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356
Rodriguez-Fernandez etal. [60] developed a uorimetric sensor for measuring
VSC and suggested that this method could be an alternative to commercial systems
such as Halimeter. It is shown that the VSC monitor with the zinc oxide semiconductor sensor they developed could be used to diagnose halitosis [45]. They made a
comparison with organoleptic evaluation in patients with severe halitosis. They
stated that this monitor could be used in routine clinical studies and oral-dental
screenings, as they found a high correlation. Hanada etal. [61] developed a portable
GC system using a high-sensitivity indium oxide semiconductor gas sensor as a
detector. In their study, Amano etal. [62] found a statistically signicant relationship when they measured the VSC level by gas chromatography and the ammonia
level by ammonia monitoring in 25 patients.
İ. Dişikırık and M. A. Kanmaz
26.14.2.2 Measurement ofGalactosidase Activity
Deglycosylation of glycoproteins is considered the initial stage in forming lousy
breath. β-Galactosidase is one of the essential enzymes in deglycosylation. In this
method, which is based on measuring the activity of this enzyme, the color change
caused by the saliva sample taken on a paper disk is scored as 0: No color change,
1: Light blue color, and 2: Dark blue color. Some studies have found a signicant
relationship between β-Galactosidase test scores and organoleptic scores [63, 64].
26.14.2.3 Ammonia Monitoring
Ammonia produced by bacteria in the mouth can cause bad breath. Therefore, a
portable monitor was developed to measure ammonia. Patients are asked to rinse
their mouths with urea solution and measurements are made with a disposable piece
placed in the mouth and connected to the gas detector. The air in the patient’s mouth
is transferred to the detector with the help of a pump, and the ammonia concentration produced by the bacteria can be seen on a scale.
26.14.2.4 Polymerase Chain Reaction (PCR)
This method is used for quantitative analysis of VSCs produced by oral bacteria. In
this method, the amount of bacterial DNA forming VSC is determined by the
amount of uorescent dye formed on the DNA probe [23, 65].
26.15 Physical Examination
After physiological halitosis and halitophobia are ruled out, physical examination
begins. A meticulous oral and otolaryngological examination is performed. 90% of
the cause of bad breath originates from inside the mouth, increasing oral examination’s importance. It is essential in the subgingival and proximal regions. Causes
such as periodontal pockets, rotten teeth, tonsils, adenoid examination, tongue
structure, whether there is a cleft tongue, aphthous lesions in the mouth, ulcerations,
gum diseases, tongue coating, or post-nasal discharge can be easily noticed.
In people with good oral hygiene and dental health and a healthy periodontium,
although the front part of the back of the tongue usually smells good, the real cause
26 Halitosis DuetoPediatric Ear, Nose, andThroat Field Infections
357
of the odor may be the back part of the tongue, that is, the tongue root. This area can
be examined by scraping with a tongue depressor. This material usually results from
postnasal discharge. Although the discharge is not initially foul-smelling when it
reaches the tongue, it may cause a foul odor as it accumulates in the future. A conclusion can be drawn by comparing the scraping taken with a tongue depressor and
bad breath.
One way to understand that the smell is coming from the mouth is to compare the
smell coming from the mouth with the smell coming from the nose. If the smell
comes from the mouth, the place to be investigated is the mouth. The odor may
intensify during sleep, under stress, when the mouth is dry due to long conversations
and side effects of medications, and in such cases, gum can be chewed for a few
minutes to increase saliva secretion and to see whether the odor decreases. If we
think that the odor is caused by oral etiology, the patient is told to gargle for a week
and pay attention to dental cleaning (brushing, ossing). If the odor disappears, it is
understood that it is caused by oral etiology [45]. If the odor originates from the
nasal passage, lungs, or stomach, it will not disappear with mouthwash and teeth
cleaning.
Another way to understand bad breath is to stick out the tongue thoroughly, hold
the tip of the tongue with gauze, and scrape the base with another gauze for 45s,
Wait, and then smell. If an unpleasant odor is detected after these waiting periods,
there is a halitosis problem [45].
Some people’s bad breath worsens when they start talking when it does not normally exist. Therefore, in addition to exhaling through the mouth and nose, the
patient should be asked to count out loudly 20 and simultaneously smell.
It is also essential to detect a ssured tongue (scrotal tongue) during physical
examination. Enzymes such as lysozyme, myeloperoxidase, and immunoglobulin
are higher in ssured tongues than in non-ssured tongues. When the ssured
tongue becomes ulcerated and the rust is removed, saliva leaks. Excessive bacterial
growth causes inammation and odor occurs [45].
26.16 Treatment ofHalitosis
A treatment plan is made to eliminate the cause and improve oral health. Although
there are many factors in the etiology of bad breath, it is primarily due to oral causes.
Therefore, it is aimed to reduce the amount of intraoral bacteria and convert persistent VSCs into non-volatile substrates. The treatment methods are listed below:
1. Using masking products
Masking products alone do not treat halitosis. These are mints, toothpaste,
mouthwashes, sprays, lozenges, and gums [4].
2. Mechanical reduction of microorganisms and their substrates
It is possible by consuming breakfast, increasing saliva secretion, chewing
gum, brushing teeth, using dental oss, toothpicks, tongue cleaning, and professional oral care [4].
358
İ. Dişikırık and M. A. Kanmaz
Bad breath, which is intense in the morning as a result of the proliferation of
microorganisms found in food residues and releasing proteins as a result of not
washing the tongue as a result of fasting throughout the night and food residues
accumulating on the tongue and decreasing saliva secretion, will be eliminated
by eating solid foods and bad breath will decrease [66]. In a study, a 60%
decrease in the hydrogen sulde concentration and an 83% decrease in the
methyl mercaptan concentration, which causes bad breath, was observed in people with bad morning breath despite no oral cleaning performed 1h after breakfast [52]. Even just eating dry bread has been shown to reduce VSC concentration
without any other action [67].
3. Brushing teeth
It reduces the amount of bacteria in the mouth [68, 69], but studies have
shown that tooth brushing alone is ineffective in eliminating bad breath [70, 71].
4. Tongue brushing
Brushing the tongue reduces the tongue coating and, therefore, the number of
microorganisms and the amount of substrates on the tongue [37, 72, 73]. The
tongue coating should be removed during tongue brushing, especially on the
posterior part of the tongue. In one study, brushing the tongue dorsum with
toothpaste was more effective than brushing your teeth.
The clinician must nd the source of the odor before starting treatment. It
often requires dental treatment. The most effective method in the treatment of
halitosis is to reduce anaerobes that cause VSC production by correcting periodontal disease with oral hygiene and primary dental care. An effective mouthwash should be added if bad breath persists despite good oral hygiene.
Mouthwashes eliminate lousy breath by chemically reducing the number of
microorganisms in the mouth [74]. Active agents frequently used in these products are chlorhexidine, triclosan, essential oils, and cetylpyridinium chloride
(CPC). Other effective chemical agents are allylpyrocatechol,
L-triuoromethionine, and dehydroascorbic acid [4].
Chlorhexidine, the most commonly used of these, damages the bacterial cell
membrane, increasing membrane permeability and, as a result, causes cell lysis
and cell death [75].
In their study, [49] reported that the 0.2% chlorhexidine regimen provided a
43% decrease in VCS values and a more than 50% decrease in organoleptic
scores [49]. However, long-term use of chlorhexidine also has disadvantages,
such as causing bad taste in the mouth and discoloration of teeth [75, 76].
Many essential oils used to eliminate bad breath have strong antimicrobial
properties. Olshan etal. [77] reported in their clinical study that toothpaste containing essential oil and 1% zinc citrate and essential oil effectively reduced bad
breath for 1.5–2h. Cetylpyridinium Chloride (CPC), also used to eliminate bad
breath, prevents bacterial growth [78]. Yaegaki and Sanada [70] reported in their
study that mouthwash containing CPC was 80% effective in reducing VSC for
3.5 h. L-triuoromethionine, which is also recommended in the treatment of
halitosis, works by inhibiting the production of methyl mercaptan, which occurs
as a result of bacteria metabolizing methionine and causes bad breath.
26 Halitosis DuetoPediatric Ear, Nose, andThroat Field Infections
Toothpaste, mouthwashes, lozenges, and other products reduce halitosis by
chemically neutralizing odor compounds, including VSC.Common active ingredients of these products are metal ions and oxidizing agents. Metals such as zinc,
sodium, tin and magnesium are thought to interact with sulfur. Zinc, one of these
products, has advantages such as being non-toxic, non-cumulative, and not causing coloration compared to other metal ions. For this reason, it is one of the most
preferred substances for controlling bad breath [79].
Sodium bicarbonate is frequently used in teeth cleaning in Japan and North
America. It was reported in the studies of Brunette etal. [80] that toothpastes
containing sodium bicarbonate were effective in reducing VSC levels.
Oxidizing tablets are thought to reduce bad breath due to the activity of dehy-
droascorbic acid, which is formed by the peroxide-based oxidation of ascorbate.
On the other hand, probiotics are among the recommended treatment options.
Probiotics strengthen the host’s immune system by producing the antimicrobial
substance necessary to destroy or inhibit pathogenic microorganisms [81].
In their study, Suzuki etal. reported that daily consumed acid-resistant probi-
otic lactobacilli would play an essential role in the regression of lousy breath and
odor-related factors, along with ensuring oral care and hygiene [82].
If we consider a diagnosis of Halitophobia after all organic causes have been
excluded, the patient should be referred to the relevant branch for evaluation by
a psychiatrist.
359
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İ. Dişikırık and M. A. Kanmaz
Dysphonia inChildren
27
İbrahimÇukurova andİlterDenizoğlu
27.1 Introduction
Communication in the childhood has a crucial role in personal and social development. Pediatric dysphonia creates serious communication problems and restrictions
in social and emotional functioning with improper voice quality, pitch and loudness,
and voice breaks [1, 2]. A dysphonic child will be negatively affected (aggressive,
sad, frustrated) emotionally and perceived more negatively (angry and noisy) by
peers and adults [1, 3, 4]. They also report frustration and limited participation in
important events due to their vocal inabilities [1].
Diagnosis, treatment, and follow-up in pediatric dysphonia must be considered
with continuously changing structural and developmental biomechanical factors.
Laryngeal position, vocal tract length (vertically short), histoanatomical structure,
and functions of the larynx change throughout childhood. The vocal fold length is
only 2.5–3.0mm in the newborn and it reaches adult dimensions (female 11–15mm
and male 17–21mm around 10–14years of age) [5]. Lamina propria in the newborns is loose and pliable and does not have a layered structure. Vocal ligament
appears between 1 and 4years and the three-layered lamina propria is not clear until
15years of age [6].
İ. Çukurova (*)
İzmir University of Health Sciences, Tepecik Training and Research Hospital, Section of
Otorhinolaryngology, Izmir, Turkey
İ. Denizoğlu
Department of Speech Language Therapy, Tinaztepe University Faculty of Health Sciences,
Izmir, Turkey
© The Author(s), under exclusive license to Springer Nature
Switzerland AG 2024
H. Yüksel et al. (eds.), Pediatric Airway Diseases, Comprehensive ENT,
https://doi.org/10.1007/978-3-031-74853-0_27
363
364
İ. Çukurova and İ. Denizoğlu
27.2 Epidemiology
It is not easy to estimate the real prevalence of pediatric dysphonia because the
pediatric dysphonia remains undiagnosed mostly. However, studies show a range
between 1.4% and 23.9% [7–11]. These values increase in school age children from
6% to 38% [1, 9, 12]. Boys are more affected than girls between 7 and 12years of
age, while dysphonia is more frequent in girls after puberty [13]. Benign vocal fold
lesions tend to be the most common etiology in childhood [14, 15]. Vocal fold nodules have been reported to have an incidence of 17–30% in the pediatric population
[16, 17].
27.3 Etiology andPathogenesis
Various etiologies can be dened in pediatric dysphonia: traumatic, infectious,
inammatory, iatrogenic, congenital, metabolic, and psychogenic [18, 19]. The
most common reason for pediatric admission to the voice clinic is children who
shout a lot and develop irritative chronic laryngitis and prenodular edema or nodules
due to vocal trauma. Risk factors include childhood hearing problems, frequent
upper respiratory tract problems, and family dynamics. Differential diagnosis of
lesions such as vergeture that accompany and cause nodules is also important in
treatment strategy.
Vocal fold nodule is a mucosal reaction to mechanical trauma. The glottic gaps
(hourglass-shape, posterior gaps, etc.) create higher mucosal impact pressure on
smaller parts of the vocal fold mucosa. The child tries to express him/herself by
increasing the phonatory effort, and this vicious circle results with mucosal inammatory response that continues with epithelial thickening.
The mucosal trauma creates a chronic tissue reaction, which restrains lowloudness phonation. Since low-pressure glottic closure will not be possible due to
the nodular masses in between, the perception that “our boy always talks shouting”
settles in the family as if it were a way of behavior. These patients develop a new
type of glottic closure and breathing to compensate for this condition. Less common
reasons may be congenital anomalies, laryngopharyngeal reux, chronic sinonasal
infections or allergies, papillomatosis, polyps, webs, cysts, sulci, laryngeal tumors,
and metabolic and hormonal disorders.
Puberphonia is a functional dysphonia that affects mainly boys during puberty.
Its prevalence is reported as 2–3% [20]. Physioanatomical alterations at the phonatory apparatus are under the effect of abrupt hormonal changes [21], the mean
fundamental frequency decreases (1 octave in males and 3–5 semitones in
females), and reaches the adult levels [20]. Puberphonia is a register shift between
chest and falsetto registers. The child cannot adapt to the physioanatomical
changes and uses the falsetto register that resembles the prepubertal pitch. The
vocal output becomes a high-pitched metallic sound in addition to vocal instability, poor voice control, pitch breaks, breathiness, effortful phonation, and monotonous speech [22].
27 Dysphonia inChildren
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27.4 Diagnosis
Diagnosis and management of pediatric dysphonia require multidimensional thinking and a strategic approach. Coinciding pathologies such as nasal obstruction,
attention decit, and hyperactivity disorder (ADHD) should be considered.
Hyperactivity, various communication disorders, aggression, academic success
problems, and personality problems must be consulted with child and adolescent
psychiatrists. Children are generally less aware of the problem and are referred by
their families. This condition may not create a need for a denitive treatment, but
providing a better voice for communication can satisfy the family and the patient.
Children may not be able to provide sufcient anamnesis. Family and school environments provide important clues about pediatric dysphonia. In this context, when
taking anamnesis, family members as well as responsible teachers at the school can
be contacted.
27.5 Signs andSymptoms
The family or teacher often notices voice problems in children. They are referred to
the clinic primarily for shouting behaviors, changes in vocal timbre, limitation of
vocal communication abilities, and discomfort in the neck and face during speech.
27.5.1 Clinical Assessment
Evaluation for dysphonia in children usually involves laryngoscopy to evaluate for
vocal fold lesions and vocal fold mobility [23]. Videolaryngostroboscopic evaluation is not as easy as in adults, but it is still a golden standard in children. It can be
applied quickly by rigid or exible endoscopes, assessment through general anesthesia may be a choice in some cases.
Acoustic evaluation can be made by voice analysis and perceptual (patient and/
or clinician-based) questionnaires. Improvements during and after treatment in selfreported quality of life scales [24–26] may indicate that patients feel less limited by
their voices in their social environments. Although auditory-perceptual evaluation
may not give objective results [27–29], the clinician’s ears are the most delicate tool
for dysphonia.
Acoustic and aerodynamic voice analysis may also help for diagnostic and follow-up measures [30–32]. Voice therapy was shown to reveal improvements in
cycle-to-cycle variation in frequency and amplitude (jitter, shimmer) as well as
decreased noise in the voice signal (harmonic-to-noise ratio) [33, 34]. The aerodynamic improvement can be analyzed by phonation threshold pressure [35, 36] that
also indicates vocal fold biomechanical changes (increased laryngeal pliability and
decreased vocal fold viscosity) following therapy [2]. Acoustic-aerodynamic analysis may also give clues about the changes at vocal fold mass [24] but they never
substitute endoscopic visualization.