White patch on the tonsil – differential diagnosis

white patch?

1. WHITE PATCH ON THE TONSIL – DIFFERENTIAL DIAGNOSIS

2. ANATOMY OF THE PALATINE TONSILS Occupies the tonsillar sinus or fossa between the palatoglossal and the palatopharyngeal arches. Two surfaces: medial and lateral Two borders: anterior and posterior Two poles: upper and lower

3. Anatomy contd.... Anterior border: Palatoglossal arch Posterior border: Palatolpharyngeal arch Plica triangularis : Vestigial fold of mucous membrane covering the anteroinferior part of the tonsil. Plica semilunaris : semilunar fold that may cross the upper part of the tonsil. Intratonsillar cleft: Largest crypt of the tonsil.

4. Arterial Supply of Tonsil

5. Histology Oral aspect is covered by stratified non keratinized epithelium which dips into the underlying tissue to form crypts. The lymphocytes lie on the sides of the crypt in the form of nodules.

6. Development

7. Functions of the Tonsil Act as sentinels to guard against foreign intruders. Two mechanisms: Providing local immunity. Providing a surveillance mechanism so that the entire body is prepared for defence .

8. WHITE PATCH ON THE TONSIL Membranous tonsillitis Diphtheria Vincent’s angina Infectious mononucleosis Agranulocytosis Leukemia Aphthous ulcer Malignancy tonsil Traumatic ulcer Candidal infection of tonsil

9. Membranous tonsillitis Acute membranous tonsillitis. It is a stage ahead of acute follicular tonsillitis when exudation from the crypts coalesces to form a membrane on the surface of tonsil.   It occurs due to pyogenic organisms. An exudative membrane forms over the medial surface of the tonsils, along with the features of acute tonsillitis, like red and swollen tonsils with marked hyperaemia of the pillars, uvula and soft palate.

10. Diphtheria Diphtheria is an  infection  caused by the  bacterium   Corynebacterium diphtheriae .   Unlike acute tonsillitis which is abrupt in onset, diphtheria is slower in onset with less local discomfort. the membrane in diphtheria extends beyond the tonsils, on to the soft palate and is dirty grey in colour . It is adherent and its removal reveals a bleeding surface. Urine may show albumin. Smear and culture of throat swab will reveal Corynebacterium diphtherium .

11. Vincent’s Angina Vincent's Angina is an acute necrotizing infection of the pharynx caused by a combination of fusiform bacilli ( Fusiformis fusiformis - a Gram - ve bacillus) and spirochetes ( Borrelia vincentii ) It is insidious in onset with less fever and less discomfort in throat. Membrane, which usually forms over one tonsil, can be asily removed, revealing an irregular ulcer on the tonsil. Throat swab will show both the organisms typical of the disease, namely fusiform bacilli and spirochaetes .

12. Infectious mononucleosis Infectious mononucleosis (IM), also known as  glandular fever, is an infection commonly caused by the  Epstein–Barr virus  (EBV)  This often attacks young adults. Both tonsils are very much enlarged, congested and covered with membrane. Local discomfort is marked. Lymph nodes are enlarged in the posterior triangle of the neck along with splenomegaly . Blood smear may show more than 50% lymphocytes, of which about 10% are atypical. Paul- Bunnell test will show high titre of heterophil antibody.

13. Agranulocytosis Agranulocytosis , also known as agranulosis or granulopenia , is an acute condition involving a severe and dangerous leukopenia (lowered white blood cell count), most commonly of neutrophils causing a neutropenia in the circulating blood. It is a severe lack of one major class of infection-fighting white blood cells.  It presents with ulcerative necrotic lesions not only on the tonsils but elsewhere in the oropharynx . Patient is severely ill.

14. Leukaemia Leukemia, s a group of  cancers  that usually begin in the  bone marrow  and result in high numbers of abnormal  white blood cells Because leukemia prevents the immune system from working normally, some patients experience frequent  infection , ranging from infected  tonsils ,  sores in the mouth , or  diarrhea  to life-threatening  pneumonia  or  opportunistic infections .  In children, 75% of the leukaemias are acute lymphoblastic and 25% acute myelogenous or chronic, while in adults, only 20 % of the leukaemias are lymphocytic and the remaining 80% non-lymphocytic. Peripheral blood shows TLC>100,000 per cu. mm. It may be normal or less than normal. Anaemia is always present and may be progressive. Blast cells are seen on examination of the bone marrow.

15. Aphthous ulcers   Aphthous ulcers are typically recurrent round or oval sores or ulcers inside the mouth on areas where the skin is not tightly bound to the underlying bone, such as on the inside of the lips and cheeks or underneath the tongue. Sometimes, it is solitary and may involve the tonsils and pillars. It may be small or quite large and may be alarming.

16. Malignancy tonsil The tonsil is the most common site of squamous cell carcinoma in the  oropharynx . Main risk factors of developing carcinoma tonsil include tobacco smoking and regular intake of high amount of alcohol. It has also been linked to a virus called Human Papilloma Virus (HPV type HPV16). [   Persistent sore throat, difficulty in swallowing, pain in the ear or lump in the neck are the presenting symptoms. Palpation of tonsillar area is done to determine the extent of the tumour . Biopsy confirms the diagnosis.

17. Traumatic ulcer Traumatic injuries involving the oral cavity may typically lead to the formation of surface ulcerations. The injuries may result from events such as accidentally biting oneself while talking, sleeping, or secondary to mastication. Other forms of mechanical trauma, as well as  chemical ,  electrical , or  thermal  insults, may also be involved.  Membrane appears within 24 hours.

18. Candidal infection of tonsil Blastomycosis Scarlet fever Lichen planus

19. Diagnosis of ulcero -membranous lesion of throat requires: History Physical examination Total and differential counts (for agranulocytosis , leukemia and infectious mononucleosis) Blood smear (for atypical cells)

20. Throat swab and culture (for pyogenic bacteria, Vincent’s angina and candidal infection) Bone marrow aspiration or needle biopsy Other tests: Paul Bunnell or mono spot test(for infectious mononucleosis) Biopsy of the lesion(for carcinoma tonsil).