Bacterial plug versus pseudocyst of the tonsils John L. Giunta, D.M.D., M.S.,* Boston, Mass. TUFTS
UNIVERSITY
SCHOOL
OF DENTAL
MEDICINE
This article presents several cases of two types of yellow lesions of the tonsils. The bacterial plug is a small, sometimes symptomatic lesion composed of mats of bacteria that fill a tonsillar crypt and is treated by dislodging the plug. The pseudocyst is a small, mostly asymptomatic smooth, epithelium-covered lesion that can regress spontaneously and need not be surgically removed for diagnosis. Both lesions are compared and contrasted to delineate diagnostic features and to suggest management. Terms are differentiated, and the relationship to the lymphoepithelial cyst is discussed. (ORAL SURG.ORAL MED. ORAL PATHOL. 1987;63:202-7)
T
he bacterial plug and the retention cyst (pseudocyst) of the tonsils are yellow-appearing lesions that may be mistaken for one another or for some other lesion. There are few reports of them, particularly the bacterial plug. The term plug indicates a mass obstructing an opening or pore. Tonsillar crypts become filled and
*Professorof Oral Pathology
occluded with massesof bacteria and some cellular debris. Plugs are yellow and may be symptomatic, particularly when they occur in the palatine tonsils and in the lateral lingual tonsils (foliate papillae). The patient may complain of a tickle in the throat or a scratchy sensation, especially on swallowing. In the otolaryngology literature, these plugs have been referred to as retention cysts or tonsilloliths.’ Presumably, inflammation leads to fibrosis at the opening of the crypts; bacteria and debris accumulate,
Fig. 1. Case 1. Bacterial plug of right palatine tonsil (left). Empty crypt immediately following removal of plug (right). 202
Volume63 Number 2
Bacterial plug versus pseudocyst of tonsils
203
Fig. 2. Case 1. Photomicrograph of cytologic smear showing matted massesof bacteria and an occasional epithelial cell /left). (Papanicolaou stain. Magnification, X300.)
forming a retention cyst (pseudocyst). These terms are confusing because they may describe other lesions in the oral cavity. An oral pseudocyst may be a lymphoepithelial cyst.2-6 If a tonsillar crypt becomes occluded the lining cells desquamate to form an expanded cystlike lesion. This pseudocyst may be indistinguishable histologically from a lymphoepithelial cyst if the communication to the overlying epithelium is not found. Furthermore, there is a hypothesis that lymphoepithelial cysts are derived from occluded crypts of oral tonsils2*5Bull7 describes palatal tonsillar retention cysts as common yellow, sessileswellings that seldom have symptoms. If they are of concern or are symptomatic, they may be surgically removed; if small, they may be ignored. Kully* reported similar lesions of the nasopharynx. In my experience, both the bacterial plug and the pseudocyst are not uncommon. They are often confused, overlooked, or not diagnosed becauseof ignorance of the conditions. Some of the many casesseen over a 15year period are presented to distinguish their features, to offer guidance in making a clinical diagnosis without biopsy, and to suggest a primary nonsurgical treatment. CASE 1
An otherwise healthy 24-year-old man had a lesion on the right tonsil for several months. He described a tickling sensation on swallowing. He had been told the lesion was a pseudocyst, and no treatment was offered. A yellowish white, opaque mass with no mucosal covering was within or associatedwith a crypt of the right palatine tonsil. The masswas removed from the crypt and a cytologic preparation was done (Fig. 1). Masses of bacteria were present, including fiiamentous forms and only rarely an epithelial cell (Fig. 2). The diagnosis was bacterial plug. It did not recur.
FIG. 3. Case 3. Bacterial plug of left palatine tonsil. Note opaquenessand lack of mucosal covering.
CASE 2
A healthy 21-year-old woman complained of a constant tickle, a “lump” in her throat on swallowing, and a foul odor to her breath. She had had multiple bouts of tonsillitis. Examination revealed a 5 X 8 mm yellow, opaque, uncovered masswithin a crypt of the left palatine tonsil. The soft, cheesy mass was removed and examined cytologically. Masses of matted bacteria and a few squamous cells were present. The diagnosis was bacterial plug. The patient had multiple recurrences at the samesite over a 2-year period. Becauseof social concerns, she consulted an otolaryngologist who performed a tonsillectomy to prevent further recurrences. CASE 3
A 5 mm nodular, opaque, yellow, uncovered circular lesion on the left palatine tonsil (Fig. 3) was discovered
204
Oral Surg. February.1987
Giunta
Fig. 4. Pseudocyst or retention cyst of right palatine tonsil (left). Note mucosal covering and thin vessels Normal tonsil after spontaneous disappearance of the pseudocyst (right).
Fig. 5. Case 4. Photomicrograph of cytologic smear showing normal nucleated squamous cells from mucosal surface of pseudocyst. (Papanicolaou stain. Magnification: Left, X200; right, X400.)
during a routine examination of a 43-year-old man. On questioning, he said that occasionally he felt “something” on the left side when he swallowed. Probing easily dislodged a foul-smelling mass.No cytologic study was done. The presumptive diagnosis was bacterial plug, and there was no follow-up.
mous cells with few associated bacterial (Fig. 5). The presumptive diagnosis was pseudocyst of the tonsil. With no further treatment, it remained the same size for several months. During the fifth month the patient reported a “popping” in his throat, and the lesion spontaneously disappeared (Fig. 4). No recurrences have been noted in 2 years.
CASE 4
An asymptomatic, nontender, yellow, 1 cm, sessile nodule on the superior aspect of the right palatine tonsil (Fig. 4) was found during a routine examination of a healthy 36-year-old man. There was no lymphadenopathy or other oral condition. The surface was smooth, and a stretched, translucent mucosa revealed small vesselsover the yellow mass. No mass or plug could be expressed. Cytologic examinations revealed numerous normal squa-
CASE 5
An oval, yellow-white, 3 X 4 mm area within a right hyperplastic residual palatine tonsil was found during a routine examination of a healthy 42-year-old woman. The tonsils had been removed, and there was notable scarring and another residual tonsil (Fig. 6). Scraping revealed a smooth, intact mucosal surface, and no contents were expressed.Cytologic examination revealed numerous nor-
Volume63 Number 2
Bacterial plug versus pseudocyst of tonsils
205
ma1 nucleated squamous cells with few bacteria. The diagnosis was consistent with tonsillar pseudocyst.With no further intervention, the lesion spontaneously disappeared in 3% months. CASE 6
Asymptomatic, multiple, 2 to 3 mm, rounded, yellowwhite lesions on the left and right palatine tonsils were discovered during a routine examination of a healthy 41-year-old woman. Scraping revealed a smooth mucosal surface, and no contents could be removed. No cytologic study was done. The presumptive diagnosis was multiple tonsillar pseudocysts. The lesions disappeared within 6 months without any treatment. CASE 7
An otherwise healthy 56-year-old man had a 1 cm yellow, sessilenodule with a smooth mucosal surface on the posterior pharyngeal wall along with other reddened tonsillar nodules. Occasionally his throat tickled. Scraping revealed a smooth surface with no material contained within or expressed.No smear was done. The presumptive diagnosis was pseudocyst. The nodule disappeared by the g-month recall visit without any treatment.
Fig. 6. Case 5. Pseudocystor retention cyst of hyperplastic residual palatine tonsil on right of another residual tonsil. Also note scarring.
There was no further treatment and no recurrence in a 6-month recall period.
CASE 8
CASE 11
A healthy 39-year-old woman was referred for a persistent lesion of the tongue. There was a white-yellow, sessile, nodular, mucosa-covered 3 X 5 mm mass within the body of the right lateral lingual tonsil (Fig. 7). Occasionally the patient felt “something” on moving her tongue and in her ears. There was no lymphadenopathy, tenderness, pus, or plug. Cytologic study revealed numerous normal nucleated squames and few bacteria. The diagnosis was tonsillar pseudocyst. No treatment was recommended, despite the fact that similar lesions in other patients had been biopsied and diagnosed as lymphoepithelial cysts. The lesion spontaneously regressedin 5 months and has not recurred.
A 47-year-old woman had an asymptomatic lingual lesion of unknown duration. Examination revealed a smooth surface with vessels over a 2 to 3 mm rounded, yellow lesion within the left lateral lingual tonsil. Scraping produced to debris, and cytologic study showed normal nucleated squames.The presumptive diagnosis was pseudocyst. The patient requested its removal. Biopsy revealed a cystic lesion distended with desquamatedsquamouscells surrounded by squamousepithelium, which extended close to the surface epithelium. The microscopic diagnosis was lymphoepithelial cyst of the lingual tonsil.
CASE 9
The eleven cases just presented show that the bacterial plug and the pseudocyst of the tonsils are
A 56-year-old man complained of a lesion on his tongue that he noted becauseof an occasional tickle. There was a yellow, rounded, 3 to 4 mm, sessile mass on the right lateral lingual tonsil. The surface was smooth and shiny, with small vessels. Scraping produced no plugs, and cytologic examination showed numerous normal nucleated squames.The presumptive diagnosis was tonsillar pseudocyst. With no treatment it disappeared spontaneously in 4% months. CASE 10
A 4Cyear-old man had a lesion of the tongue, with a tickle on the right side, especially on swallowing. Examination revealed a 2 X 3 mm bright yellow, opaque, rounded mass associated with the right lateral lingual tonsil (Fig. 8). A necrotic mass was removed from the tonsillar crypt. Cytologic study showed massesof matted bacteria and few squamous cells. The diagnosis was tonsillar bacterial plug.
DISCUSSION
separate lesions and can be distinguished at the clinical level. Both lesions tend to occur in the posterior part of the oral cavity, that is, the palatine and the lateral lingual tonsils. Both tonsils have exaggerated crypts compared with other tonsils, which could account for this site specificity. For the bacterial plug, the crypt accumulates proliferating bacteria and few cells. Eventually, a small yellow nodule forms, which may be associated with such symptoms as a tickling or malodor. Treatment consists of manipulation with a sharp probe, dislodging the plug. Confirmation may be made by cytologic smear, which reveals numerous matted bacteria. By contrast, the pseudocystor retention cyst of the tonsil apparently arises from the occlusion of the crypt at the surface. Instead of bacteria accumulat-
206
Giunta
Oral Surg. February,1987
Fig. 7. Case 8. Two views of pseudocyst of right lateral lingual tonsil. This disappeared spontaneously within 5 months.
Fig. 8. Case 10. Bacterial plug of right lateral lingual tonsil. Note opacity and lack of mucosal covering. Also note deep open crypt just anterior to the plug.
ing, desquamated epithelial cells which formerly lined the crypt, accumulate to form a rounded, yellowish mass. Probing reveals a smooth surface, and careful examination shows small superficial vessels. The cystic contents cannot be expressed unless an incision is made. Cytology reveals only surface squamous cells and few bacteria. Thus the probing distinguishes between these two lesions. There may be a tickle or fullness with a pseudocyst but malodor would not be a result of the lesion. The treatment suggested for a pseudocyst is different
from that normally recommended.2-6*g Instead of an excisional biopsy, observation seems appropriate, since the lesion can regress spontaneously. This may seem inconsistent with the generally accepted treatment for raised, nodular lesions of the oral cavity, which necessitate excision. However, considering the sites involved, it seems prudent to be cautious, especially with the extremely benign behavior of the pseudocyst. One could argue that a diagnosis of pseudocyst cannot be justified if the lesion is not biopsied. As seen in Case 11, the lesion exactly resembled others reported herein. Because there are so few yellow lesions in the oral cavity and becausethere are so few possibilities for yellow lesions involving the tonsils, it seemsreasonable to presume with a high degree of certainty that if the lesion can not be scraped away, it is a pseudocyst. In a previous study4 on lymphoepithelial cysts, the authors did not report on those occurring in the lateral lingual tonsil because the cysts were supposedly inflammatory in origin. Experience has shown that the lateral tongue is a common location for the lymphoepithelial cyst and that many of those on serial sectioning reveal either a connection or a suggestedconnection to the surface, indicating a pseudocyst. Moreover, several authorsZ~5~6 now think that the pseudocyst is a precursor to the lymphoepithelial cyst. Although the reported common location of the lymphoepithelial cyst is the floor of the mouth, this may reflect the ease of retrieving the lesion rather than the actual rate of occurrence. In summary, two yellow lesions of the palatine and
Volume 63 Number 2
lateral lingual tonsils have been shown and compared. The bacterial plug is a small (less than 0.5 cm) rounded or nodular mass of bacterial colonies filling a tonsillar crypt. It is often symptomatic with a tickle in the throat and may be expressedeasily on probing. The pseudocyst is a small (1.0 cm or less), yellow, often asymptomatic, nodular lesion covered with intact epithelium. After probing without dislodging a plug, the presumptive diagnosis of pseudocyst should be made. Treatment can be simply to follow the course of the lesion, since it can spontaneously regressover several months, or it can be treated by conservative surgery. Both lesions are innocuous and should be included in a differential diagnosis of yellow lesions of the oral cavity. REFERENCES
1. Kornblut AD: Non-neoplastic diseases of the tonsils and adenoids. In, Paparella M, Shumrick D (editors): Otolaryngology, Vol. III, Head and neck, ed. 2, Philadelphia, 1980, W. B. Saunders Company, pp. 2263-2282. 2. Knapp MH: Pathology of oral tonsils. ORAL SURG ORAL MED ORAL PATHOL 29: 295-304, 1970.
Bacterial plug versus pseudocyst of tonsils
207
3. Bhaskar SN: Lymphoepithelial cysts of the oral cavity. Report of twenty-four cases. ORAL SURC ORAL MED ORAL PATHOL 21: 120-128, 1966.
4. Giunta J, Cataldo E: Lymphoepithelial cysts of the oral mucosa. ORAL SURG ORAL MED ORAL PATHOL 35: 77-84, 1973. 5. Buchner A, Hansen LS: Lymphoepithelial cysts of the oral cavity. A clinicopathologic study of thirty-eight cases.ORAL SURG ORAL MED ORAL PATHOL 50: 441-449, 1980.
6. Chaudry AP, Yamane GM, Scharlock SE, SunderRaj M, Jain R: A clinico-pathological study of intraoral lymphoepithelial cysts. J Oral Med 39: 79-84, 1984. 7. Bull TR: Color atlas of ENT diagnosis, Chicago, 1974, Year Book Medical Publishers, Inc., pp. 180-l 8 1. 8. Kully BM: Cysts and retention abscessesof the nasopharynx (A report of eighty-eight cases).J Laryngol Otol50: 3 17-328, 1935. 9. Sakoda S, Kodama Y, Shiba R: Lymphoepithelial cyst of oral cavity. Report of a case and review of the literature. J Oral Maxillofac Surg 12: 127-131, 1983. Reprint requesrs CO:
Dr. John L. Giunta Tufts University School of Dental Medicine 1 Kneeland St. Boston. MA 02111