Q:
I am a XX year old woman in good health. All my life, I have had "large tonsils." As a child, most of my colds involved a sore throat (pharyngitis) & often a strep infection, and, often what the doctor classified has "postnasal drip."
For quite some time now, I have had halitosis. I practice good oral hygiene and have never had a cavity, but I can't seem to get rid of my bad breath.
I was recently sick for about a month and a half with a bad cold/viral infection. During that time, I noticed that I had a thick, almost fuzzy whitish coating over my tongue and could do little to nothing to get rid of it. Ever since then, the coat has reappeared often in the mornings, but is easily brushed off when I brush my teeth, etc.
The reason I am writing is to see if you have any insight to add into WHY I have chronic halitosis, and even more importantly, HOW I can get rid of it. Is this an ear/nose/throat-related problem?
A friend of mine told me that halitosis can be caused by overly large tonsils, and something known as nasal concretions, which are basically pieces of rotting food trapped within the tonsils or sinus cavities. Is this information accurate?
A: In medicine we have this concept called
"differential diagnosis," which means, "I
don't know what you have, but here are the
possibilities." This is my differential diagnosis for
bad breath (halitosis):
1. Chronic or acute sinusitis
2. Chronic or acute bacterial rhinitis
3. Chronic tonsillitis*
4. Problems with the teeth and/or gums (cavities, infections,
etc.)
5. Stomach conditions such as reflux (GERD)
6. Cancers in the oral cavity or throat
7. Ingested substances (smoking, eating onion or garlic,
etc.)
8. Psychogenic (your breath bothers you but no one else.)
9. Esophageal diverticulum (Zenker's diverticulum) or
pharyngeal pouch
To this list, I'd also add "other local infections", which would include yeast infection (thrush).
Yes, an ENT is a great place to start to figure out which of the above is your problem. It may also be necessary to see a dentist or an internist, however, so do not be dismayed if your ENT wants to get other people involved.
*Regarding chronic tonsillitis: tonsillectomy in an adult is a VERY painful operation, so you had better be very sure this is what's causing your bad breath before you agree to a tonsillectomy. A 3 to 4 week trial of an appropriate antibiotic is probably a good idea before anyone brings up the topic of surgery.
Also, you need to know that you have tonsil-type tissue (AKA lymphoid tissue) at the base of your tongue (lingual tonsils) and at the roof of your throat (adenoids). Chronic infection can also occur in these areas.
"Nasal concretions" do occur, but your friend is actually referring to "tonsilloliths", or tonsil stones. These are little concretions which collect in the pits ("crypts") of the tonsils. They are usually only smelly if crushed between your fingers . . . usually. I have known some patients whose bad breath was, indeed, due to their tonsilloliths.
My advice: find yourself a good ENT (ask your doctor(s), friends, family for recommendations).
