An 80-year-old man presented to the clinic with a 1 month history of right throat pain, odynophagia and food trapping at the back of the mouth. On examination a deep tonsillar crypt was visualised at the superior pole of the right tonsil (arrow, fig 1). This was also visible on the computed tomography (CT) scan of the neck (arrow, fig 2). A diagnosis of recessus palatinus1,2 was made.
 | Figure 1 Supratonsillar parapharyngeal cleft. |
 | Figure 2 Computed tomography scan of the neck showing the supratonsillar parapharyngeal cleft communicating with the oropharynx. |
The human palatine tonsil is polycryptic. This branching crypt system reaches its maximum size and complexity during childhood. The mouth of a deep intratonsillar cleft (recessus palatinus) opens in the upper part of the medial surface of the tonsil. Even though it is not situated above the tonsil but within its substance, it is often erroneously called the supratonsillar fossa. It is thought that the intratonsillar cleft represents the remains of the fetal second pharyngeal pouch.
In this case the deep crypt initially confused a resident who thought of a malignant ulcerative lesion. However, further examination and biopsy were still necessary to exclude a malignant lesion. Panendoscopy under general anaesthetic was otherwise normal and excision biopsy of the right tonsil was performed.
Histological features were in keeping with reactive changes due to chronic inflammation, and colonies of Actinomyces were found within the deep crypt. The tissue was benign throughout. Following the surgery there was total resolution of symptoms. The deep tonsillar crypt was likely responsible for the symptoms by retaining food debris, with resulting infection and chronic inflammation.