Actinomyces causing chronic tonsillitis: a retrospective study

INTRODUCTION

Tonsillectomy is one of the most commonly performed surgical procedures in otorhinolaryngology department. There are many indications for performing tonsillectomy. Resistant bacteria that can cause recurrent infections in tonsils have been an increasing concern over the past decade because of the widespread and prolonged use of antibiotics. Actinomycosis infection of tonsils is one such cause of tonsillitis which is often missed as many institutions do not routinely perform histopathological examination of tonsillectomy specimens.¹

Actinomyces in the tonsils was first identified in 1896.² Actinomyces is a Gram-positive, non- acid fast, anaerobic, branching, filamentous bacteria. It causes chronic suppurative inflammation. It is a common commensal in human oral cavity, colon and vagina. Colonisations of actinomyces is most common in cervicofacial region (55%), followed by thoracic region (20%) and abdomino-pelvic region (15%). About 6.7-35% of tonsillectomy specimens have been reported to have actinomyces colonies.^1,3,4 The disease is predominantly characterized by spread to contiguous tissues as it disrupts mucosal barriers and it can masquerade as any oropharyngeal malignancy/any oropharyngeal lesions.⁵ Main cause of disruption is dental caries or trauma, surgery or another infection.⁶ It has an indolent course which makes it difficult to eradicate the disease.

Objectives

Objectives were 1) to estimate the proportion of actinomyces causing chronic tonsillitis using histopathological evidence 2) to describe the histopathology of all routine tonsillectomy specimens in order to identify the difference in histopathology of tonsils affected with actinomyces.

METHODS

This is a retrospective study conducted in the department in the department of ENT, KVG medical college Sullia. We retrospectively analysed the data of patient who underwent tonsillectomy during the period from June 2018 to September 2020. We applied the following inclusion and exclusion criteria for selection of patients.

Inclusion criteria

Patients of the age of 5-50 years with recurrent episodes of tonsillitis (At least 3 episodes in each of 3 years, or five episodes in each of 2 years, or 7episodes in 1 year) undergoing tonsillectomy.

Exclusion criteria

Exclusion criteria were 1) immunocompromised patients with tonsillar hypertrophy 2) patients presenting with peritonsillar abscess.

Total 33 patients met the above-mentioned criteria and were included in the study. All of them were included in the study. All of them had undergone bilateral tonsillectomy. Hence there were 66 tonsillectomy specimens which were subjected to histopathological examination. The tonsillar tissues were fixed in formalin, embedded in paraffin and prepared slides stained with H&E stain.

The serial sections showing actinomycosis infection in the slides were stained with Gram Stain. The presence of cryptitis, reactive lymphoid follicular hyperplasia, and tonsillar fibrosis were noted. Further analysis of the data was done to determine the statistical significance of actinomycosis in association with chronic tonsillitis.

RESULTS

Out of eight tonsillar specimens from 4 patients who underwent tonsillectomy had actinomycosis infection. The most common indication for tonsillectomy was chronic tonsillitis. The mean age of patients was 17 years (range 5-42 years). There were 20 males and 13 female patients in the study. Among them 2 males and 2 females had actinomycosis showing bilateral infection with actinomyces.

Microscopic examination of the excised bilateral tonsillar tissue showed the following observations: 1) stratified squamous epithelial lining with intraepithelial lymphocytes 2) the sub epithelial region showed severe lymphoid follicular hyperplasia with prominent germinal centre 3) actinomyces bacterial colonies were seen at the centre of the inflammatory reaction comprising of neutrophils, eosinophils, lymphocytes and plasma cells 4) in one of the specimens a cyst was lined with stratified squamous epithelium, the lumen of the cyst contained numerous actinomycotic colonies. The incidence of actinomyces in this study is 12.12%.

DISCUSSION

Infection due to actinomyces in tonsils and its clinical significance is controversial in the available literature. Chronic tonsillitis due to actinomycotic infection has been reported in a small percentage of people.⁷ Most commonly actinomycosis of the head and neck region presents with abscess formation, draining sinuses, fistulae and tissue fibrosis. In our study one of the specimens consisted of tonsillar cyst containing infection of actinomyces. But the significance of actinomycetes colonization in the tonsils is not clear, even though tonsillectomy is one of the most common operations in otolaryngology. The pathogenesis of tonsillitis and tonsillar hypertrophy due to actinomyces is controversial. The disease in the cervical-facial region is precipitated by several factors like dental caries, periodontal disease and maxillo-facial trauma. About 6.7-35% of tonsillectomy specimens have been reported to have actinomyces colonies.^3,4 The incidence of actinomyces in our retrospective study is 12.12%. The reasons for this variation include differences in the sectioning and staining techniques employed by different laboratories; the ages of the patients studied and discrepancies in the indications for tonsillectomy.¹ The use of antibiotics in the treatment of patients with recurrent and chronic tonsillitis has been postulated to explain the lower incidence rate of actinomycetes colonization in these patients.⁷ The other reason for this wide incidence rate is because not all institutions routinely do histopathology of tonsillar specimen. Hence, the actual disease burden has not been assessed in a larger scale.

Pransky et al found that accurate detection of the presence of these organisms was possible only by histopathological studies of core tissues.8 Many authors found no evidence of co-relation between chronic tonsillitis and actinomyces, Gaffney et al reviewed 42 tonsils with actinomycosis and found no correlation between the presence of actinomyces and chronic tonsillitis. Lierop et al examined 344 tonsils and found no tissue reaction due to actinomyces colonies.⁹ But in our study, we found definitive tissue reaction to actinomyces like lymphoid hyperplasia, bacterial colony surrounded by inflammatory cells. Several authors have found similar co-relations like Aydin et al found the incidence of Actinomycosis to be 6.7% and cryptitis was the common finding.¹⁰ Assimakopoulos et al studied the histopathological specimens of 238 tonsils and concluded that actinomyces colonisation has role in causing chronic tonsillitis.⁴ Ozgursoy et al advocated that actinomyces colonisation could cause lymphoid hyperplasia in chronic tonsillitis.¹¹ As actinomyces is a part of dental plaque biofilm, so maintaining oral hygiene is crucial in prevention of actinomyces infection in cervical region. Most of the authors have reported male preponderance in this condition which was not the case in our study.

CONCLUSION

Actinomycosis of tonsil is a common condition which is usually missed as routine histopathology examination of tonsillectomy specimen is not done. Hence, we recommend routine histopathology examination of all tonsillectomy specimens irrespective of age to know the burden of the disease and to establish causal relationship with chronic tonsillitis.

ACKNOWLEDGEMENTS

The authors would like to thank department of pathology, KVG medical college and hospital.

Funding: No funding sources

Conflict of interest: None declared

Ethical approval: The study was approved by the Institutional Ethics Committee

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