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| ORIGINAL ARTICLE |
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| Year : 2017 | Volume
: 19
| Issue : 2 | Page : 37-42 |
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Histopathological criteria for recurrent, (chronic) tonsillitis. Clinical and pathological correlation
Wael Abdelkafy1, Amr Soliman2, Nehal Khamis3, Diaa El Hennawi4
1 Lecturer, Otolaryngology Department, College of Medicine, Suez Canal University, Egypt Consultant ENT Surgeon Erfan & Bagedo General Hospital, Jeddah, Saudi Arabia
2 ENT Specialist Suez Canal Authority Hospital, Egypt
3 Medical Education, Department College of Medicine, King Saud University, Riyadh, Saudi Arabia
4 Professor, Otolaryngology Department, College of Medicine, Suez Canal University, Egypt
| Date of Web Publication | 7-Jan-2020 |
Correspondence Address:
Wael Abdelkafy
Department of ENT, Erfan Bagedo General Hospital, Jeddah
Saudi Arabia
 Source of Support: None, Conflict of Interest: None
DOI: 10.4103/1319-8491.275313
Introduction: Recurrent tonsillitis is diagnosed when an individual has 7 episodes of tonsillitis in 1 year, 5 episodes in 2 consecutive years, or 3 episodes each year for 3 years consecutively. Chronic tonsillitis is a poorly understood definition and the difference between chronic and recurrent tonsillitis is not well known.
Materials and Methods: This is a prospective study aimed at finding the correlation between the diagnostic histopathological criteria in cases with recurrent tonsillitis with laboratory findings. This was carried out in the Otorhinolaryngology Departments of Suez Canal University and Ismailia General Hospitals and the Pathology laboratory, Suez Canal University Hospital, Egypt. The study included 175 patients sampled from those patients attending the E.N.T outpatient clinic. There were 69 females and 106 males. The patient’s age ranged between 4-12 years old.
Results: Histopathological examination of removed tonsils revealed that all samples studied had small to moderate lymphocytic infiltration. Diffuse lymphocytic infiltration was observed in 78.3%. Ugras abscess was found in 52.6%. Half of the patients (50.9%) had 2 histopathological findings and 40% had 3 findings while only 9.1% had one finding.Ugras abscess was more common among patients with elevated ESR. Most of patients with normal ESR were found to have only 2 histopathological findings (67.6%) while 44.7% of patients with elevated ESR were found to have three of the histopathological findings of chronic tonsillitis. Ugras abscess were more common among patients with elevated ASOT (62.2% versus 35.9% in patients with normal ASOT). Total number of histopathodlogical findings of chronic tonsillitis was not significantly different between patients with normal ASOT and elevated ASOT.
Conclusion: Recurrent tonsillitis is a clinical criterion and different from chronic tonsillitis which is a pathological diagnosis. Chronic tonsillitis is found in tonsils with fewer recurrence rate. Combined clinical and laboratory criteria increase the likelihood for the diagnosis of chronic tonsillitis.
Keywords: Chronic tonsillitis, recurrent tonsillitis, histopatholocal criteria
How to cite this article:
Abdelkafy W, Soliman A, Khamis N, El Hennawi D. Histopathological criteria for recurrent, (chronic) tonsillitis. Clinical and pathological correlation. Saudi J Otorhinolaryngol Head Neck Surg 2017;19:37-42 |
How to cite this URL:
Abdelkafy W, Soliman A, Khamis N, El Hennawi D. Histopathological criteria for recurrent, (chronic) tonsillitis. Clinical and pathological correlation. Saudi J Otorhinolaryngol Head Neck Surg [serial online] 2017 [cited 2023 Mar 27];19:37-42. Available from: https://www.sjohns.org/text.asp?2017/19/2/37/275313 |
| Introduction | |  |
Tonsillar diseases are among the most common health- related problems in the general population. Surgical removal is frequently done, which is still the most frequently performed surgical procedure in children and young adults [1].
Recurrent tonsillitis is a disease with relapsing and remitting acute attacks or a subclinicl form of a resistant infection, a poorly treated kind [2]. Chronic tonsillitis is a poorly understood definition and the difference between chronic and recurrent tonsillitis is not well described. Only if a patient’s tonsils returned macroscopically and histologically to normal between episodes could recurrent tonsillitis be differentiated from chronic tonsillitis [3].
Although chronic tonsillitis is still the most common reasons for tonsillectomy [4], histopathological criteria for this infection have not been well studied. All investigations were confined to the lymphoid follicle, germinal centre and crypts, rather than investigating the changes in the entire tonsil area including surface epithelium. Thus the results from these studies have been inconclusive [5].
To our knowledge, specific and reliable histopathologic criteria of the chronic tonsillitis had not been described in the literature until recently. Few researchers have been interested in this field. A study performed by Uğraş and Kutluhan in 2008 revealed the presence of certain histopathological findings in 97.93% of the patients. These included slight-moderate lymphocyte infiltration and the presence of Ugras’s abscess and/or diffuse lymphocyte infiltration leading to the defect in the surface epithelium [1].
This study was carried out to describe the histopathological findings of recurrent (chronic) tonsillitis and it’s correlation to laboratory and clinical findings.
| Materials and Methods | | |
The aim of the this prospective study was to correlate the diagnostic histopathological criteria in cases with recurrent tonsillitis with laboratory findings. The study was carried out in the Otorhinolaryngology Departments of Suez Canal University, Ismailia General Hospitals and Pathology laboratory, Suez Canal University Hospital, Egypt.
The study population were children presenting to the outpatient clinic of Otorhinolaryngology of the above mentioned hospitals with chronic tonsillitis. Inclusion criteria included patients of both sexes in the age group 4-12 years old, complaining from recurrent tonsillitis (defined as those who had more than seven episodes per year or three episodes per year for ≥ 2 years).
The following signs were included: one or more of congested tonsils, congested tonsillar anterior pillar, unequal tonsil size on both sides, and enlargement of jugulodiagastric lymph nodes.
Children where exclude from the study if they had one or more of the following signs; bleeding diathesis, chronic illness that interfere with anaesthesia or surgery, anaemia (Hb less than 10).
Data collection included demographic data, preoperative evaluation, clinical evaluation (Signs & symptoms), and laboratory findings (ASOT & ESR).
Tonsillectomy was done using the dissection method and bleeding was controlled using bipolar diathermy. Removed tonsils were stained by Hematoxylin and Eosin Stain.
| Results | | |
The study included 69 females (39.4%) and 106 males (60.6%) patients. The age ranged between 4-12 years old. Fifty one patients were from urban areas (29.1%) and 124 patients were from rural areas (70.9%).
Histopathological examination for evidence of chronic tonsillitis was performed as described by Ugras and Kutluhan [1]. These included slight to moderate lymphocytic infiltration (SMLI) [Figure 1], diffuse lymphocytic infiltration (DLI), Ugras abscess [Figure 2] in addition to sub-epithelial fibrosis. [Figure 3]  | Figure 1: Moderate Scattered small lymphocyte groups in the surface epithelium and lymphocytes in the subepithelial region. (Hematoxylin and Eosin, original magnification X 40)
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 | Figure 2: Ugras’s abscess causing a defect in the surface epithelium (Arrow). (Hematoxylin and Eosin, original magnification X 40) epithelial region. (Hematoxylin and Eosin, original magnification X 40)
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 | Figure 3: Frequency of presence of pathological findings in studied tonsillar tissue sample SMLI: slight to moderate lymphocytic infiltration, DLI: Diffuse lymphocytic infiltration
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Ugras abscess were more common among patients with elevated ESR. Most of patients with normal ESR were found to have only 2 histopathological findings (67.6%) while 44.7% of patients with elevated ESR were found to have three of the histopathological findings of chronic tonsillitis. [Figure 4] [Table 1] | Figure 4: Frequency of combined pathological findings amongst studied tonsillat tissue samples
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 | Table 1: The Relationship between histopathological findings and ESR (n=175):
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Ugras abscess were more common among patients with elevated ASOT (62.2% versus 35.9% in patients with normal ASOT). Total number of histopathological findings of chronic tonsillitis was not significantly different between patients with normal ASOT and elevated ASOT. [Table 2] and [Figure 5] show the relationship between the ASOT, ESR and the histopathological findings. | Table 2: The Relationship between histopathological findings and ASOT (n=175)
It of chronic tonsillitis was not significantly different between patients with normal ASOT and elevated shows that Ugras abscess were more common among patients with elevated ASOT (62.2% versus 35.9% in patients with normal ASOT). Total number of histopathological findings ASOT.
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 | Figure 5: Relationship between the laboratory investigations results and histopatholopgical findings
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Infection rate was higher among patients with Ugras abscess versus patients without Ugras abscess. DLI was associated with higher infection rate per year. Reporting three or two histopathological findings were associated with higher infection rate than presence of only one histopathological finding. [Table 3] | Table 3: The Relationship between histopathological findings and infection rate (n=175):
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| Discussion | | |
Despite the prevalence of chronic tonsillitis and tonsillectomy, relatively few studies were concerned with the histopathologic diagnosis of the chronic tonsillitis. These studies were confined to the lymphoid follicle, germinal center and crypts, but the entire tonsil area including surface epithelium was not examined.
Among previous studies that have examined the pathological diagnosis via examining the lymphoid follicle, germinal centre and crypts, Friedmann in 1986 [6]. suggested that the principal features of chronic tonsillitis are lymphoid hyperplasia, distension of the crypts and fibrosis of the parenchyma. Bieluch et al, 1989 [3] found that chronic cryptitis, various degrees of lymphoid hyperplasia and intact tonsillar architecture in tonsils from patients with chronic tonsillitis. Woodruff, 1980 [7] found the same findings as an exuberant cryptitis and intact tonsillar architecture.
Alvi Vartanian, 1998 [8] also found same findings as cryptitis and lymphoid hyperplasia in tonsils from patients with chronic tonsillitis.
In the palatine tonsils of the healthy person, the epithelia lining the crypts are infiltrated with non-epithelial cells (mainly lymphocytes), and are underlined with disrupted basement membrane but no thick connective tissue band. The degree of reticulation and lymphocytic infiltration is pronounced in the palatine tonsils [8]. Therefore, histopathologic criteria as cryptitis and chronic cryptitis should not be used as chronic tonsillitis criteria.
Ugras and Kutluhan [1] demonstrated numerous lymphocytes in the lymphoepithelium, and degenerated cells and cellular debris in the crypts. Ugras and Kutluhan [1] did not diagnose chronic tonsillitis with these findings which can be seen in healthy population. It is important to differentiate surface epithelium and crypt epithelium. Because it may be difficult to differentiate since surface epithelium may show diffuse lymphocyte infiltration. In that case it is necessary to evaluate basal membranes and subepithelial thick connective tissue band. Although crypt epithelium is underlined with disrupted basement membrane but no thick connective tissue band, surface epithelium is underlined with normal basement membrane and there is a thick connective tissue band in subepithelial region. It was previously postulated that lymphoid hyperplasia is a nonspecific finding, which may be seen in tonsillar hypertrophy, acute tonsillitis and chronic tonsillitis in the palatine tonsil [1] . Therefore this finding should not be used as only the chronic tonsillitis criteria
In chronic tonsillitis group, Ugras and Kutluhan [1] observed SMLI, Ugras’s abscess and/or DLI in the surface epithelium. SMLI and Ugras’s abscess and/ or DLI were present in almost all of the patients in every age group and both sex, and in the groups with 3-5 attacks or in the patients with 6 or more attacks. Therefore, these three findings are very helpful and reliable diagnostic features to diagnose chronic tonsillitis histopathologically. The presence of one of these criteria is not enough to diagnose chronic tonsillitis. Ugras and Kutluhan [1] believed at least two of three findings can be seen all of cases of the chronic tonsillitis, particularly if several tissue specimens were examined.
Slight-moderate lymphocyte infiltration and the presence of Ugras’s abscess and/or diffuse lymphocyte infiltration leading to the defect in the surface epithelium not present in normal tonsils. Therefore, combination of three findings is fairly diagnostic for chronic tonsillitis (1). In our study Ugras abscess was found in 52.6% and DLI was found in 78.3%. This is relatively low prevalence when compared to findings of Urgas and Kultuhan [1] as they have reported that these findings are present in 97 and 93% in chronic tonsillitis, respectively.
No previous studies have correlated the clinical and laboratory findings with histopathological findings. We have found that Ugras abscess was more common among patients with elevated ESR (57.4%), elevated ASOT (62.2%). Among the clinical findings, All histopathological findings were associated with higher infection rate.
| Conclusion | | |
Recurrent tonsillitis is a clinical criterion and different from chronic tonsillitis which is a pathological diagnosis. Chronic tonsillitis is found in tonsils with fewer recurrence rate.
Combined clinical and laboratory criteria increase the likelihood for the diagnosis of chronic tonsillitis.
Pathological examination of the removed tonsils is beneficial for making better clinical and pathological correlation and clinical judgment for chronic tonsillitis. Investigating the relative risk of different clinical findings for the different histopathological findings revealed that an infection rate higher than 5 times/ years is a significant risk for the presence of SMLI and 3 histopathological findings. Enlarged regional lymph node was found to be significant risk for presence of Ugras abscess and three histopathological findings.
| References | | |
| 1. | Uğraş S, Kutluhan A. Chronic Tonsillitis can be diagnosed with histopathologic findings. Eur J Gen Med. 2008;5(2):95-103.  |
| 2. | Kornblut AD. Otolaryngology. In: Paparella MM, Shumrick DA, eds. Non-neoplastic diseases of the tonsils and adenoids. Philadelphia: WB Saunders Company. 1991:2129-48. |
| 3. | Bieluch VM, Martin ET, Chasin WD et al. Recurrent tonsillitis: Histologic and bacteriologic evaluation. Ann Otol Rhinol Laryngol. 1989;98:332-5. |
| 4. | Zhang PC, Pang YT, Loh KS et al. Comparison of histology between recurrent tonsillitis and tonsillar hypertrophy. Clin Otolaryngol. 2003;28:235-9. |
| 5. | Gorfien JL, Hard R, Noble B et al. Quantitative study of germinal center area in normal and diseased tonsils using image analysis. Ann Otol Rhinol Laryngol. 1999;108:398-402. |
| 6. | Friedmann I. (ed) Systemic Pathology: Nose, Throat and Ears. Singapore, Churchill Livingstone.1986:161-71. |
| 7. | Woodruff C. Non-neoplastic and inflammatory disorders of Waldeyer’s ring. Ear Nose Throat J. 1980;59:457-62. |
| 8. | Alvi A, Vartanian AJ. Microscopic examination of routine tonsillectomy specimens: is it necessary? Otolaryngol Head Neck Surg. 1998;119:361-3. |
| 9. | Perry M, Whyte A. Immunology of the tonsils. Immunol Today. 1998;19:414-21 |
[Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5]
[Table 1], [Table 2], [Table 3]
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