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OMFS-0141InfectionadvancedSubmandibular region

Chronic submandibular swelling with sulphur granules

44-year-old male

Draft — educational study aid, pending faculty review.

§Chief complaint

Firm lump under the jaw discharging yellow granules for 3 months

§Medical & dental history

  • 01No immunosuppression
  • 02Poor oral hygiene, heavy smoker
  • 03Extraction of 38 four months ago with delayed healing

§Clinical examination

  • 01Indurated, board-like swelling of the left submandibular region with multiple discharging sinuses
  • 02Yellow granular material expressed from a sinus tract
  • 03Skin bluish and tethered; minimal tenderness
  • 04No fever; previous partial response to short antibiotic courses

§ figuresFigures (2)

Fig. 1Actinomycosis Colony of Actinomyces within an abscess. A Gram stain is needed to see the filamentous organisms. Large colonies of Actinomyces can appear macroscopically as yellow granules whch have been termed "sulfur gr

“Actinomycosis 2” · Yale Rosen · CC BY-SA 2.0 · Wikimedia Commons

Fig. 2Colony of Actinomyces within an abscess. A Gram stain is needed to see the filamentous organisms. Large colonies of Actinomyces can appear macroscopically as yellow granules whch have been termed "sulfur granules". The d

“Actinomycosis (5287905500)” · Yale Rosen from USA · CC BY-SA 2.0 · Wikimedia Commons

Verified open-access images only, reproduced for education under their stated licences · no AI-generated or illustrative artwork · Cervicofacial Actinomycosis figures pending faculty review.

§Differential diagnosis

Cervicofacial actinomycosisChronic indurated mass, multiple sinuses, sulphur granules
Tuberculous lymphadenitisMatted nodes, cold abscess, systemic symptoms
Osteomyelitis with cutaneous fistulaBone involvement with sequestra
Metastatic carcinomaHard fixed node, primary elsewhere

§Final diagnosis

Cervicofacial actinomycosis following third molar extraction

A woody, indurated swelling that crosses tissue planes and discharges through multiple sinuses containing sulphur granules, with only partial response to short antibiotic courses, is characteristic. Anaerobic culture and histology showing filamentous colonies confirm it.

§Investigations

  • 01Pus and granule specimen for anaerobic culture (transported promptly) — Actinomyces israelii isolated
  • 02Histology of a sinus tract biopsy — filamentous colonies with Splendore-Hoeppli phenomenon
  • 03CT — soft tissue mass with tissue plane involvement; assess for bone involvement
  • 04Exclude tuberculosis and malignancy

§Treatment plan

  • 01Prolonged high-dose antibiotics: IV penicillin for 2-6 weeks then oral amoxicillin for 6-12 months
  • 02Surgical debridement, excision of sinus tracts and drainage of collections
  • 03Remove the odontogenic source and improve oral hygiene
  • 04Regular clinical review to confirm resolution

§Surgical procedure

  • 01Excision of sinus tracts and debridement of necrotic tissue
  • 02Curettage of the 38 socket region

§Histopathology report

Chronic granulomatous inflammation containing basophilic filamentous bacterial colonies surrounded by eosinophilic clubbed material (Splendore-Hoeppli phenomenon) and neutrophils. Actinomycosis.

§Follow-up & outcome

  • 01Sinuses closed by 8 weeks
  • 02Oral antibiotics continued for 9 months in total
  • 03No recurrence at 2 years

§Clinical pearls / learning points

  • 01Actinomycosis is treated in months, not days — short courses cause relapse.
  • 02It spreads across tissue planes and ignores lymphatic boundaries, unlike malignancy.
  • 03Send pus for anaerobic culture promptly; the organism is difficult to grow.

§References

  • Wong VK et al. Actinomycosis. BMJ 2011.

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