Case 20: Bad Breath

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I carried it around with me the entire shift. I showed it to my E.R. colleagues, the internists, and even a couple of surgeons. I’d tell them the story. “Never,” one of them said. “Not in twenty-eight years. Never seen that before.”

One of them held the small urine jar up to a light and began unscrewing the lid.

“Don’t!” I said.

“Why not?”

“It stinks. You wouldn’t believe how much it stinks. We aerosolized the room and closed the door. You could still smell it for hours. It’s awful. Putrid.”

“Abscess,” was the presenting complaint. There’s something satisfying about draining an abscess. It’s one of the few procedures that can provide instant relief to the patient. Sandra Lee, the Dermatologist also known as Dr. Pimple Popper has squeezed, pinched, punctured to the delight of over one hundred million viewers on YouTube.

The patient was in his mid-30s and came in at his wife’s insistence on a Friday night. Earlier in the day, he’d noticed a small lump under his tongue. He’d planned to stop into a walk-in clinic later that weekend, but his family couldn’t take the stench. The nurse at triage took his pulse, and blood pressure, but just as soon as he’d opened his mouth and raised his tongue, she said “that’s good,” waved him off, and took breaths through her mouth.

“I’ve had problems with the right side of my mouth for years,” he said.

“How many years?”

“Over twenty. It swells under my tongue on this side,” he said, thumb planted into his lower jaw. “It comes, then it goes.”

“What brought you in today?”

“It began to swell, and then I felt a lump under my tongue. Right in the middle.”

I asked him to raise his tongue. A tiny whitehead was on the floor of his mouth, right in the middle. “It looks like it’s infected,” I told him. “I just need to make a small incision.” Seconds later, I poked it with the tip of a scalpel, expecting a surge of pus to relieve the pressure. It was rock hard. When I tapped it a second time, the patient winced as the flesh under his tongue bulged. “It’s not an abscess,” I told the patient, as the odor hit me. It didn’t smell like pus – it smelled worse. It was the putrid pungence of blue cheese – only without the cheese – just the blue.

I returned with forceps, two masks around my lips and nose, and a cinematographer named Pez. I grabbed the tip of the whitehead and pulled it. It slid out smoothly, and looked like a small saber-tooth.

It was a sialolith – a salivary duct stone.

The estimated frequency of sialoliths in the general adult population is 1.2% As with this patient, most occur in the submandibular gland, or its duct – Wharton’s duct – and can be seen on x-ray if symptomatic. Most stones are smaller than 10 mm, and they are rarely larger than 15 mm. In fact, those larger than 15mm can be classified as ‘Giant’ Salivary gland calculi, and only 14 well-documented cases of giant stones were reported in medical literature between 1942 and 2002.

Although there were no signs of infection after removal, it was likely that the stone itself was harboring bacteria that had clumped on to it, and festered, considering the horrendous stench.

And the patient? He was relieved to have finally the (giant) 23 mm stone removed. And six months later, the patient reported no residual symptoms.

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10 comments

  1. I made it here from the /r/popping subreddit and just spent a few hours reading your past posts. Your stories are fascinating and your writing is fantastic! Thank you for caring for these patients and sharing, and keep doing what you do.

  2. Wow. That’s what those are called. I had one in my early 20s and after two days of swelling under my tongue I couldn’t take it anymore. I felt around in there and noticed a lump in my right saliva duct. I tried pushing it out but that didn’t work so I sucked to try and produce spit. My left side worked but not the right. So I sucked harder until pop! It came out. Then foul spit was in my mouth. I figured it was foul due to the blockage. My stone was tiny I thought it was a grain of salt that got stuck and started to get covered like an oyster pearl. Instant relief though, after a mouth rinse.

  3. same here as last story, I went to my Dr after I Google blocked saliva duct..if I pushed it in fluid would spray out like a check valve. it was causing a lot of pain but I ended up pushing it out with my tongue family Dr never heard of it before. I don’t remember a crazy odor tho and it wasn;t that big that’s for sure

  4. I have had a Sialolith since i could remember. I am now win my late 20’s and am going to go to a dentist/oral surgeon in hopes of getting it removed. I know mine is large. It flares up from time to time and i have to drink lemon water and also chew gum to alleviate the pain. I am hoping they are able to extract the stone without any problem. I am afraid alot of inflammation and scarring occured since i first found out about it about 7 years ago. Thanks for the article.

  5. Very interesting, my stone journey started in 2000 when my doctor sent me to a specialist as my right side saliva duct was swollen and extremely painful. The otolaryngologist told me it was a saliva stone and my choices were 1) let it be if I could manage the pain 2) have it removed by a small incision. Over the years it never went away and often acting up but manageable. January 6, 2017 I started Chemo FEC-D, two weeks later I was in my doctor’s office in pain, difficulty eating and swallowing. She made an appointment with a specialist but that takes time. The following week was my next chemo appointment so I suffered through the pain unable to eat, drink or swallow much of anything as my saliva gland kept getting bigger and so inflamed looking. My Oncologist postponed chemo and put me on antibiotics for possible infection with orders to go to the hospital if this did not calm down. By this time I had difficulty talking and could hardly move my tongue for the excruciating pain. 24 hours later I woke up in the middle of the night as I thought I lost a tooth only to spit out a stone and was astonished to find that it was a stone then noticed a small white pimple on my saliva gland. As I looked and poked at it, I was shocked when a 2nd stone (not a pimple) seemed to be making its way out so I started taking pics – totally fascinated and grossed out at the same time!! Immediate relief!!! Both stones together measured 3/4 inch and as larger as the end of a Q-tip swab. This second stone took no more than 30 minutes to make its way out as I snapped lots of pictures from various angles. Left a significant hole in my saliva gland and very dark in color but no blood and no bad odor, I rinsed my mouth with salt water and by morning absolutely nothing… not a signs whatsoever. Without these pictures I wouldn’t even believe myself! Happy to know I’m not alone, as none of my doctors had ever seen anything like this

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