Can tonsillitis occur in the tonsillar pillars after a tonsillectomy?

Can Tonsillitis Occur in the Tonsillar Pillars After Tonsillectomy?

Yes, peritonsillar inflammation and even abscess formation can occur after tonsillectomy, though it is rare, because the tonsillar pillars contain minor salivary glands (Weber's glands) and residual lymphoid tissue that can become infected. 1, 2

Anatomical Basis for Post-Tonsillectomy Infection

The peritonsillar space contains structures that can become infected even after complete tonsil removal:

• Minor salivary glands (Weber's glands) are present in the peritonsillar space in approximately 67.5% of patients and can serve as a source of infection 2
• These glands are located near the tonsillar pillars and show signs of infection in 94.8% of cases when positioned close to where tonsillar tissue was located 2
• Congenital branchial fistulas may also serve as potential infection sources in the peritonsillar region 1
• Residual lymphoid tissue in the oropharynx can harbor pathogens even after tonsillectomy 3

Clinical Evidence of Post-Tonsillectomy Peritonsillar Abscess

While uncommon, peritonsillar abscess formation after tonsillectomy is well-documented:

• A systematic literature review identified 11 cases of peritonsillar abscess occurring in the complete absence of tonsillar tissue 1
• The mean interval between tonsillectomy and subsequent peritonsillar abscess was 16 years, though it can occur at any time 1
• Nine of these patients had no prior peritonsillar infections between their tonsillectomy and the abscess formation 1
• The most common original indication for tonsillectomy in these cases was recurrent tonsillitis or previous peritonsillar abscess 1

Pathophysiology of Peritonsillar Inflammation

The mechanism differs from typical tonsillitis but produces similar clinical presentations:

• Periductal inflammation of minor salivary glands is significantly more common in peritonsillar abscess cases (82.1%) compared to recurrent acute tonsillitis (42.9%) 2
• Infection of these glands, rather than tonsillar tissue itself, may be the primary pathogenic mechanism 2
• The pharyngeal tissue and remaining lymphoid structures can still harbor Group A Streptococcus and other pathogens 3

Clinical Implications

Patients who have undergone tonsillectomy remain susceptible to throat infections and can develop peritonsillar inflammation or abscess, though the risk is substantially reduced:

• Tonsillectomy provides only modest reduction in throat infections: 1.4 fewer episodes in the first year, with benefits diminishing thereafter 3
• By the third year post-tonsillectomy, infection rates between surgical and non-surgical groups show no statistically significant difference 3
• The number needed to treat with tonsillectomy to prevent one sore throat per month for the first year is 11 3

Management Approach

When peritonsillar inflammation or abscess occurs post-tonsillectomy:

• Manage with incision and drainage or needle aspiration with antibiotics, identical to management in patients with intact tonsils 1
• Consider alternative infection sources including Weber's glands, branchial fistulas, or dental disease 1
• These alternative sources should be investigated particularly when peritonsillar abscess occurs without concurrent pharyngitis 1

Important Caveat

The absence of tonsils does not eliminate the anatomical structures (tonsillar pillars, peritonsillar space, minor salivary glands) that can become inflamed. While the term "tonsillitis" technically requires tonsils to be present, peritonsillar inflammation and infection of the pillar region can and does occur post-tonsillectomy, representing infection of residual structures rather than tonsillar tissue itself. 1, 2