Halitosis as an indication for tonsillectomy in chronic hypertrophy tonsillitis

Agata Zalewska1, Marek Bochnia2, Monika Morawska-Kochman3

1MD, PhD, Wroclaw Medical University Poland, Faculty od Dentistry Department of Otolaryngology; 2MD, PhD, Wroclaw Medical University Poland, Faculty od Dentistry Department of Otolaryngology; 3MD, PhD, Wroclaw Medical University Poland Faculty of Medicine, Clinic of Otolaryngology, Head and Neck Surgery.

International Research Journal of Otolaryngology

Main purpose: This paper aimed to confirm a relationship between chronic hypertrophic tonsillitis (CHT) and bad mouth odour. To this end, detailed identification of the microbial flora inhabiting affected tonsils was carried out. The results obtained might be helpful in specifying indications for tonsillectomy.

Materials and method: From among 247 patients with clinically diagnosed CHT, 33 generally healthy individuals aged 18- 40 (10 male and 23 female) were selected. Patients in whom other causes could be the possible reason for their fetor ex ore (halitosis) were not included. Before and 2 to 3 months after tonsillectomy, organoleptic and halimeter testing was undertaken for each patient. A swab was collected from the interior of the enucleated tonsils in a sterile manner, and was inoculated onto surfaces enabling the culture of aerobic and anaerobic bacteria and fungi. A histopathological examination was subsequently performed.

Results: Fetor ex ore was initially found in 95% of the patients with CHT. In 90% of cases with confirmed halitosis, after tonsillectomy a significant reduction in its intensity was observed. On average, the concentration of VSC in the patient decreased by approximately 75 ppb (62%), which was statistically significant (p < 0.0001). It was also shown that the concentration of VSC in carriers of anaerobic bacteria, compared to carriers of only aerobic bacteria, was significantly reduced (p < 0.05). The results obtained confirm the role of CHT in the pathogenesis of halitosis.

Conclusions: Halitosis in patients with CHT requires a number of laboratory tests and specialist consultations to exclude other possible causes of fetor ex ore. A dental examination plays an important role in the differential diagnosis. Performing targeted microbiological testing to determine the patient’s carrier state for anaerobes should eventually be considered. When these conditions are met, halitosis can be considered an independent indication for tonsillectomy.

Keywords: Halitosis, Indication for Tonsillectomy, Chronic Hypertrophy Tonsillitis

Free Full-text PDF

How to cite this article:
Agata Zalewska, Marek Bochnia, Monika Morawska-Kochman. Halitosis as an indication for tonsillectomy in chronic hypertrophy tonsillitis.International Research Journal of Otolaryngology, 2019, 2:8. DOI: 10.28933/irjo-2019-07-0205


1. HUGES F.J., McNAB R., Oral maladour – a review, „Archives of Oral Biology” 2008, nr 53, sup. 1: s. 1–7.
2. PARADOWSKA A., SŁAWECKI K., Halitoza – przegląd piśmiennictwa „Czasopismo Stomatologiczne” 2008, nr 61: s. 815–822.
3. LEE P.P., MAK W.Y., NEWSOME P., Th e aetiology and treatment of oral halitosis: an update, „Hong Kong Medical Journal” 2004, nr 10: s. 414–418.
4. BOLLEN C.M., ROMPEN E.H., DEMENEZ J.P., Halitosis – a multidisciplinary problem, „Revue Médicale de Liège” 1999, nr 54: s. 32–36.
5. MENINGAUD J.P., BADO F., FAVE E., BERTRAND J.C., GUILBERT F., Halitosis in 1999, „Revue de Stomatologie et de Chirurgie Maxillo-faciale” 1999, nr 100: s. 240–244.
6. PARADOWSKA A., MARCZEWSKI B., PAWŁOWSKA-CIERNIAK E., Selfperception of halitosis among students of Wrocław Medical University, „Advances in Clinical and Experimental Medicine” 2007, nr 16: s. 543–548.
7. TOMAS CARMONA I., LIMERES POSSE J., DIZ DIOS P., FERNANDES FEIJOO J., VAZGUEZ GARCIA E., Extraoral etiology of halitosis, „Medicina Oral” 2001, nr 6: s. 40–47.
8. RAYMAN S., ALMS K., Halitosis among racially diverse populations: an update, „International Journal of Dental Hygiene” 2008, nr 6: s. 2–7.
9. BOSY A., Oral malodor: philosophical and practical aspects, „Journal of the Canadian Dental Association” 1997, nr 63: s. 196–201.
10. ATTIA E.L., MARSHALL K.G., Halitosis, „Canadian Medical Association Journal” 1982, nr 126: s. 1281-1285.
11. QUIRYNRN M., DADAMIO J., VAN DEN VELDE S., DE SMITH M., DEKEYSER C., VAN TORNOUT M., VANDEKERCKHOVE B., Characteristic of 2000 patients who visited a halitosis clinic, „Journal of Clinical Periodontology” 2009, nr 36: s. 970–975.
12. IMFELD T., Bad breath-aetiology, diff erential diagnosis and therapy, „Th erapeutische Umschau” 2008, nr 65: s. 83-89.
13. FELLER L., BLIGNAUT E., Halitosis: a review, „SADJ: Journal of the South African Dental Association” 2005, nr 60: s. 17–19.
14. SANZ M., ROLDAN S., HERRERA D., Fundamentals of breath malodour, „Journal of Contemporary Dental Practice” 2001, nr 15: s. 1–7.
15. SPIELMAN A.L., BIVONA P., RIFKIN B.R., Halitosis. A common oral problem. „New York State Dental Journal” 1996, nr 62: s. 36–42.
16. NALÇACI R., DÜLGERGIL T., OBA A.A., GELGÖR I.E., Prevalence of breath malodour in 7–11-year-old children living in Middle Anatolia, Turkey, „Community Dental Health” 2008, nr 25: s. 173–177.
17. VAN DEN VELDE S., QUIRYNEN M., VAN HEE P., VANSTEENBERGHE D., Halitosis associated volatiles in breath oh healthy subjects, „Journal of Chromatography B: Analytical Technologies in the Biomedical and Life Sciences” 2007, nr 853: s. 54–61.
18. TONZETICH J., Production and origin of oral malodor: a review of mechanisms and methods of analysis, „Journal of Periodontology” 1977, nr 48: s. 13–20.
19. KAZOR C.E, MITCHELL P.M., LEE A.M., STOKES L.N., LOESCHE W.J., DEWHIRST F.E., PASTER B.J., Diversity of bacterial populations on the tounge dorsa of patients with halitosis and healthy patients, „Journal of Clinical Microbiology” 2003, nr 41: s. 558–563.
20. WASHHIO J., SATO T., KOSEKI T., NOBUHIRO T., Hydrogen sulfi d-producing bacteria in tongue biofi lm and their relationship with oral malodour, „Journal of Medical Microbiology” 2005, nr 54: s. 889–895.
21. WALER S.M., On the transformation of sulfur-containing amino acids and peptides to volatile sulfur compounds (VSC) in the human mouth, „European Journal of Oral Sciences” 1997, nr 105: s. 534–537.
22. GANCARZ R., MIKŁASZEWSKA I., MALISZEWSKA I., FRĄCKOWIAK A., BRUZEWICZ-MIKŁASZEWSKA B., Gram negative microorganisms and oral malador, „Dental and Medical Problems” 2004, nr 41: s. 235–239.
23. STERER N., ROSENBERG M., Streptococcus salivarius promotes mucin purifi cation by Porphyromonas gingvinalis, „Journal of Dental Research” 2006, nr 85: s. 910–914.
24. BRUZEWICZ-MIKŁASZEWSKA B., URBANOWICZ I., OWCZAREK H., Microbiological aspects of halitosis, „Dental and Medical Problems” 2003, nr 40: s. 117–120.
25. LOESCHE W.J., KAZOR C.E., Microbiology and treatment of halitosis, „Peridontology” 2000–2002, nr 28: s. 256–279.
26. GOLDBERG S., KOZLOVSKY A., RESENBERG M., Association of diamines with oral malodor, [w:] ROSENBERG M. (red.), Bad Breath Research Perspectives, Tel Aviv: Ramot Publishing 1995, s. 71–86.
27. KLEINBERG I., CODIPILLY M., Biological basis of oral malodor or formation, [w:] ROSENBERG M. (red.), Bad Breath Research Perspectives, Tel Aviv: Ramot Publishing 1995, s. 13–40.
28. PERSON S., CLAESSON R., CARLSSON J., Th e capacity of subgingval species to produce volatile sulfur compounds in human serum, „Oral Microbiology and Immunology” 1989, nr 4: s. 169–172.
29. MCNAMERA T.F., ALEXANDERJ F., LEE M., Th e role of microorganisms in the production of oral malodour.
30. YAEKI K., SANADA K., Biochemical and clinical factors infl uencing oral malodor in peridontal patients, „Journal of Periodontology” 1992, nr 63: s. 783–789.
31. DE BOEVERE E.H., LOESCHE W.J., Assessing the contribution of anaerobic microfl ora of the tongue to oral malodor, „Journal of the American Dental Association” 1995, nr 126: s. 1384–1393.
32. HARASZTHY V.I., ZAMBON J.J., SREENIVASAN P.K., ZAMBON M.M., GERBER D., REGO R., PARKER C., Identifi cation of oral bacterial species associated with halitosis, „Journal of the American Dental Association” 2007, nr 138: s. 1113–1120
33. DONALDSON A.C., MCKENZIE D., RIGGIO M.P., HODGE P.J., ROLPH H., FLANGAN A., BAGG J., Microbiological culture analysis of the tongue anaerobic microfl ora in subject with and without halitosis, „Oral Diseases” 2005, nr 11, sup. 1: s. 61–63.
34. MATHEW J., VANADA K.L., Detection and measurement of oral malodour in periodontitis patients, „Indian Journal of Dental Research” 2006, nr 17: s. 2–6.
35. LEE H., KHO H.S., CHUNG J.W., CHUNG S.C., KIM Y.K., Volatile sulfur compounds produced by Helicobacter pylori, „Journal of Clinical Gastroenterology” 2006, nr 40: s. 421–426.
36. LEE H., KHO H.S., CHUNG J.W., CHUNG S.C., KIM Y.K., Volatile sulfur compounds produced by Helicobacter pylori, „Journal of Clinical Gastroenterology” 2006, nr 40: s. 421–426.
37. BOENNINGHAUSE H-G., Otolaryngologia, Warszawa: Springer PWN 1997.
38. DARROW D.H., SIEMENS C., Indications for tonsillectomy and adenoidectomy, „Laryngoscope” 2002, nr 112, sup. 100: 6–10.
39. MYERS E.N., Operative Otolaryngology Head and Neck Surgery, Philadelphia: Saunders 2008.
40. SNOW J.B. Jr, WACKYN P.A., Ballenger’s Otorhinolaryngology 17: Head and Neck Surgery, Hamilton, Ontario: BC Decker 2008.
41. TANYERI H.M., POLAT S., Temperature-controlled radiofrequency tonsil ablation for the treatment of halitosis, „European Archives of Oto-Rhino-Laryngology” 2011, nr 268: s. 267–272
42. Al-ABBASSI A.M., Tonsillectomy for the treatment of halitosis, „Nigerian Medical Journal” 2009, nr 18: s. 295–298.
43. CHLOE R.A., FADDIS B.T., Anatomical evidence of microbial biofi lms in tonsillar tissues: a possible mechanism to explain chronicity, „Archives of Otolaryngology – Head and Neck Surgery” 2003, nr 129: s. 634–636
44. KANIA R.E., LAMERS G.E., VONK M.J., HUY P.T., HIEMSTRA P.S., BLOEMBERG G.V., GROTTE J.J., Demonstration of bacterial cells and glycocalyx in biofi lms on human tonsils, „Archives of Otolaryngology – Head and Neck Surgery” 2007, nr 133: s. 115–121
45. ORENDORZ-FRĄCZKOWSKA K., BOCHNIA M., Badania mikrobiologiczne w przewlekłym ropnym zapaleniu migdałków podniebiennych u dzieci, „Nowa Pediatria” 1999, nr 6: s. 140–141.
46. RADOSZ-KOMONIEWSKA H., ROGALA-ZAWADA D., ZIENTARA M., RUDY M., NOWAKOWSKA M., Bacterial Flora in pharyngitis and tonsillitis, „Medycyna Doświadczalna i Mikrobiologia” 1998, nr 50: s. 63–68.
47. ZAUTNER A., KRAUSE M., STROPAHL G., HOLTFRETER S., FRICKMANN H., MALETZKI C., KREIKEMEYER B., PODBIELSKA A., Intracellular Persisting Staphylococcus aureus Is the Major Pathogen in Recurrent Tonsillitis, „PLOS One” 2010, nr 5: s. 9452.
48. LUBBERT C., ALBERT J.G., HAINZ M., PODSZUHN A., SEUFFERLEIN T., Tonsillar actinomycosis as a rare cause of oral malodor. Diagno

Terms of Use/Privacy Policy/ Disclaimer/ Other Policies:
You agree that by using our site, you have read, understood, and agreed to be bound by all of our terms of use/privacy policy/ disclaimer/ other policies (click here for details).

This work and its PDF file(s) are licensed under a Creative Commons Attribution-NonCommercial 4.0 International License.