A 47-year-old businessman presented with a long-standing but increasingly concerning problem of bad breath. He had tried all the usual OTC medications with little success and visits to his dentist and oral hygienist had been unfruitful.
He was normally in good health with no concerns. He said that he did not drink more than 20 units of alcohol a week and that he was a non-smoker. He was unaware of any reflux or indigestion and said his diet was quite varied, although he had the occasional takeaway or other 'convenience food'.
On examination he appeared to be healthy and generally well. His BMI was 24kg/m2. His oral cavity looked normal but he had a mild but noticeable, almost putrid, odour. The examination of his neck was unremarkable, his nose and sinuses appeared normal.
This man had already had two courses of antibiotics (erythromycin and doxycycline) prescribed by his dentist for possible underlying infection in his sinuses but without benefit.
The question was either to treat this patient pragmatically for symptom relief or to refer to a specialist. It was important also to consider whether referral would be to a gastroenterologist or an ENT specialist.
Although this patient was keen to receive treatment quickly, we agreed on some basal blood tests including liver function, renal function, blood sugar, inflammatory markers, CRP, amylase and FBC as well as a stool test for Helicobacter pylori. We also considered a trial course of PPIs because OTC treatments such as ranitidine had not helped.
In general, halitosis is very common and often only temporary, dependent on certain foods or other oral intake. For example, patients on high-protein diets might be aware of the potential effect of these on their breath.
The majority of causes for halitosis are systemically quite harmless and can be found within the oral cavity, typically as a result of inadequate hygiene. These would normally be effectively dealt with by dental practitioners by instruction on oral hygiene, tongue-cleaning and mouth rinsing.
Apart from infections and inflammation of either the teeth or gums, these conditions can be part of more systemic medical problems, for example dryness in Sjogren's syndrome.
Certain drugs (such as oral nitrates and disulfiram) may alter the smell of the breath. Acute infections of the upper or lower respiratory tract and the digestive system are associated with halitosis.
Chronic lung conditions (bronchiectasis, cystic fibrosis, lung abscesses and TB) can lead to chronic bad breath, often also associated with cough and breathing symptoms.
Nasal and sinus conditions such as atrophic rhinitis, postnasal drip and chronic sinusitis are sometimes overlooked. Reflux or silent reflux (either H pylori positive or negative) are often underdiagnosed and underestimated in their relevance for a number of problems, including halitosis.
Some disorders of the liver or kidneys, or related disorders to diabetes, may display characteristic kinds of bad breath, though these often show other signs as well. Very rarely, toxic causes such as thallium and arsenic might need to be considered.
Some patients may present with pseudohalitosis and its more severe form, halitophobia (patient worried about bad breath, despite it not being noticed by anybody else) as an aspect of possible psychosomatic problems.
All the requested results for this patient returned normal, apart from a minimally elevated CRP of 23mg/L and a borderline gammaglutamyl transpeptidase of 55IU/L.
The patient was advised that he might consume more alcohol than he actually estimated and probably would benefit from cutting down. He did not experience any benefit from PPIs and was subsequently referred to ENT for further assessment.
Suspicion of a small pharyngeal pouch (Zenker's diverticulum) was confirmed by barium swallow.
A pharyngeal pouch is caused by a mechanical weakness between the thyropharyngeal and the cricopharyngeal muscle.
It is more common in men than in women and tends to present later in life. Clinical features often include dysphagia, due to the gradually increasing obstruction of the pouch which fills up with food.
Eventually, regurgitation of food follows in many cases. The swelling of the pouch is likely to be palpable and might even be visible. Sometimes it produces characteristic gurgling noises. Patients are at increased risk of aspiration pneumonia.
In this scenario, the pouch was small enough to remain asymptomatic regarding swallowing, but big enough to trap very small quantities of food which would then start to smell.
The patient opted for surgery, which was performed as a simple myotomy, which cured him of his problem.
- Dr Jacobi is a salaried GP in York.