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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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8 Comment on “Case 20: Bad Breath

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