VIEWS: 16 PAGES: 4 POSTED ON: 3/27/2012
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 In our study, the tonsillar surface and core culture 1. Inci E, Karakullukcu B, Aygun G, Yasar H, swabs showed S. aureus in 14 and 20 cases, while Enver O, Yagiz C. Fine-needle aspiration as Group A beta haemolytic streptococci was found in a diagnostic tool for recurrent tonsillitis. J Int 12 and 18cases. These findings were comparable to Med Res 2003; 4:307-11 the findings of Ozek et al(13) who identified S. aureus 2. Lindroos R. Bacteriology of the tonsil core in in 33% and beta haemolytic streptococci in 30% recurrent tonsillitis and tonsillar hyperplasia-- isolates. a short review. Acta Otolaryngol Suppl 2000; In a study by Surow et al(4), the tonsils of 97 543:206-8. children undergoing tonsillectomy were studied to 3. Kurien M, Stanis A, Job A, Brahmadathan, determine the correlation between surface culture Thomas K. Throat swab in the chronic swab and culture of tonsillar core, Staphylococcus tonsillitis: how reliable and valid is it? was the most common isolate from both surface Singapore Med J 2000 Jul; 41:324-6. and core. 4. Surow JB, Handler SD, Telian SA, Fleisher In the study by Brook et al(14) specimens from both GR, Baranak CC. Bacteriology of tonsil the surface and the core of tonsils from 23 children surface and core in children. Laryngoscope with recurrent tonsillitis were cultured for aerobic 1989; 99:261-6. and anaerobic microorganisms. The predominant 5. Kindo AJ, Somu L, Srikanth P, Varadrajan M, aerobic isolates were alpha-hemolytic streptococci, Lakshmanan K. Role of surface swab, core Staphylococcus aureus, beta-hemolytic streptococci, swab and fine needle aspiration in isolating 132 Motassim Al-Roosan, Nemer Al-Khtoum*, Hussein Al-Said the core bacteria in inflammed tonsils. Indian J Pathol Microbiol 2001; 44:293-5. 6. Kurien M, Sheelan S, Jeyaseelan L, Bramhadathan, Thomas K. Fine needle aspiration in chronic tonsillitis: reliable and valid diagnostic test. J Laryngol Otol 2003; 117:973-5. 7. Gaffney RJ, Cafferkey MT. Bacteriology of normal and diseased tonsils assessed by fine- needle aspiration: Haemophilus influenzae and the pathogenesis of recurrent acute tonsillitis. Clin Otolaryngol Allied Sci 1998; 23:181-5. 8. Donnelly MJ, Quraishi MS, Shane MC. Indications for paediatric tonsillectomy GP versus Consultant perspective. J Laryngol Otol 1994; 108:131-4. 9. Paradise JL, Bluestone CD, Bachman R, et al. Efficacy of tonsillectomy for recurrent throat infection in severely affected children. N Engl J Med 1984; 310:674-83. 10. Thomas R. Discussion: is the removal of tonsils and adenoids necessary? J R Soc Med 1960; 54:395-9. 11. Geoffrey SB, Iain CK. Comparison of size of tonsils in children with recurrent tonsillitis and in controls. BMJ 1989; 298:804. 12. Cable HR, Batch AG, Stevens DJ. The relevance of physical signs in recurrent tonsillitis in children. J Laryngol Otol 1986; 100:1047-51. 13. Ozek O, Egilmcz S, Ang O, Savas I. A bacteriologic study of chronic tonsillitis. Acta OtoLaryngologica 1967; 63:455-61. 14. Brook I, Yocum P, Shah K. Surface v/s core tonsillar aerobic and anaerobic flora in recurrent tonsillitis. JAMA 1980; 244:1696-8. 15. Rosen G, Samuel J, Vered I. Surface tonsillar microflora versus deep tonsillar microflora in recurrent tonsillitis. J Laryngol Otol 1977; 91:911-3.
Pages to are hidden for
"Correlation between surface swab culture and tonsillar core culture"Please download to view full document