice guidelines for tonsillectomy (the patient experienced less than 7 documented episodes in the last year),¹ he was referred to the hospital and bilateral tonsillectomy was performed. The specimen was sent for histopathological examination revealing actinomyces. The patient was maintained on a combination of a long course of intravenous and oral antibiotics and was responding well on follow up 4 months later.

The presence of actinomyces and its role in tonsillar hypertrophy and recurrent tonsillitis is debatable.² Recurrent acute tonsillitis may be due to microbial infections, foreign body or other artifacts. Actinomycosis can mimick oropharyngeal malignancies and hence if diagnosis is missed, appropriate treatment through surgical intervention is not instituted and patient care is hampered.

In cases of recurrent tonsillitis and tonsillar hypertrophy, tonsillectomy should be a choice and histopathological examination of the resected tissue is strongly advocated. Actinomyces are difficult to culture and the diagnostic pitfall is that the patient may be treated only for other pathogenic organisms which are more readily evident on culture. Microscopic examination may reveal actinomyces which may not be evident on culture.

Post surgical high-dose of intravenous penicillin followed by 3–6 months of oral penicillin is the current recommendation, even after complete resolution of symptoms to prevent recurrence.³ There were minor differences of opinions both in diagnostics and treatment, within our team, since studies have demonstrated that sending routine tonsil specimens following tonsillectomy operation for histopathological examination are not cost-effective. Histopathological examination however can accurately diagnose Actinomycosis, which compared to other infectious causes requires a long-term course of high-dose penicillins, even after surgery to prevent recurrence. From our point of view selected patients should definitely be treated surgically and biopsy should be more often included in the practice.

With the guidelines becoming day by day narrow sighted and at the end looking to become blindfolded –not only in ENT based conditions but in almost each and every medical aspect -the clinician must always seek what is best for the patient. Inflexible guidelines with rigid rules about what is appropriate are popular with managers, quality auditors, and lawyers but are decried as “cookbook medicine” by doctors faced with non-uniform clinical problems.⁴ At the very centre of the Hippocratic ideals are the principles of “doing no harm” and “absolute regard for life". Although many investigations and interventions have potential adverse effects and complications, it is the balance of potential benefit and harm of each intervention that is the most important consideration. What is best for patients overall, as recommended in guidelines, may be inappropriate for individuals; blanket recommendations, rather than a menu of options or recommendations for shared decision making, ignore patients' preferences reducing individualized care for patients that “decide” not to go with the flow. If overall benefits outweigh potential complications, this Hippocratic ideal is still respected, "feeding" therefore both the patients specific needs and the insatiable advancement of medicine in a financially demanding environment.