Differential Diagnosis of Membrane Over Tonsil
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🦠 Differential Diagnosis of Membrane Over Tonsil
A membrane over the tonsil refers to the presence of a whitish, greyish or yellowish coating over the tonsillar surface, which may be a true membrane or a pseudomembrane.
It may occur due to:
- Infection
- Necrosis
- Infiltrative disease
📋 Classification of Causes of Membrane Over Tonsil
1- Infectious Causes
Bacterial
- Acute membranous tonsillitis
- Diphtheria
- Vincent's angina
Viral
- Infectious mononucleosis
Fungal
- Candidal infection
2- Non-Infectious Causes
Ulcers
- Traumatic ulcer
- Aphthous ulcer
Malignancy
- Malignancy of the tonsil
- Leukemia
- Agranulocytosis
💡 Mnemonic - DAMN TV CALM
| Letter | Cause |
|---|---|
| D | Diphtheria |
| A | Agranulocytosis |
| M | Mononucleosis (Infectious mononucleosis) |
| N | Neoplasm (Malignancy of tonsil) |
| T | Tonsillitis (Acute membranous tonsillitis) |
| V | Vincent's angina |
| C | Candidal infection |
| A | Aphthous ulcer |
| L | Leukemia |
| M | Mechanical (Traumatic ulcer) |
1- Acute Membranous Tonsillitis
⭐ One of the most common causes.
What is the Pathogenesis of Acute Membranous Tonsillitis?
Causative Organism
Mostly pyogenic organisms.
👉 Group A Beta Hemolytic Streptococcus (Most common)
Features
- Exudative membrane over the medial surface of the tonsil
- Easily removed, does not bleed
- Features of acute tonsillitis - sore throat, fever, dysphagia
What are the types of Acute Tonsillitis?
2- Diphtheria
Causative Organism
👉 Corynebacterium diphtheriae
Features
- Slower onset
- Less local discomfort
- Thick, dirty grey membrane over the tonsil, may extend beyond the tonsil to the soft palate
- True membrane — firmly adherent, leaves a bleeding raw surface on removal
- Bull neck appearance
What is the reason behind bull neck appearance in Diphtheria?
Investigations
- Throat swab and culture → Corynebacterium diphtheriae
- Urine test → Albumin
What are the differences between True Membrane vs Pseudomembrane?
3- Vincent's Angina
🔍 What is it?
An acute necrotizing infection of the pharynx.
What is the Causative Organisms in Vincent's Angina?
Features
- Insidious onset
- Fever is less common
- Less discomfort in the throat
- Foul breath
- Membrane usually over one tonsil only (unilateral)
- Pseudomembrane - easily removed, revealing an irregular ulcer over the tonsil
Investigations
- Throat swab → Fusiform bacilli and spirochaetes
4- Infectious Mononucleosis
Causative Organism
👉 Epstein-Barr Virus
Most commonly affects young adults.
Features
- Both tonsils enlarged, congested and covered with a membrane
- Marked local discomfort
- Lymph node enlargement in the posterior triangle of the neck
- Splenomegaly
- ⭐ Failure of antibiotic treatment
What is the other name for Infectious Mononucleosis?
What are the investigations done to diagnose Infectious Mononucleosis?
5- Candidiasis
Causative Organism
👉 Candida albicans
Features
- White curdy patches or plaques all over the mouth
- On removal, leave a red raw surface without bleeding
- ⭐ Mainly seen in immunocompromised patients
6- Traumatic Ulcer
Causes of Trauma
- Toothbrush injury
- Pencil injury
- Tooth bite
- Fish bone
- Very hot food
Features
- ⭐ History of trauma present
- Membrane appears within 24 hours of the trauma
- Slough comes off, revealing a raw ulcer base
7- Aphthous Ulcer
Features
- Round or oval ulcer with an erythematous base
- Recurrent
- May involve any part of the oral cavity or oropharynx, including the tonsil and pillars
- May be single or multiple
- May be of any size
- ⭐ Very painful
8- Malignancy of Tonsil
Risk Factors
- Tobacco smoking
- Alcohol
- Exposure to Human Papillomavirus (HPV)
Features
- ⭐ Unilateral tonsillar enlargement (bilateral involvement is very rare)
- Ulcer with an indurated base, which bleeds on touch
- Hard palpable cervical lymph nodes
- Referred pain in the ear
- Persistent sore throat
- Difficulty in swallowing
9- Leukemia
A hematological malignancy.
Types
| Age Group | Distribution |
|---|---|
| Children | 75% acute lymphoblastic; 25% acute myelogenous or chronic leukemia |
| Adults | 20% lymphocytic; 80% non-lymphocytic |
Features
- Membrane formed by necrotic slough over the tonsil
- Bleeding gums
- Anemia
- Hepatosplenomegaly
Investigations
- Total count → More than 1 lakh/mm³; may also be normal or below normal
- History of progressive anemia
- Bone marrow examination → Presence of blast cells
10- Agranulocytosis
Features
- Ulcerative necrotic lesions on the tonsils and elsewhere in the oropharynx
- Patient is severely ill
Investigations
| Form | Findings |
|---|---|
| Acute fulminant | Total count below 2000, may be as low as 50; polymorphonuclear neutrophils reduced to 5% or less |
| Chronic / Recurrent | Total count below 2000, with less marked granulocytopenia |
What is Agranulocytosis?
Discuss about approach to a case of membrane over tonsil.
🧠 Viva Pearls
- Acute membranous tonsillitis is the next stage of acute follicular tonsillitis.
- Diphtheria shows a thick, dirty grey membrane and a bull neck appearance.
- Vincent's angina is an acute necrotizing infection of the pharynx, with a unilateral membrane.
- Infectious mononucleosis is caused by the Epstein-Barr virus.
- Infectious mononucleosis shows posterior triangle lymphadenopathy, splenomegaly and failure of antibiotic treatment.
- Paul Bunnell test shows high titres of heterophile antibody in infectious mononucleosis.
- Candidiasis is mainly seen in immunocompromised patients.
- In traumatic ulcer, the membrane appears within 24 hours of the trauma.
- Malignancy of the tonsil shows unilateral enlargement with an indurated ulcer that bleeds on touch.
- Bone marrow examination in leukemia shows blast cells.
- Agranulocytosis shows severe leukopenia, mainly affecting the neutrophils.
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