11-Year-Old With an Anterior Tonsillar Pillar Defect

Introduction. An 11-year-old girl presented to her pediatrician with a 1-day history of progressive right ear pain, clear rhinorrhea, and mild generalized abdominal pain. The physical examination was significant for an incidental defect in the right anterior tonsillar pillar that had not been noted in prior clinic visits.

Patient history. The patient’s past medical history was significant for obstructive sleep apnea requiring adenotonsillectomy 3 years prior, behavioral insomnia of childhood, attention deficit hyperactivity disorder (ADHD), generalized anxiety disorder, and nocturnal enuresis. She had no known allergies. Her medications included melatonin 2.5 mg chewable tablet as needed for insomnia and methylphenidate hydrochloride extended-release 25 mg daily for ADHD. She had an uncomplicated birth history, was current on vaccinations, and had no history of hospitalizations. There was no significant family history.

On physical examination, she appeared well, with growth parameters that were within normal limits, a weight of 41.1 kg (52nd percentile) and was afebrile. An otoscopy was performed and showed she had transparent tympanic membranes, typical bony landmarks, light reflexes, and patent external auditory canals without erythema or exudate bilaterally.

A nasal examination demonstrated patent nares without turbinate edema or erythema but with mild clear rhinorrhea. While the posterior oropharyngeal examination revealed no erythema or exudate, there was a small, hole-like defect in the right anterior tonsillar pillar (Figure 1). Scar tissue was noted lateral to the defect. There was no swelling, tenderness to palpation, asymmetry of the soft palate, or other oropharyngeal lesions. No visible remnants of the tonsils were present. The remainder of her physical examination was within normal limits.

Figure 1. The patient’s oropharynx demonstrates a small, circular defect in the right anterior tonsillar pillar (black arrow).

The patient and her family were informed about the defect, which they were unaware of, and no symptoms such as food sticking, oropharyngeal pain, bleeding, or voice changes were reported by the patient. Subsequent examination of the patient’s medical records revealed that the adenotonsillectomy, performed with coblation, was completed 3 years prior without immediate complications such as hemorrhage or a tonsillar pillar defect. However, there was no documentation regarding a post-operative otolaryngology appointment or follow-up examination, although this was recommended 1 month post-operatively.

Diagnostic testing. No additional laboratory tests, imaging, dermoscopy, or biopsies were required to confirm the diagnosis.

Differential diagnosis. The differential diagnosis for the defect noted in the anterior tonsillar pillar in this case included surgical or intubation trauma from her prior adenotonsillectomy, scar tissue contracture, and chronic inflammation of the tonsils.

Treatment and management. Based on her 1-day history of clear rhinorrhea and ear pain, she was diagnosed with a viral upper respiratory infection (URI). She was given instructions for supportive care (increasing oral fluids, using a nasal saline spray as needed, and a cool mist humidifier). The incidentally noted, asymptomatic abnormal tonsillar pillar finding was discussed and reviewed with otolaryngology for further recommendations. Based on the physical examination findings, a tonsillar pillar hole or fistula was confirmed by otolaryngology. As long as the defect remained stable in size, otolaryngology recommended routine surveillance by her pediatrician.

Outcome and follow-up. At a routine wellness exam 2 weeks later, the patient remained asymptomatic without throat pain or swallowing concerns, and the defect in the anterior pillar appeared unchanged.

Discussion. There is limited information describing perforations of the anterior tonsillar pillar and even fewer are depicted in the pediatric population. Several potential causes for the anterior tonsillar pillar defect, as was observed in this case, include surgical trauma, intubation-related trauma, infection, scar tissue contracture, and chronic inflammation.^1-6

The observed defect noted during the patient’s physical examination is likely attributable to surgical trauma to the anterior tonsillar pillar, an infrequent complication described in previous literature.¹ Perforation of the anterior tonsillar pillar may result from direct surgical trauma, such as an inadvertent incision made lateral to the tonsil, necessitating a subsequent incision to complete the adenotonsillectomy. Alternatively, damage to the anterior tonsillar pillar could occur during the dissection of the tonsillar tissue within the tonsillar fossa, leading to a button-hole injury. Should the initial incision or button-hole injury fail to undergo healing by secondary intention, characterized by granulation tissue growth from the wound edges, a defect in the anterior tonsillar pillar may become evident.² It is noteworthy that the operative report for the patient’s adenotonsillectomy does not indicate an initial lateral incision or a button-hole injury to the anterior tonsillar pillar.

Electrocautery is commonly employed in adenotonsillectomy to dissect tonsillar tissue utilizing electrical current, minimizing hemorrhage risk.⁷ In contrast, coblation utilizes radiofrequency ablation and continuous saline delivery, reducing bleeding risk and tissue temperature during the procedure.⁷ During this patient’s adenotonsillectomy, coblation was used during tissue dissection. Although tissue temperature is lower with coblation, prolonged exposure to radiofrequency energy may lead to local tissue destruction, potentially compromising surrounding vasculature and impairing wound healing.³ In this case, the radiofrequency introduced by the coblation instrument could have compromised the vasculature of the internal side of the anterior tonsillar pillar, resulting in a defect as the tissue began to heal post-operatively.

Another commonly described complication of adenotonsillectomy is hemorrhage, given the highly vascular nature of the tonsillar fossa.¹ Intra-operative immediate hemorrhages, often stemming from insufficient cauterization, necessitate further cauterization for management.¹ However, this can pose technical challenges due to obstructed visualization caused by active hemorrhage. Consequently, electrocautery may exhibit reduced precision and inadvertently damage surrounding mucosal structures in the oropharynx, such as the anterior tonsillar pillar. This mechanism can lead to compromised vasculature, potentially resulting in a mucosal defect as the wound heals.

While rare, several case reports described injuries to the anterior tonsillar pillar during endotracheal intubation. One case report described a soft-palate injury in a 44-year-old man from intubation.⁴ In this case, the endotracheal (ET) tube punctured the anterior tonsillar pillar superior to the tonsil and required suturing to repair.⁴ Of note, the palatal injury was recognized during the removal of the video laryngoscope.⁴ However, in our patient’s case, a defect in the anterior tonsillar pillar was not noted during her tonsillectomy nor her follow-up care. In another case report, an ET tube punctured the anterior tonsillar pillar in a 58-year-old woman.⁵ In this instance, the anterior tonsillar pillar was perforated when the ET tube was placed, and there were no known sequelae from the perforation other than a persistent defect in the anterior tonsillar pillar.⁵ A medical literature review did not identify any case reports involving pediatric patients.

Similar mechanisms may cause anterior tonsillar pillar perforations as palatal perforations. One study examined adults with palatal perforations, finding that most were related to recreational drug use, infectious diseases, or trauma.⁶ In pediatric patients, it is more likely that infectious disease or trauma is responsible for palatal perforations. This study found that mucormycosis was the most common infectious etiology, and surgical trauma, including adenotonsillectomy and orotracheal intubation, were the most common trauma-related causes in adults.⁶ However, infection with mucormycosis is often linked to uncontrolled type II diabetes mellitus, immunodeficiency, or hematologic malignancy, none of which were present in the patient in our case.^6,8 While our patient was diagnosed with a viral URI, her symptoms resolved with supportive care, and she had no other features suggestive of severe infection on her physical exam, making an infectious cause of her anterior tonsillar defect less likely.

Because our patient had a tonsillectomy 2 years before presentation, it is possible that, over time, a scar tissue contracture formed a defect in her anterior tonsillar pillar.⁹ The anterior tonsillar pillar consists of the palatoglossus muscle, which is comprised of higher amounts of elastin and collagen than other oropharyngeal muscles.¹⁰ In a tonsillectomy procedure, this tissue may be injured, resulting in scar tissue formation and decreased elasticity.¹⁰ One case report describes a 52-year-old woman who was difficult to intubate due to a contracture of scar tissue of the anterior tonsillar pillar from prior tonsillectomy; this complication has rarely been described in the medical literature.⁹ However, oropharyngeal stenosis resulted from this scar tissue contraction, not a defect in the mucosa as seen in our patient. Additionally, the visualized defect in our patient shows scar tissue adjacent to the defect rather than surrounding it completely, suggesting that scar tissue contracture alone is an unlikely cause.

Another possible etiology is crypta magna erosion through the anterior tonsillar pillar due to chronic inflammation of the tonsils. The tonsils contain crypta magna, deep branching crypts that contain lymphoid tissue for immune function and are lined by epithelium.¹¹ Chronic inflammation of the tonsils leads to tonsillar hypertrophy, as seen in our patient, due to immune dysregulation.¹¹ Enlargement and inflammation of the tonsils may result in abnormal adherence of the tonsillar tissue to the anterior tonsillar pillar, resulting in perforation over time. This is an improbable cause in our patient as her tonsils were removed before the defect was observed.

In our patient, the most likely etiology of her anterior tonsillar pillar defect is surgical trauma resulting from coblation-induced vascular compromise in the mucosal tissue of the anterior tonsillar pillar, contributing to the formation of the defect during mucosal healing: this explains the absence of immediate visualization post-operatively. In the absence of infection, it is reasonable to continue to monitor at routine well-care visits without further workup if an anterior tonsillar pillar defect is visualized in a pediatric patient with a history of adenotonsillectomy. Alternatively, a more-detailed examination is warranted if a pediatric patient has not had their tonsils removed or if it is suspected that the tonsillar pillar defect is secondary to or caused by an oral infection. In those cases, further workup and referral to an otolaryngologist may be necessary.