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Correlation between surface swab culture and tonsillar core culture

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									Khartoum Medical Journal (2008) Vol. 01, No. 03, pp. 129 - 132                                                      129



Correlation between surface swab
culture and tonsillar core culture in
patients with recurrent tonsillitis
Motassim Al-Roosan, Nemer Al-Khtoum*, Hussein Al-Said

            ‫االرتباط بني زراعة املسحة السطحيّة وزراعة لب اللوزة في مرضى التهاب اللوزتني املتكرّر‬
            ِ                 ِ                        ِ                      ِ
          .‫الهدف: تقرير االرتباط بني زراعة املسحة السطحية وزراعة لب اللوزة في مرضى التهاب اللوزتني املتكرر‬
            ّ                ِ                            ِ       ِ ّ          ِ     ِ                    ْ
.‫املرضى والطرق: متت دراس��ة مائة مريض من كال اجلنس��ني فوق عمر 3 سنوات الذين تقرر لهم استئصال اللوزتني‬
                      .‫كان هناك 83 أنثى و26 ذكر بني أعمار 3 -53 سنة. متت زراعة عينات من كال السطح ولب اللوز‬
‫النتائج: في 63 حالة، مت عزل مسببات مرضية بزراعة لب اللوزة لكن لَيس بزراعة املسحة السطحية. في 24 حالة‬
                                                     ِ                                                          ِ َ
‫مس��ببات مرضية دقيقة مت عزلها بزراعة لب اللوزة، تختلف عن البكتيريا الس��طحية. تناقض بني زراعة املس��حة‬
‫الس��طحية وزراعة لب اللوزة بالنس��بة إلى وجود أَو غياب املسببات املرضية ا للبية كان في 26 حالة )26 %( بينما‬
                               َ                        َ
                                                                                       .(% 38) ‫كان مماثالً في 83 حالة‬
                                                                                                                    َ
    َ                                                                        َ
‫في 02 حالة )02 %( ا ملسببات املرضية كانت موجودة على زراعة املسحة السطحية بينما زراعة لب اللوزة كانت‬
                                 ّ
                                        .‫طبيعية. 41 حالة )41 %( من اجملموعة الدراسية أظهرت جراثيم طبيعية‬
                                                                                        ْ ِ
                                   َ
‫املسببات املرضية الرئيسية التي مت عزلها من كال املسحة السطحية ولب اللوزة كانت املكورة العنقودية البرتقالية‬
                    ُ                             ّ
‫ بيتا املكورة االنحاللية. املكورة ذات الرئة، إنفلونزا اجملزأة احملبة للدم، اجلراثيم العصوية واملكورة‬A ‫يليها مجموعة‬
                                                                                                     .‫العقدية اخملضرة‬
َ
‫اخلامتة: تش��ير الدراسة بأن زراعة املس��حة البلعومية ال ت َعكس وجود األسباب املرضية بشكل موثوق في لب لوزة‬
                                                                                                   َ
‫احللق. س��طح لوزة احللق يعكس بشكل رئيسي جراثيم طبيعية في احللق، بينما لب لوزة احللق يظهر منو الكائنات‬
                                                              .‫احلية التي نادرا ً ما تظهر في زراعة املسحة السطحية‬
                                                                ّ
Abstract
Objective: To determine the correlation between surface culture swab and culture of tonsillar core in patients
with recurrent tonsillitis.
Patients and Methods: One hundred patients booked for elective tonsillectomy were studied. There were 38
females and 62 males between the ages of 3 and 35 years. Specimens from both surface and core of tonsils
were cultured.
Results: Pathogens were isolated by core culture but not by the surface culture in 36 cases. In 42 cases
pathogenic micro flora were identified from the core of tonsils differing from the surface bacteria. Discrepancy
between surface and core culture as to the presence or absence of core pathogens was in 62 cases (62%) while
it was identical in 38 cases (38%). In 20 cases (20%) pathogenic microflora was present on surface culture with
normal core flora. 14 cases (14%) of the study group showed normal flora.
The principal isolate from both the tonsillar surface and core were Staphylococcus aureus followed by Group A
beta hemolytic streptococci, S. pneumonia, Haemophilus influenza, Escherichia coli, Pseudomonas aeruginosa
and S. viridans.
Conclusion: The study indicates that pharyngeal swab cultures do not reliably reflect the presence of pathogens
in the tonsil core. The tonsil surface reflected mainly the normal flora of the oropharynx, whereas tonsil core
showed growth of organisms like Hemophilus and Staph aureus, which were rarely reflected in the surface
culture.

Introduction                                                     may occur in great numbers. A high tissue concentration
                                                                 of these bacteria correlates with clinical parameters of
Acute tonsillitis is a common disease. Repeated antibiotic       infection and hyperplasia of the tonsils(2).
treatment may fail leading to tonsillectomy. Superficial
swab cultures do not sufficiently represent the core             The diagnostic test of swabbing the surface of the
                                                                 tonsil as a culture specimen for the determination of
bacteria present(1).
                                                                 the organism responsible for the tonsil infection is
In recurrent tonsillitis, the tonsil core harbours               still in practice despite controversy (3).
numerous bacteria, some of which are pathogenic and              In many cases, pathogenic organisms were found in
*Corresponding author: PO Box 1834 Amman 11910                   the tonsil core, despite the fact that surface cultures
Jordan.                                                          revealed only normal respiratory flora(4). Differences
130                                                                   Motassim Al-Roosan, Nemer Al-Khtoum*, Hussein Al-Said

between tonsil surface and core bacterial flora may         during the 3 weeks prior to tonsillectomy.
explain the increasing failure rate in the eradication      After the patient was intubated a tonsillar surface
of the infection from the tonsil particularly by the        swab was obtained by rotating a sterile cotton wool
penicillin group of antibiotics leading to chronic stage,   swab over the surface of the tonsil not touching other
therefore the rationale of treating chronic tonsillitis     parts of the oropharynx. Following this, tonsillectomy
medically should be based on the knowledge of the           was performed by dissection technique. Immediately
common core pathogen(5).                                    after excision, the tonsil was immersed in povidine-
Identifying the bacterial organism within the infected      iodine solution for 30 seconds. Then it was thoroughly
tonsil for appropriate antibiotic therapy could             rinsed with sterile saline, placed in sterile tray and
revolutionize the management of chronic tonsillitis(6).     sectioned into two pieces with the help of sterile
The aim of the present study was to determine the           scalpel under strict aseptic condition. The same
correlation between surface culture swab and culture        procedure of rubbing a sterile swab was applied to the
of tonsillar core.                                          core of the excised tonsils avoiding its outer surface.
                                                            Paired samples from individual patients were put in
Material and Methods
                                                            the thioglycollate broth immediately for transport to
This study was conducted in the Department of
                                                            the laboratory. In the laboratory the specimens were
Otorhinolaryngology, Princess Haya hospital
                                                            cultured on 5% sheep blood agar, chocolate agar and
(Aqaba-Jordan). After institutional ethical committee
                                                            in Robertson cooked meat medium. The plates were
clearance and written informed consent, one hundred
                                                            incubated at 37°C in the presence of 5-10% CO for
patients of both sexes above 3 years of age booked
                                                            24-48 h. All the isolates were identified by standard
for elective tonsillectomy were studied. The group
                                                            techniques (2).
included 38 females and 62 males between the age of
3 and 35 years.
                                                            Results
The indication for tonsillectomy was recurrent
tonsillitis defined as at least five attacks of acute       Results of cultures from both the surface and the
inflammation of the tonsil during a single year. Recent     core of tonsils were compared. A large percentage
upper respiratory tract infection was ruled out. The        of the patients had no correlation between organisms
diagnosis was made on the basis of history of recurrent     cultured simultaneously from the two sites. See Table
attacks of sore throat, odynophagia and pyrexia. On         1 below.
physical examination, the patients revealed erythema
and debris in tonsil crypts with palpable juglo-digastric
lymph nodes. The patients received no antibiotics


                Table 1: Comparison between surface and core cultures in 100 cases

                 Surface culture               Core culture                                No. of cases
                 Normal flora                  Pathogen present                            36
                 Pathogen present              Pathogen present (same)                     24
                 Pathogen present              Pathogen present (different)                6
                 Pathogen present              Normal flora                                20
                 Normal flora                  Normal flora                                14

In a large group constituting 36 cases, pathogens were      cultures.
isolated by the core culture but not by the surface         The principal isolate from both the tonsillar surface
culture, thus surface culture did not reliably reflect      and core were Staphylococcus aureus followed
the core pathogens. In 42 cases pathogenic microflora       by Group A beta haemolytic streptococci, S.
were identified from the core of tonsil, differing from     pneumonie, Haemophilus influenza, Escherichia coli,
the surface bacteria.                                       Pseudomonas aeruginosa and S. viridans. See Table
Discrepancy between surface and core culture as to          2.
the presence or absence of core pathogens was in 62
cases (62%) while in 38 cases (38%) it was identical.
Therefore, one should question the value of the surface
culture in predicting the real pathogens in recurrent
tonsillitis.
In 20 cases (20%) pathogenic microflora were present
on surface culture with normal core flora. 14 cases
(14%) of the study group showed normal flora in both
Correlation between surface swab culture and tonsillar core culture in patients with recurrent tonsillitis                     131


                  Table 2: Pathogenic microflora isolated from the tonsils in 100 cases

                            Pathogenic microflora                               Tonsillar surface            Tonsillar core
                   Staphylococcus aureus                                               14                         20
                   Group A beta haemolytic streptococci                                12                         18
                   S. pneumonia                                                        10                         14
                   Haemophilus influenza                                                2                          6
                   Escherichia coli                                                     4                          2
                   Pseudomonas aeruginosa                                               2                          2
                   S. viridans                                                          2                          0

In core cultures, staphylococcus aureus was the most                       and Haemophilus sp.
common pathogen. Another important organism                                In the present study in a large group constituting 36
found in core culture, which was rarely predicated in                      cases, pathogens were isolated by the core culture but
surface culture was Hemophilus influenze. Four cases                       not by the surface culture. Similar observations were
of polymicrobial infection were encountered in the                         noted in other studies (4).
study. In these cases the causative agent was S. aureus                    Overall surface culture was in variance as to the
and beta haemolytic streptococci.                                          presence or absence of core pathogens in 62 cases
                                                                           (62%). Similarly, Rosen et al(15) found 48% variance
Discussion                                                                 between surface and core micro-organisms.
The pathogenesis of recurrent tonsillitis is largely                       These findings may explain recurrence of tonsillitis
unknown. Selection of appropriate antibiotic therapy                       and makes the reliability of the conventional tonsillar
for patients with recurrent tonsillitis is difficult because               culture questionable. Surgical extirpation of the tonsils
of the limitations of traditional methods of sampling                      seems to be the only treatment since deep bacteria
tonsillar microflora and the increasing incidence of                       remain unidentified and resist the antibiotic therapy
beta-lactamase producing bacteria in the tonsil(7).                        that may affect only the surface microflora.
In the present study, the commonest indication for
tonsillectomy was recurrent tonsillitis. The current                       Conclusion
widely accepted criteria for surgery are of the order of                   The study indicates that pharyngeal swab cultures do
seven episodes of tonsillitis in the preceding year, five                  not reliably reflect the presence of pathogens in the
episodes in each of the preceding two years or three                       tonsil core. Routine culture of the throat by surface
episodes in each of the preceding three years, these                       swab for the accurate diagnosis of bacterial flora in
were arrived at arbitrarily(8,9).                                          chronic tonsillitis is neither reliable nor valid.
There is near unanimity regarding this indication                          The tonsil surface reflected mainly the normal flora of
among various authors(10,11). Cable et al(12) found no                     the oropharynx, whereas tonsil core showed growth of
correlation between the size of the tonsils and the                        organisms like Hemophilus and Staph aureus which
indication for tonsillectomy. Barr et al(11) echoed a                      were rarely reflected in the surface culture.
similar view.                                                              References
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12 and 18cases. These findings were comparable to                                Med Res 2003; 4:307-11
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