Unilateral Asymmetrical Tonsil - Next Steps?

I have a unilateral asymmetrical mass on my left tonsil that was discovered in December. Had a CT scan 3 weeks ago and seeing ENT on Tuesday. Would appreciate any insight on: 1. Any questions to ask; 2. Whether this could still be something sinister (and if so, what the probability of that would be); and 3. Whether this is something that might typically be operated on or biopsied.

All background info and results are below - CT, ultrasound, and blood work.

BACKGROUND

  • F47, located in western Canada.
  • Had thyroid nodule (benign oncocytoma) removed in 2016. During that surgery my left recurrent laryngeal nerve was cut, which led to left vocal cord paralysis. Had hydroxyapatite injection into left vocal cord in 2016 and that has allowed me to speak normally ever since.
  • Medications: Hormone replacement therapy (Estradot 50 & Prometrium 100) for premature ovarian failure diagnosed at age 38. Escitalopram 10mg and bupropion 300mg for anxiety (since early 2021), and Vyvanse 40mg (since late 2023).

CURRENT SITUATION & IMAGING RESULTS

A regular dental checkup on December 12, 2024 revealed that I have a left unilateral asymmetrical enlarged tonsil. Both the dentist and hygienist said it doesn’t look like inflammation or an infection and asked me to get it checked out by an ENT. I had a dental cleaning six month prior (been to this same dentist for over 15 years) and they mentioned that they would have made note of this in my chart if they had seen it then. We’re guessing that this showed up some time between June - December 2024.

I saw my family doctor a week later, who took a look with these magnifying goggles. He referred me to an ENT (that appointment is scheduled for February 25). My doctor said he doesn’t know what to make of it and described it as “lobulated” and like a bulb off one side of my left tonsil.

My doctor said there is no sign of infection or inflammation, ears look normal, and strep swab was negative.

NECK ULTRASOUND from December 18, 2024:

My doctor sent me for a neck ultrasound before Christmas and that was normal. No enlarged lymph nodes or signs of anything.

“CLINICAL HISTORY: - Left neck anterior lymph node, query prominent. Change in left tonsil, lobulated. - Distant left thyroidectomy for Hürthle cell tumor. COMPARISON: 24 August 2020 FINDINGS: - No enlarged lymph nodes in the upper, mid or lower neck. - Parotid glands appear within normal limits. - Submandibular glands appear within normal limits. - The patient's region of concern in the left superior/anterior neck, normal appearing lymph nodes noted. IMPRESSION: - No significant abnormality.”

CT SCAN WITH CONTRAST from February 3, 2025:

CT SOFT TISSUE NECK - ENHANCED HISTORY: CT Neck. Left tonsilar hypertorphy ( x less than 6 months) with transient discomfort in left throat and left ear during bouts. ? Neck pathology causing sx. TECHNIQUE: Soft tissue neck protocol. COMPARISON: MRI brain October 2024, CTA head and neck October 2024

FINDINGS: PHARYNGEAL MUCOSA AND ORAL CAVITY: No suspicious lesion. LYMPH NODES: No lymphadenopathy. LARYNX: No suspicious lesion. CT findings of left vocal cord palsy. MAJOR SALIVARY GLANDS: No parotid or submandibular gland mass bilaterally. THYROID: Prior left hemithyroidectomy. No suspicious nodule or mass. VESSELS: Major vascular structures enhance normally. INTRACRANIAL COMPARTMENT: Visualized brain parenchyma is unremarkable. ORBITS: No mass lesion or extra ocular muscle enlargement. PARANASAL SINUSES: Mild scattered mucosal thickening. BONES: No worrisome lesion. UPPER THORAX: Unremarkable. OTHER: None significant.

IMPRESSION No worrisome CT finding.

SYMPTOMS

  • Mass on tonsil was asymptomatic in December. Gradually it started to feel irritated, sharp (not shooting), and just angry. This has been ongoing for about 3 days/week for the 7-8 weeks.
  • On January 5-8 the pain was so sharp, felt irritated, and had left fullness in ear. On the 8th it also felt like my airway had swelled up and like there was a flap or something dangling down my throat that wouldn’t go away. Swallowing became difficult. I ended up taking Claritin and it actually started feeling better. I did see my doctor to follow up, and it was at this appointment that he referred me to this CT scan rather than waiting to see what the ENT has to say (ENT appointment isn’t until Feb. 25).

  • I haven’t had breathing issues since, but every 2-3 days still get this sharp, burning (?), angry pain in that area.

  • The tonsil is described by my doctor, dentist, and hygienist as smooth with one bulb-like thing off the side. It looks very uniform.

  • There are no jagged sides.

  • Colour looks normal. Nothing is white or yellow.

  • No ulceration.

  • Some ear fullness on same (left) side.

  • Left tonsil does not touch the uvula.

  • No tonsil stones are seen.

  • There is no lymphadenopathy as confirmed by ultrasound.

  • No sore throat.

  • No coughing.

  • No bleeding.

  • No weight loss.

  • No change to voice, other than one day of hoarseness a couple of weeks ago.

  • No fever.

  • No history of smoking ever.

  • Only drink occasionally (maybe one drink a month on average).

BLOODWORK from November 28, 2024:

I had my annual physical in early December 2024 before I was aware of this. Bloodwork was done at that time (for the annual physical; there has been no bloodwork ordered specifically for this). All came back normal, except for blood in urine that said Erythrocytes 5-10 Ery/uL. My doctor said this is not anything of concern.

URINALYSIS (this isn’t everything listed under urinalysis): - Leukocytes: negative - Blood: 5-10 Ery/uL (reference: negative). This was the only result flagged as abnormal. - WBC: 0-5/ HPF (reference: 0-5) - RBC: 0-5/ HPF (reference: 0-5) - Squamous/Transitional Epithelial Cells, Urine: 0-5/HPF (reference: 0-5)

CBC AND DIFFERENTIAL - All of these are in normal reference range: - Auto WBC, RBC - Genogkobin, hematocrit - MCV, MCHC, RDW, platelets, nRBC - Neutrophils absolute, immature granulocytes absolute, lymohocytes absolute, monocytes absolute, eosinophils absolute, basophils absolute

TSH - normal LIPID PANEL - all normal CREATININE- Creatinine and eGFR in normal range FERRITIN - normal HBA1C - 5.5%

QUESTIONS:

Based on the above (most notably normal CT), 1. What is the chance that this is benign vs. something sinister? Does the CT rule out that it’s something bad, or could the laryngoscope that the ENT will presumably do reveal something else? It’s the same ENT I’ve seen in the past for my vocal cord paralysis, so he’d have those as a comparison. 2. Is this something that would normally get removed, and if so, just that tonsil with this thing on it, or would both be removed? 3. Any other questions I should be asking the ENT?

I have a photo showing this, but cannot add it to posts here. Feel free to DM me to see photo.