Bad breath/post-nasal drip - what's causing this?
November 2, 2014 12:30 PM   Subscribe

A few months ago I had a cough, runny nose, light sore throat, and feeling like my sinuses were sending nasty stuff in to my throat. I eventually took a 5-day course of azithromycin for it (sinusitis, the doc said), and it knocked most of it down. But it seems to linger. The only real problem this causes is bad breath. Need help troubleshooting in a systematic way.

Here's the deal:

* Runny/stuffy nose
* Feeling like nose is draining gunk in to throat, I swallow and it's still there
* Mild sore throat
* Resulting bad breath

I have tried
* Nasal irrigation (Alkolol or saltwater)
* 7 days of loratidine 10mg (Claritin)

My doc recommended loratidine to see if I was having a histamine reaction (allergy to something). It seems to reduce the symptoms somewhat, but doesn't eliminate them. The only thing I'm sure I'm allergic to is dust mites and a little bit to grass. stop allergist? Health care is expensive, and not every doc is good at troubleshooting while watching costs. Ideas?

Thanks, MeFites.
posted by 4midori to Health & Fitness (13 answers total)
I read recently that GERD (acid reflux) can sometimes manifest this way, without heartburn. If you have other pointers toward GERD, like a lot of weight at the belly, or having a bent or lying-down posture often, eating late at night, or you eat a lot of trigger foods (acidic foods, chocolate, caffeine...), it might be worth trying a Pepsid an hour before eating, and trying other remedies for GERD - avoiding trigger foods, standing for a period after eating, not eating for several hours before bed, elevating the head of your bed. You could maybe try this for a few days or a week and see if it makes a difference?
posted by LobsterMitten at 12:49 PM on November 2, 2014 [3 favorites]

I would consider either trying a different non drowsy antihistamine (Zyrtec/cetirizine works better for me than Claritin/loratidine) or testing out a stronger antihistamine like Benadryl/diphenhydramine to see if it has a more noticeable effect. (Obviously you should leave at least 24 hours in between these different meds so that you don't double up.) I also find mucinex can help loosen up mucus enough to help it drain better, especially in combination with nasal irrigation.

Did your doctor tell you that the next step would be to see an allergist? It seems like it could be a toss up between that an ear, nose and throat doc since this sounds like it started as a sinus infection. This might be another reason to try out the different antihistamines so you can get some idea of whether this seems to be allergy related. Of course, IANAD and IANYD. I'm just someone who has a lot of personal experience with sinus problems.
posted by litera scripta manet at 12:55 PM on November 2, 2014

Try some good old-fashioned OTC antihistamines. They work by drying you up while, with most people, making you a bit sleepy. Think Diphenhydramine. No brand names needed, the generics are just as effective, and usually very inexpensive. If you take CNS depressants (like benzos) you may get by with half a 25mg tablet. If nothing else, it should tell you if the bad breath is being caused by the drainage, which is most likely. The loratidine (Claritin) is good if taken over a period of time. The Diphenhydramine works within an hour or so. I am not your doctor, of course, but I am a sufferer of fall allergies - complete with all of your symptoms.

Good luck!
posted by Gerard Sorme at 12:56 PM on November 2, 2014

Best answer: Well, first of all, azithromycin won't do shit for sinusitis. I mean, it's not recommended. Sometimes it helps because it has an anti-inflammatory effect. We usually use a course of a amoxicillin/Augmentin/rarely a quinolone, for bacterial sinusitis.

And that's only if we really think it's bacterial sinusitis or symptoms don't get better with conservative management.

What would make me think it's sinusitis? Well, sinus pain/headache, fever and purulent snot. Or if things don't get better with conservative management, which usually takes care of other causes of sinusitis.

Other causes include viruses and allergies, as you'd mentioned. Conservative management includes what you've tried: antihistamines, saline irrigation, and decongestants.

I'd recommend a regular regimen of decongestants, continued and frequent irrigation with a Neti pot or a gentle saline spray, and, if loratidine didn't work, Benadryl. First-generation antihistamines such as Benadryl are generally superior to second-generation ones, like loratidine, though people prefer the latter as they're not as sedation. I'd try some ibuprofen as well, as an anti-inflammatory. The idea being: shrink stuff down, get things moving.

But I'd recommend that if someone came to me with a few days or a week of symptoms. If you've had this for a few months without improvement, I'd be more likely to write for antibiotics. Any primary care physician should be able to make this diagnosis and simple treatment plan. So would any ENT/otolaryngologist.

tl; dr: CHEAP & EASY: try pseudoephedrine, Benadryl, Neti pot, ibuprofen. If things don't get better after a week, seek ye some antibiotics that're more appropriate for the treatment of bacterial sinusitis (amoxicillin and Augmentin are dirt cheap). Not azithromycin.

I am an MD, but not your MD, and I don't know if you're allergic to penicillins or not. So please don't just seek out amoxicillin or Augmentin because some random person on the internet said so. It might kill you.
posted by herrdoktor at 12:57 PM on November 2, 2014 [4 favorites]

This advice is not at all medical but rather a general practical tip: are you drinking enough water, including a lot of fiber in your diet, etc.? I realize that it's unlikely to solve the bad breath if the matter is a complicated medical issue. However, sometimes we slack on the basics when we're feeling ill and getting back on track can help us start feeling better in others ways. In any case, I hope things start getting better for you soon!
posted by smorgasbord at 1:45 PM on November 2, 2014

As an addendum: how could I forgot the utility of steroid nasal sprays like fluticasone? It's gone generic in the US, should be reasonably cheap. Requires a prescription, and should considered as part of a treatment plan for sinusitis.
posted by herrdoktor at 1:46 PM on November 2, 2014 [2 favorites]

As a home remedy while you're trying to get this sorted with your doctor:

Gargle with warm saltwater. Sounds disgusting, I know! But since you're tasting snot constantly, not as disgusting as you might think. I usually do:

1. Nasal irrigation with 8oz. warm saltwater (I use the "sinus rinse" squeeze bottle, not the neti pot, but same diff. Also, I heat the water so it's warmish -- 22 sec. in my microwave).

2. Fill a juice glass with table salt and water, heat for ~22 sec. in the microwave, gargle until the water is gone. When you spit out each bit of water REALLY REALLY spit. Have a paper towel handy. This can sometimes get rid of a lot.

3. Nasal irrigation again. Gargle again, too, if you need it.

4. Saline spray. I don't "spray" it, though. I have the generic from CVS, and what I do is put my head horizontal and then shoot a stream of the saline solution into my nostril until I can feel it coming down my throat in the back. THIS IS HORRIBLE and will make you cough, but it works better than just putting some saline mist up there.

Right now I'm recovering from sinus surgery and doing this multiple times a day, but it's all stuff that I was told to do for chronic sinusitis anyway and tried to do back then (though nasal irrigation is difficult if you have a deviated septum, so I mostly stuck to the gargling).

Also, sleep with your head above your heart, for better drainage. I think sleeping on your back instead of your side helps, too, but YMMV. I also find it helps to drink TONS of water and to limit alcohol, though again, YMMV.
posted by rue72 at 2:12 PM on November 2, 2014 [2 favorites]

Out of left field, but a possibility. When I've had my tooth implant procedures, one of the stages was to close the gum to let the bone build before the actual implant. I had a sinus lift. What that meant, was that there was communication between the gum area and the sinus cavity. It takes time for that opening (which allows communication) to close. In that time, I had symptoms pretty much like you did, minus the sore throat. Here's what most people don't know: there are discrete colonies of bacteria in different parts of your mouth, and the character of each colony is quite different, with different species etc. - think in terms of the ecology of a forest, where low growth is going to be different than tops of trees etc.. Well, when you open a channel between the gums and the sinus, bacteria can start migrating, and because they find themselves in a different environment, trouble results.

Anyhow, once the opening closed, all the symptoms went away. Here's what you might want to consider. If you have had serious bone loss somewhere in the upper molar area beneath the sinus chamber, the bone might have become so porous that it allows communication - or even might have broken completely. That becomes a reservoir of constant infective agents passing through and giving you those symptoms. The only thing that might argue against this is the sore throat (though that's based on *my* experience, and perhaps is not representative), but I think it's worth considering.

How is your dental health, in particular upper molars? Have you experienced any upper molar loss, or do you have any loose teeth there, particularly ones that have had a root canal? If all else fails, you might get an X-ray of the area on your next dental cleaning/checkup to see if there is any breach/significant thinning of the sinus bone above.
posted by VikingSword at 5:21 PM on November 2, 2014

Try taking diphenhydramine (Benadryl) before bed.
posted by Jacqueline at 5:59 PM on November 2, 2014

Is your tongue whitish in the mornings or other times? Do you get a sour taste in your mouth at all? Could be GERD, like Lobster Mittens suggests.

You could try Tums or some other calcium-type antacid tablets and see if they clear up any of your symptoms.
posted by pickles_have_souls at 6:20 PM on November 2, 2014

Sometimes my tonsils fill up with stinky gunk (tonsilloliths) after a sinus infection.
I get a kind of syringe with no needle and wash out the crevices.
Also, brush as far back on your tongue as you can manage.
Good luck!
posted by Elysum at 11:51 PM on November 2, 2014 [1 favorite]

GERD doesn't cause congestion or postnasal drip, so I doubt it's that - or at least not only that.
posted by treehorn+bunny at 9:38 AM on November 3, 2014

Seconding Elysum-- in regards to tonsil stones.

There is a subreddit devoted to extracting and admiring tonsil stones

And a more objective description on WebMD
Your tonsils are filled with nooks and crannies where bacteria and other materials, including dead cells and mucous, can become trapped. When this happens, the debris can become concentrated in white formations that occur in the pockets.

Tonsil stones, or tonsilloliths, are formed when this trapped debris hardens, or calcifies.
posted by ohshenandoah at 9:29 PM on November 3, 2014

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