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. 2017 Oct-Dec;7(4):34–51.

PAEDIATRIC OTORHINOLARYNGOLOGICAL PRESENTATION OF HALITOSIS IN A DEVELOPING COUNTRY

AW, Adegbiji 1, TG, Olajide 2,✉, AG, Olusola 1, F, Olatoke 3, CC, Nwawolo 4
PMCID: PMC6237313  PMID: 30479990

Abstract

Background

Halitosis is a common medico social symptom among children.

Aim

To determine the clinical, epidemiological patterns, aetiology and psycho-social issues of halitosis among children in a tertiary hospital in Nigeria.

Methodology

This was a prospective hospital based study of children with complaints of halitosis. The study was carried out in Ear, Nose & throat Department, Ekiti State University Teaching Hospital, Ado Ekiti over a period of two years, (October 2015 to September 2017). Consent was obtained from the parents/guardian. Data was obtained by using pretested interviewer assisted questionnaire.

All the data obtained were collated and analyzed by using SPSS version 16.0.

Ethical clearance was obtained from the ethical committee of the institution.

Results

The prevalence of halitosis in this study was 6.8% and there were 58.5% males and 41.5% females with a male to female ratio of 1.5:1. Their age ranged from 1 year – 18 years with a mean of 9.48 ± 5.84 SD years.

Sources of referral for the otorhinolaryngology, head and neck care were mainly from general practitioners (52.3%) and from pediatricians (24.6%).

Halitosis was noticed by family members in 50.8% and from family friends in 23.1%.

Nasal and throat diseases in 49.2% and 29.2% respectively were the commonest otorhinolaryngology, head and neck disorders that were responsible for halitosis. The major causes were rhinosinusitis in 24.6%, impacted nasal foreign body in 23.1% and adenotonsillar hypertrophy in 18.5%.

Associated disabilities in children and family with halitosis include social withdrawal in 35.4%, low social interaction in 32.3% and depression in 29.2%.

Acute halitosis (<3/12) accounted for 50.8% while chronic halitosis (>3/12) accounted for 49.2%. In all, fifty four (83.1%) of the patients were successfully treated.

Conclusion

Bad breath is a common ear, nose and throat symptom in children it is commonly due to nasal and pharyngeal diseases which are amenable to treatment.

Keywords: Halitosis in children, Rhinitis, Tonsillitis, Impacted foreign bodies

Introduction

Halitosis is an unpleasant universal medico social problem that arises from offensive breath from sufferer to the people in their vicinity1,2. Halitosis greatly affects social communication, health condition, frequent psychological alterations with social and personal isolation 3-5.

This can be classified into three groups6,7. When the halitosis is a real problem that can be easily diagnosed either by organoleptic or by physico-chemical means, it is known as genuine halitosis. If halitosis does not exist, but the patient believes that he has, it is called pseudo-halitosis. While halitophobia occurs after a successful treatment for either genuine halitosis or pseudo-halitosis and the patient still believes that he has halitosis.

Epidemiological studies have shown that halitosis is a universal medico-social problem; affecting 50-65% of the adult population worldwide8,9. It is a common complaint of up to one-third of the general population10. Researchers in Japan found that 15% of adults had halitosis and was more common in the city of Tokyo11 while in China; more than 25% of a study population had halitosis 12. In a Kuwaiti population nearly 25% of the population also had halitosis 13 while in the United States, 43% of people over 60 years had bad breath problems14.

Halitosis mostly arises from a variety of organs in the aero digestive system like the nose, sinuses, tonsils, gastrointestinal tract, lungs, and the oral cavity15. It is estimated that about 10% of cases of halitosis are due to disorders in the ear, nose and throat region16. Tonsilloliths and acute tonsillitis are thought to be a common cause17,18.

Nasal and sinuses infections cause postnasal drip from mucus glands of the nasal and paranasal sinuses19. In chronic sinusitis, 50%–70% of the patients may complain of halitosis20. Impacted foreign bodies in the nasal cavity and congenital sinonasal disorder like cleft palate with secondary bacterial infection may also be the origin of halitosis21. Laryngeal diseases are uncommon causes of halitosis.

Systemic diseases that may cause halitosis include; renal impairment and uncontrolled diabetes mellitus26.

There is paucity of literature on the subject halitosis among ear, nose, throat, head and neck surgical patients in Nigeria. Thu this study is aimed at determining the clinical, epidemiological patterns, disability and aetiology of halitosis among children seen in a tertiary hospital in Nigeria.

Materials and Methods

This is a prospective hospital based study of children with clinical complaints of halitosis. This study was carried out at the Ear, Nose and Throat Department of Ekiti State University Teaching Hospital, Ado Ekiti, Nigeria.

The study was carried out over a period of two years (October 2015 to September 2017). Consent was obtained from the parents/guardians. A total number of 65 patients who gave consent were enrolled into the study.

Data were obtained by using a pretested interviewer assisted questionnaire. General and detailed history about type, frequency, time of day, precipitating, aggravating, relieving factors and extent of halitosis was obtained. History on previous therapies by physicians the resultant psychological stress were documented.

Prior to clinical evaluation, patients were instructed not to eat onion, or perform oral hygiene for at least 4 hours before arrival at the clinic. They were also to refrain from chewing gum, use of candy or mouthwash.

The examination findings of the ear, nose, and throat were documented. Based on the findings, appropriate investigations such as radiology and microbiology were requested and findings were documented.

An organoleptic evaluation was carried out with the distance of operator to patient to detect oral malodor (bad breathe): thus grade 1 is at 10 cm, grade 2 is at 30 cm while grade 3 is at 100cm (Seemann 2001). `

All the data obtained were collated and analyzed by using SPSS version 16.0. The obtained information were expressed by descriptive method and illustrated by using frequency tables, bar chart and pie charts.

Ethical clearance was sought for this study from the ethical committee of the institution.

Results

During the study period a total of 962 patients were seen in the ear, nose and throat department, out of which a total of 65 children had complaints of halitosis giving halitosis prevalence in children of 6.8%. All the paediatric age groups were involved with peak age at preschool age group (1-5 years) as shown in Fig. 1. There were 38 (58.5%) males and 27 (41.5%) females with male/female ratio of 1.5:1. Majority 42 (64.6%) of the patients were urban dwellers while minority 23 (35.4%) were rural dwellers. Assessment of the educational level of their parents showed that, 24 (36.9%) of them were graduates while 19 (29.2%) were secondary school leavers. Parents’ occupations showed that; 29 (44.6%) were civil servants, 11 (16.9%) health workers and 3 (4.6%) were farmers. The sociodemographic features of children with halitosis are shown in Table 1.

Fig. 1. Age group of the children with halitosis.

Fig. 1

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Table 1. Sociodemographic features of the patients.

Sociodemographic features Number Percentage (%)
Gender 58.5
Male 38 41.5
Female 27
Domicile 64.6
Urban 42 35.4
Rural 23
Religion 90.8
Christianity 59 9.2
Islamic 6
Parent Education level 12.3
None 8 21.5
Primary 14 29.2
Secondary 19 36.9
Tertiary 24
Parent Occupation 16.9
Health workers 11 10.8
Artisans 7 44.6
Civil servant 29 4.6
Farming 3 13.9
Trading 9 9.2
Others 6 58.5
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Findings on sources of awareness on halitosis among the studied patients revealed that 33 (50.8%) were by family members and 15 (23.1%) by family friends. Fig. 2 illustrates sources of awareness of halitosis among patients.

Fig. 2. Sources of awareness of halitosis among patients.

Fig. 2

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Sources of referral for otorhinolaryngology, head and neck review and management were 34 (52.3%) from general practitioners and 16 (24.6%) from paediatricians. Other modes of referrals included parents and dentists; 8 (12.3%) and 4 (6.2%) respectively. This is shown in Fig. 3.

Fig. 3. Sources of referral of halitosis patients.

Fig. 3

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Nasal diseases 32 (49.2%) were the commonest causes of halitosis. Throat and psychogenic disorders were responsible for 19 (29.2%) and 7 (10.8%) respectively. This is shown in Fig. 4.

Fig. 4. Identifiable sites of diseases causing halitosis among the patients.

Fig. 4

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The aetiology of halitosis is as summarized in Table 2.

Table 2. Identifiable diseases among children with halitosis.

Aetiology Number Percentage (%)
Rhinosinusitis 16 24.6
Nasal foreign body impaction 15 23.1
Tonsillitis 10 15.4
Adenotonsillar hypertrophy 12 18.5
Orodental disorders 2 3.1
Gastrooesophageal reflux disorder 3 4.6
Psychogenic 7 10.8
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Fig. 5 shows the psycho social issues noted.

Fig. 5. Identifiable psycho-social problems among children with halitosis.

Fig. 5

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Acute halitosis (<3/12) was seen 33 (50.8%) while chronic halitosis (>3/12) was seen in 32 (49.2%) of the patients. 54 (83.1%) of the patients were satisfied with otorhinolaryngological treatment while 11 (16.9%) were unsatisfied.

Discussion

The prevalence of halitosis in this study was 6.8%. Studies from developed countries have reported a higher prevalence27,28. The low prevalence in this study was due to low level awareness of the significance of halitosis and management in developing countries.

This study revealed male preponderance over female. Reports from other study revealed similar finding29. While a previous study revealed equal sex proportion 30. More than half of halitosis patients were urban dwellers this may be due to easier accessibility to the patients. Geographical location barriers to access surgical services are a major challenge facing health care systems31.

Prevalence of halitosis is more common in the preschool age group (1-5years) in this study. This finding was contrary to findings in other studies that showed peak prevalence among the elderly32. In this study, there was a gradual decrease in prevalence of halitosis with age and final peak at 16-18 years.

General, few patients were self-conscious of bad breath. Majority of the sufferers have no idea of the halitosis unless from the conscious indication by other people or conscious by presumptions from the attitude of others. In this study less than half of the patients were self-aware of their halitosis. Majority of the studied patients were aware of bad breath indications by friends and family members.

Rhinosinusitis and nasal foreign body impaction constituted about half of the aetiology of nasal and sinuses diseases. Unlateral nasal discharge is pointer to impacted nasal foreign body. Tonsillitis and adenotonsillar hypertrophy were the commonest throat disorders that was responsible for halitosis in this study. Other studies have reported that tonsillitis is the commonest cause of halitosis 33-35. However, it is important to differentiate bad taste from bad breath. Oro-dental pathology is the least cause in this study. This finding is contrary to other study 36. This may be due to fact that these were mainly patients referred to the otorhinolaryngology clinic.

Social withdrawal, low social interaction and depression were the commonest psycho social effects associated with halitosis in this study. Halitosis inhibits the sufferer leading to social withdrawal; irritability and anxiety were commoner among the older children. They are afraid of attending socio-gathering (sociophobia) because of bad breathe emanating from them.

Patients with acute halitosis (when <3 months) were more than those with chronic halitosis (when >3 months). Parent of children with acute halitosis tend to look for early medical intervention. After diagnosis, treatment offered to the patients range from surgical, medical or referral to others specialist for multidisciplinary approach. Otorhinolaryngology treatment outcome was satisfactory in the majority the children and unsatisfactory to the minority of the patients in this study. This is comparable to treatment outcome in other reports37. Contrasted outcome was recorded in other study38.

Limitations of this study include lack of instruments for assessment of exhaled air and inability to assess quality of life issues with validated questionnaires.

Conclusions

Bad breath is a common ear, nose and throat symptom in children it is commonly due to nasal and pharyngeal diseases which are amenable to treatment.

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