White Patch On Tonsil: Differential Diagnosis

1. Membranous tonsillitis: 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.
2. Diphtheria: 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 diphtheriae.
3. Vincent’s angina: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.
4. Infectious mononucleosis: 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. Attention to the disease is attracted because of the failure of antibiotic treatment. Blood smear may show more than 50% lymphocytes, of which about 10% are atypical. WBC count may be normal in the first week but rises in the second week. Paul-Bunnell test will show high titre of heterophil antibody.
5. Agranulocytosis: it presents with ulcerative necrotic lesions not only on the tonsils but elsewhere in the oropharynx. Patient is severely ill. In acute fulminant form, TLC is reduced to <2000 per cu. mm. or even as low as 50 per cu. mm and PMNs may be reduced to 5% or even less. In chronic or recurrent form, TLC is reduced to 2000 per cu. mm with less marked granulocytopenia.
6. Leukaemia: 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.
7. Aphthous ulcers: They may involve any part of oral cavity or oropharynx. Sometimes, it is solitary and may involve the tonsils and pillars. It may be small or quite large and may be alarming.
8. Malignancy tonsil: 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.
9. Traumatic ulcer: Any injury to oropharynx heals by membrane formation. Trauma to the tonsil area may occur accidentally when hit with a tooth brush, a pencil held in the mouth or fingering in the throat. Membrane appears within 24 hours.
10. Candidal infection of tonsil.

Diagnosis of ulcero-membranous lesion of throat requires:

1. History
2. Physical examination
3. Total and differential counts (for agranulocytosis, leukemia and infectious mononucleosis)
4. Blood smear (for atypical cells)
5. Throat swab and culture (for pyogenic bacteria, Vincent’s angina and candidal infection)
6. Bone marrow aspiration or needle biopsy
7. Other tests:

• Paul Bunnell or mono spot test(for infectious mononucleosis)
• biopsy of the lesion(for carcinoma tonsil).