Discussion
This study has demonstrated a significant correlation between recurrent tonsillitis and halitosis. Tonsillitis is a very common clinical condition, with tonsillectomy being performed when patients suffer from repeated disabling episodes4. Recurrent tonsillitis causes significant morbidity for the patient including time of work, with a major impact on a patient’s quality of life8. The TIO-14 is a disease specific quality of life tool for assessing sore throat. In this study the mean TOI-14 score was 48.22, comparable to Skevas et al and Roplekar et al5,9. Laajala et al demonstrated that a TOI-14 score of greater than 40 suggests a patient has severe symptoms of tonsillitis. There was no evidence of correlation between the TIO-14 and sex, BMI, reflux or smoking status comparable to the findings by Laajala et al.
Although oropharyngeal pathology is frequently listed as a cause for halitosis, there is little published literature to support this. The few papers that discuss halitosis in relation to oropharyngeal pathology tend to highlight tonsoliths as the cause of halitosis, rather than provide evidence that tonsillitis is the cause. In this paper only 3 patients had tonsil stones, and this was not significantly related to the HALT score. The HALT has never been used in patients with recurrent tonsillitis. Halitosis can significantly impact on a patient’s quality of life, with it being considered one of the most socially unattractive aspects of social interactions10. Patients can have low self-esteem, anxiety, depression and poor self-confidence. The halitosis can also impact on relatives and friends as they may need to reassure or counsel the sufferer about their bad breath. There is also a large economic burden associated with halitosis, with Meninguad et al reporting that over 2 billion dollars is spent annually on products to mask halitosis11. Therefore a considerable amount of psychological, social and economic resources are dedicated to patients with halitosis, in a similar way to those with recurrent tonsillitis. The HALT was not associated with smoking, although smoking is commonly linked to severity of halitosis. Halitosis is not an indicator for tonsillectomy in the UK, however some countries list it as a relative indication. This is the first evidence that patients with poor quality of life due to sore throat also have poor quality of life due to halitosis.
The significant correlation of the TIO-14 and HALT could be attributed to the questionnaires asking the same questions, however there is only one question that is the same in both questionnaires – patients are asked about sore throat. There is no overlap between the other questions.
It is well established that tonsillectomy improves the TIO-14 score in patients. It is currently unknown if the HALT score is modified by tonsillectomy.