White patch on the tonsil – differential diagnosis

WHITE PATCH ON THE TONSIL
– DIFFERENTIAL DIAGNOSIS

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

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.

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.

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

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

Membranous tonsillitis
o 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.
o 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.

Diphtheria
o Diphtheria is
an infection caused by
the bacterium Corynebacteri
um diphtheriae.
o 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

Vincent’s Angina
o 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 )
o 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.

Infectious mononucleosis
o Infectious
mononucleosis (IM), also
known as glandular
fever, is an infection
commonly caused by
the Epstein–Barr
virus (EBV)
o 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

Agranulocytosis
o 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.
o It presents with ulcerative necrotic
lesions not only on the tonsils but
elsewhere in the oropharynx. Patient is
severely ill.

Leukaemia
o Leukemia, s a group of cancers that usually begin
in the bone marrow and result in high numbers of
abnormal white blood cells
o 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.
o 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.

Aphthous ulcers
o 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.
o Sometimes, it is solitary
and may involve the
tonsils and pillars. It may
be small or quite large
and may be alarming.

Malignancy tonsil
o The tonsil is the most common
site of squamous cell carcinoma
in the oropharynx.
o 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).[
o 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

Traumatic ulcer
o 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.
o Membrane appears

Candidal infection
of tonsil
Blastomycosis
Scarlet fever
Lichen planus

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)

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).

White patch on the tonsil – differential diagnosis

White patch on the tonsil – differential diagnosis

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White patch on the tonsil – differential diagnosis