Multiple Epidermal Inclusion Cysts in a Case of Chronic Tonsillitis: A Rare Finding

Case Report

Multiple Epidermal Inclusion Cysts in a Case of Chronic Tonsillitis: A Rare Finding

Nandita Katoch ^*
Aditya Jamwal

Department of Pathology, Dr. Rajendra Prasad Govt. Medical College, Kangra, Himachal Pradesh, India.

*Corresponding Author: Nandita Katoch, Department of Pathology, Dr. Rajendra Prasad Govt. Medical College, Kangra, Himachal Pradesh, India.

Citation: Katoch N, Jamwal A. (2024). Multiple Epidermal Inclusion Cysts in a Case of Chronic Tonsillitis: A Rare Finding, International Clinical Case Reports and Reviews, BioRes Scientia publishers. 2(2):1-3. DOI: 10.59657/2993-0855.brs.24.012

Copyright: © 2024 Nandita Katoch, this is an open-access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.

Received: May 29, 2024 | Accepted: June 13, 2024 | Published: June 17, 2024

Abstract

Palatine tonsil enlargement can be caused by conditions like tonsillitis and malignancies. Epidermal inclusion cysts in palatine tonsil are a rare incidental finding which can be seen in cases of tonsillitis. Histopathological diagnosis on tonsillectomy specimen can confirm their presence. Here, we are presenting such a case in a young female.

Keywords: palatine tonsil; otolarygorhinology; tonsillitis

Introduction

Epidermal inclusion cysts are benign lesions occurring throughout body. Their incidence in head and neck region is 1.6–6.9% [1]. Intraorally, they commonly arise in the sublingual, submental, submandibular, labial/lingual region. However, in tonsillar area this is an extremely rare finding with the incidence of less than 0.01% [2]. Here we present a case of a young female with the incidental detection of epidermal inclusion cysts in the tonsillectomy specimen done for Chronic tonsillitis.

Case Report

A 28-year-old female presented to the Otolarygorhinology OPD with the chief complaint of throat pain since the last two years. She was apparently well two years back when she starts having throat pain. It was insidious in onset and gradually progressive. It was associated with difficulty in swallowing and occasionally low-grade fever. There was no history of postnasal drip, cough, or acid reflux. She had a history of recurrent tonsillitis since childhood. Throat examination revealed flushing of bilateral anterior tonsillar pillars along with Grade III tonsillar enlargement. Chronic Tonsillitis was diagnosed, and tonsillectomy was performed. The specimen was sent to our Department of Pathology. On Gross examination, two grey whites to grey brown globular soft tissue pieces were received, measuring. On cut section, both were grey white. One of the soft tissues revealed multiple small cystic areas ranging in maximum dimension from 0.2 to 0.5 cm. They were filled with whitish pultacious material (image 1). Sections were taken and processed. Microscopic examination of the sections revealed stratified squamous epithelium lined tissue with lobules of lymphoid cells along with many germinal centres. Multiple Cystic structures lined by stratified squamous epithelium including granular cell layer, filled with keratin flakes were also seen. Diagnosis of hyperplastic tonsils with epidermal inclusion cysts was given (Image2).

Figure 1: Gross examination of tonsils with cystic structures(arrow)

Figure 2: Microscopic examination revealing cyst (red star) filled by keratin flakes surrounded by lobules of lymphoid tissue (black star) (40x, H&E)

Figure 3: on higher magnification, cyst is lined by stratified squamous epithelium including stratum granulosum (400x, H&E)

Discussion

Tonsils are the masses of lymphoid tissue present in the oral cavity. They play an important role in antimicrobial defence. Different types of cystic lesions can develop in tonsils, including tonsillar retention cyst, lymphoepithelial cyst, hydatid cyst, and the epidermoid cyst. Epidermoid cysts were first described by Roser in 1850. They can be congenital or acquired. Congenital epidermoid cysts are found at places where embryonic remnants fuse while acquired cysts forms secondary to trauma or surgery. Remark and Bucy in 1854 proposed that the inclusion of ectodermal tissue during embryogenesis can lead to the development of an epidermoid cyst. Metaplastic theory was given by Wendt in 1873, which stated that chronic infection can cause metaplastic changes in the non-keratinized stratified squamous epithelium lining the tonsil. Later in 1920, Ewing proposed implantation theory, according to which trauma can lead to implantation of epithelium at different sites [3].

Epidermal cysts in oral Cavity accounts for 0.01% of the cases and they usually present as a slow growing mass [4]. Thorough research through the literature revealed only 14 cases of epidermal inclusion cysts in palatine tonsil till now [4-17]. The age of presentation in these cases ranges from 6 to 59 years of age and only four of them were males. So, the mean age of presentation was 27.20 years. Our patient was 28 years old female. The lesion was unilateral in all the cases, and it was multifocal in only four cases [5,11,13,17]. In our case the lesion was unilateral and multifocal. Epidermoid cysts of tonsil can cause asymmetric enlargement and mimic malignancy on clinical examination [6]. They are easily diagnosed on histopathological examination. Differential diagnosis includes dermoid cyst with adnexal structures, lymphoepithelial cysts with large amount of lymphoid tissue on the wall and squamous cell carcinoma in the presence of dysplasia and invasion. Multiple epidermoid cysts are associated with Gardner syndrome, basal cell nevus syndrome, pachyonychia congenita and Lowe syndrome [4,18]. These genetic syndromes should be ruled out when multiple cysts are identified. However, out of the above reported cases and in our case, no such association was there. Complications of epidermal inclusion cysts are rare, but they can cause infection, scarring from removal and recurrence. Malignancies are quite rare.

Conclusion

The importance of this case report is to highlight the rarity of intratonsillar epidermal inclusion cyst which presented as an incidental finding in our case. Histopathological examination is necessary to diagnose them and to rule out malignancy.

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