ENT Picture of the Day 4-2-11

[HeadNeckPA]

This is a 35 yr old female who complains of chronic throat irritation associated with bad halitosis and occasional coughing smells where she expectorates what she describes as foul-smelling debris.

 

She smokes a pack a day and is otherwise healthy with the exception for some dietcontrolled hypertension. She denies and weight loss, fevers, or trouble swallowing. She is extremely nervous and anxious for "something on her tonsil."

 

You examine the patient's oral cavity and you see the picture below.

 

What are your thoughts and what else would you like to know?

 

[Acebecker]

The things that come to mind are tonsillar stones or possibly a Zenker diverticulum. I have very little experience in ENT and I realize that Zenker's typically occur further down in the esophagus, but from my recollection they can occur anywhere in the oropharynx. I would get a CT or neck MRI to visualize the area better (unless there are imaging techniques more commonly used in ENT practice that would fit the picture better). Interesting case - thanks for the pics.

[acozadd]

Looks like some fairly large tonsiliths.

[delco714]

The first paragraph of the hpi is textbook zenker's as above said. But something has to be said about those left tonsils in the pic! Dunno what to really make of them though..

[ventana]

cryptic tonils with nasty degrading food in them...... to make sure just take a wooden qtip and see if they do not "pop" out with manipulation

 

halitosis can be severe

 

have sent pt's to ENT for tonsilectomy due to this....

 

course I could be wrong....

 

other chronic tonsilitis DDx..... strep, thrush, acute - diptheria, Gonorrhrea, PTA

[HeadNeckPA]

This is indeed a case of tonsiliths (ie tonsil stones) or as we often refer to it in the ENT world, chronic sebaceous tonsillitis.

 

The debris in the tonsillar crypts is usually a combination of tonsil secretions, bacteria and occasionally food particles.

 

Very often these patients have a longstanding h/o chronic halitosis that is the underlying reason why they present. We will frequently do tonsillectomies on these patients if their symptoms are bothersome enough.

 

Good oral hygiene is the best initial treatment and I will often recommend the use of a dental water pick and listerine rinses. Some patient's can't tolerate debridement due to their gag reflex, making the decision for tonsillectomy that much easier.