--- title: "Differential Diagnosis of Membrane Over Tonsil" description: "ENT notes on the differential diagnosis of membrane over tonsil." source: "The ENT Resident" author: "Dr. Mausumi Das" canonical_url: "https://www.theentresident.com/ent-notes-lectures/differential-diagnosis-membrane-over-tonsil" categories: ["Pharynx"] video: "https://www.youtube.com/watch?v=8DpzQdWYkuY" image: "https://media.theentresident.com/og-images/differential-diagnosis-membrane-over-tonsil.png" --- # Differential Diagnosis of Membrane Over Tonsil ENT notes on the differential diagnosis of membrane over tonsil. Watch the full video lecture on YouTube: https://www.youtube.com/watch?v=8DpzQdWYkuY ## 🦠 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** | **D**iphtheria | | **A** | **A**granulocytosis | | **M** | **M**ononucleosis (Infectious mononucleosis) | | **N** | **N**eoplasm (Malignancy of tonsil) | | **T** | **T**onsillitis (Acute membranous tonsillitis) | | **V** | **V**incent's angina | | **C** | **C**andidal infection | | **A** | **A**phthous ulcer | | **L** | **L**eukemia | | **M** | **M**echanical (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. --- ## About This Note This free ENT note on Differential Diagnosis of Membrane Over Tonsil was written by Dr. Mausumi Das and is paired with a corresponding video lecture. 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