Dr Paulose

World Class ENT Plastic and Laser Surgeon

Throat

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Halitosis: Bad Breath

 

Bad Breath or Halitosis can be a source of embarrassment and shame. Some people with bad breath aren’t even aware there’s a problem. Bad breath (Halitosis) is a widespread condition affecting about a quarter of population. The most common cause of bad breath is decaying food debris between the teeth and gum (poor oral hygiene).

What are the causes Bad Breath

Anything that decreases the flow of saliva or stimulates the growth of anaerobic bacteria.Saliva irrigates the mouth, stimulates swallowing thereby flushing away debris. As saliva contains oxygen, the dryer your mouth and the thicker your saliva, the less the washing action and the lower the oxygen level creating a more anaerobic environment for bacteria to produce sulfur compounds. This oral stagnation is more pronounced in mouth breathers and those who snore. Certain medications for high blood pressure, antihistamines and depression can decrease saliva flow. Dehydration and stress also reduces the flow of saliva. Morning breath occurs due to decreased salivary flow during sleep.

These anaerobic bacteria breakdown proteins as the start to digestion, and produce these sulfur compounds as a by-product. These proteins come from oral cellular debris dead bacteria, saliva, food debris, mucous, post nasal drip and phlegm.

An important factor in bacterial growth is the pH of the mouth. Bacteria reproduce faster in a more acid environment. Coffee and acidic foods increase acidity. Hormonal changes have even been implicated with bad breath. During menstruation, estrogen causes sloughing of body lining tissue including that of the mouth. This gives additional nutrition for anaerobic bacteria.

Other causes of bad breath include:

and tonsil or throat infection -Chronic pharyngitis, Tonsillolith
and dry mouth
and smoking
and alcohol and certain foods e.g. Garlic
and inflammation of the oesophagus, (Oesophagitis), reflux GERD
and inflammation of the sinuses – Chronic Sinusitis and Postnasal drip
and build up of bacteria on the tongue-Stomatitis
and crash dieting – when energy producing food such as Carbohydrates are with held from the body, stored body fat is broken down instead. The waste product from this type of energy break down are ‘Ketones’, which give a sweet and sickly smell

Sinusitis and bad breath

Chronic sinus infections are among the most common form of upper respiratory infection in children and adults.

The most common symptoms of chronic sinus infection include:
1. Purulent postnasal discharge.
2. “Fullness” or congestion around the sinus areas
3. Chronic coughing, frequently at night.
4. Chronic sore throat.
5. Bad Breath.
Recognize the symptoms of chronic sinus infection and to prevent the causes of sinus infection, including removing the irritants from the environment or treating the allergies.

Postnasal Drip

Post nasal drip refers to the sensation of thick phlegm in the throat, which can become infected.This is part of the mucous – nasal cilia system that defends us from disease. When the amount of liquid secreted by the nose and sinus is reduced, and the cilia of the nose and sinus slow down, the fluid thickens and you become aware of its presence. This also gives bad taste and smel in mouth.

Gingivitis

Bacteria play an important role in many dental problems such as bad breath (halitosis), gum disease, plaque and possibly sensitive teeth. Plaque also starts out with a sticky film of live bacteria. If it is not removed at this stage, it starts growing on the sugar and minerals and hardens to become calculus which may lead to gum irritation, gingivitis and eventually to periodontal disease causing halitosis

Chronic Tonsillitis

Chronic tonsillitis and chronic pharyngitis is a common cause of Halitosis.
Tonsil Stones (tonsilloliths) are caused by an accumulation of sulfur-producing bacteria and debris that become lodged in the tonsils. This debris (which can include mucous from post nasal drip) putrefies in the back of your throat, and collects in the tonsil crypts (small divots or pockets which appear on the surface of the tonsils).
When this debris combines with the Volatile Sulfur Compounds produced by the anaerobic bacteria beneath the surface of your tongue, along with the tonsil stones it can also create chronic Halitosis.

How is Bad Breath treated?

and Improving oral hygiene – correct brushing technique and regular flossing of teeth
and avoiding smoking, drinking alcohol and eating spicy foods
and using an antiseptic mouth wash -Betadine gargle
and chewing sugar free gum to increase the flow in saliva
and using a tongue cleaner to brush and clean the tongue

Medications

If all the above self help remedies fail, go to a dentist and ENT surgeon, he may be able to help you. A course of Ciprofloxacin with metronidazole or Tinidazole may help to curb the anaerobic infections.

Migratory Glossitis
(Geographic Tongue)

Geographic tongue is a map-like appearance of your tongue due to irregular patches on its surface.

Causes

The specific cause of geographic tongue is unknown, although vitamin B deficiency may be involved. Other causes may include irritation from hot or spicy foods, or alcohol. The condition appears to be less common in those who smoke.

The pattern on the surface of the tongue may change very rapidly. This pattern changes occur when there is a loss of the tiny finger-like projections, called papillae, on the tongue’s surface. This makes areas of the tongue flat. These areas are said to be “denuded.” Denuded areas may persist for more than a month.

Symptoms

  • Map-like appearance to the surface of the tongue
  • Smooth, beefy red patches and lesions on the tongue
  • Patches that change location from day to day
  • Soreness and burning pain

Treatment and Prognosis

No treatment is usually necessary for benign migratory glossitis and stomatitis. Symptomatic lesions can be treated with topical prednisolone and a topical or systemic antifungal medication (Flucanazole) can be tried if a secondary candidiasis is suspected. Occasional symptomatic cases respond well to topical tetracycline or systemic, broad-spectrum antibiotics, but this should not be expected.

Try avoiding causative factors.

Apthous ulcers

Some people seem to be prone to develop repeated aphthous ulcers, while others may have similar damage to the cheek but without having an ulcer developing from it. This may depend on the general resistance of the body and on the type of bacteria normally in the mouth. Stress appears to lower the resistance of the mouth to such ulcer formation.

Treatment

If subject to repeated ulcers, it is worth discussing the problem with a dentist or oral hygienist. Identifying food allergies can be difficult but the type of food known to bring about an ulcer may become obvious to you after some time.

The aim of treatment is to reduce the pain and inflammation. Local anaesthetic lozenges or gel can be used as often as necessary to reduce discomfort. people benefit from the anti-inflammation effects of hydrocortisone. This can be administered in the form of pellets which are sucked.

Tetracycline is sometimes very effective. A capsule containing 250 mg of this antibiotic is prized open. Half the yellow powder content is put into a tumbler which is approximately one-third filled with warm salt water. Rinse your mouth with this solution, on each occasion keeping the liquid in contact with the ulcer for 5 minutes at a time. This method often reduces the period of pain to 1 or 2 days.

Gargle warm salt water with turmeric powder is also good.

Steroid paste is applied to the ulcer help healing fast. Steroid (cortisone-like) drugs and tetracycline can both cause an infection by yeast organisms (thrush) in the mouth if used for an excessively long period.

Cauterising with silver nitrate helps healing and reduce pain.

Most aphthous ulcers improve after 6 or 7 days and have disappeared within 2 weeks. Large ulcers may take up to 30 days to heal, especially if there is continued irritation.

All ulcers eventually heal, although the period of pain is often longer if nothing is done to reduce the inflammation.

Regular antiseptic mouthwashes have not been shown to be of real benefit.

Tetracycline can stain growing teeth, and therefore should not be used in children under age 12.

Biopsy of the ulcer should be considered if it is not healed in 2 weeks.

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Tonsil Adenoid Problem in Children

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Tonsillitis in Children
Tonsillitis is an infection of the tonsils. It is caused by either a virus or bacteria (usually the bacteria known as streptococcus) Tonsillitis mostly occurs in young children.

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Tonsils and Adenoids

The tonsils are a pair of lymphoid tissue located of the mouth on both sides of the throat. The adenoids are similar to the tonsils but are located in the upper portion of the throat behind the nose (Nasopharynx).

Tonsils and adenoids protect against germs during early childhood by producing antibodies.. By attacking bacteria and viruses, antibodies play an important role in the body’s immune system. The problem is that in the process of protecting the body, the tonsils and adenoids can become infected themselves.

As children grow and develop, the tonsils and adenoids eventually begin to shrink and are probably no longer important in protecting against disease-causing organisms. Even in young children, removal of infected tonsils or adenoids does not seem to weaken the body’s defenses. There are many other tissues in the body that are part of the immune system. These tissues, known as lymphoid tissues, also make antibodies to fight against infection.

When tonsils become so enlarged that a child’s voice changes, it is called “hot potato” voice. This is one sign that the tonsils should be removed.


The Symptoms of Tonsillitis

The main symptom of tonsillitis is a sore throat.

Tonsillitis can occasionally become serious. For example, infection may spread beyond the tonsil to form an abscess (Quinsy), which is a localized collection of pus.This almost always, develops on one side only, and usually in adults rather than children.

Another type of abscess, one that develops mainly in young children, is a retropharyngeal (behind the throat) abscess. This usually causes high fever and great difficulty in swallowing. If detected very early, peritonsillar or retropharyngeal abscesses can sometimes be treated successfully with antibiotics. In most cases, however, surgery is required to drain the abscess.

Complications-rare these days
The most serious complication of tonsillitis is rheumatic fever, which often is accompanied by rheumatic heart disease. Rheumatic fever develops only if the tonsillitis is due to a type of bacterium known as group A beta hemolytic streptococcus. It also usually occurs only in children who have had repeated infections that have not been adequately treated with antibiotics.

Another complication of streptococcal tonsillitis is a type of kidney disease known as acute glomerulonephritis. However, whether glomerulonephritis can be prevented by early antibiotic treatment of streptococcal tonsillitis is not clear.

A common complication of tonsillitis is infection of the lymph nodes in the neck, known as cervical Lymphadenitis. This type of infection can usually be successfully treated with antibiotics. Occasionally the infection progresses, an abscess forms, and surgery is required to drain it.

Other possible complications of tonsillitis include middle-ear infections (otitis media) and sinus infections. More often, however, these infections develop at the same time as, or independently of, tonsillitis.

Tonsillitis – Treatment
Treatment of tonsillitis aims to relieve its symptoms.

It is not always necessary to identify the exact cause of tonsillitis before beginning treatment.

Tonsillitis caused by streptococcus bacteria must be treated with penicillin or other suitable antibiotics like cephalosporin in order to prevent the development of rheumatic fever. For children who are allergic to penicillin, other suitable antibiotics are available.

Tonsillitis due to viruses, like other infections due to viruses, does not respond to any currently known antibiotics.

Paracetamol may relieve sore throat and other symptoms of tonsillitis. Aspirin is best avoided in children of any age because of the risk of Reye’s syndrome.

Tonsillitis may sometimes be due to other types of bacteria that also may respond to antibiotic treatment. Judgments about such treatment should be left to your doctor.

 

Tonsillectomy1

Surgery

Tonsillectomy is the surgical removal of the tonsils.

Tonsillectomy is definitely required when the tonsils are so large they obstruct breathing, swallowing or both. Before surgery, however, antibiotics should be tried, perhaps for as long as a month, to see whether your child’s condition can be improved. Children with obstructing tonsils commonly sleep restlessly and may have periods during sleep when breathing stops for seconds at a time because of blockage of the airway (Sleep apnea).There will be loud snoring too. I

Tonsillectomy also is justified if your child is having repeated bouts of infection, to the point that everyday activities are substantially disrupted despite adequate antibiotic treatment. It is indicated in children who have developed at least 5 bad episodes of throat infection in 1 year i.e. Fever of 101 degrees F (38.3 degrees C) or higher, Enlarged or tender lymph nodes in the neck., A pus-like coating, known as exudates, covering the tonsils or the surrounding throat area. And Evidence that the infection is streptococcal in origin.

Tonsillectomy is indicated in those who had Peritonsillar abscess (quinsy); the infection causes a painful throat, high temperature, headache, impaired speech, drooling, and swollen tender lymph glands in the neck. Not all experts believe that surgery is called for following a single case of peritonsillar abscess. Often, no further difficulty develops once the condition is successfully treated. However, following a second peritonsillar abscess, tonsillectomy is definitely indicated.

tonsillectomy3

tonsillectomy2

The Operation of Tonsillectomy
In children, removal of either the tonsils or the adenoids requires a general anesthetic.

The mouth is held open to expose the tonsils.

The tonsils are grasped with clamps and pulled toward the middle of the mouth. The tonsils are removed by gentle dissection of the surrounding tissues.

Bleeding is controlled either by pressure, sutures, clamps or ties, or with use of electrocautery, a procedure in which heat is applied to blood vessels to seal the ends that have been cut during surgery.

If the adenoids are to be removed, this is done using a specially designed instrument called curette that passes through the mouth and into the upper part of the throat behind the nose, where the adenoids lie.

After Surgery
Your child will likely experience moderate nasal congestion and drainage, a sore throat, and earaches for a few days after surgery. Allow about two weeks for full recovery. During this time, keep your child from engaging in strenuous physical activity.

It is best for a parent to be at the bedside when the child wakes up from surgery.

Be prepared for your child to experience substantial pain while swallowing for the first day or two. Swallowing may continue to be somewhat painful for 5-7 days.

Use Pareacetamol to relieve pain. Aspirin should not be used.

When your child’s appetite returns, encourage him or her to eat and drink. Many children find it more comfortable to swallow warm liquids than cold ones.

Activity
Your child should rest for 2 or 3 days, and then resume normal activities gradually. Have your child avoid vigorous exercise for two weeks after surgery. Bathe or shower your child as usual.

Diet
Following tonsillectomy, swallowing tends to be quite painful for the first day or two and somewhat painful for 4 or 5 days. Nonetheless, you should encourage your child to eat and drink as soon as any postoperative nausea has subsided. Many children find it more comfortable to swallow ice cream or cold drinks.

Back to School
Usually, children can return to school (and adults to work) about a week after surgery. However, if there have been any complications or if your child does not feel perfectly well, return to school should be delayed accordingly. Rest at home not only helps recovery from surgery but also helps to minimize contact with other children who may have contagious respiratory infections.

Possible Complications
As with any operation, there is always a small risk associated with general anesthesia.

Bleeding from the operation site may occur immediately after surgery, or several days later when the crust that has formed at the operative site drops away. Bleeding usually can be readily controlled, but occasionally requires a return to the operating room for more intensive treatment. Rarely, blood transfusion may be required.

The risk of bleeding can be minimized by avoiding surgery during and immediately following episodes of infection and by avoiding the use of aspirin to control pain following surgery, as aspirin can reduce the blood’s ability to clot.

Adenoid
The main symptoms of adenoiditis are nasal stuffiness and nasal discharge. In this respect, adenoiditis is not really distinguishable from the common cold. In children who develop a common cold, the adenoids become inflamed as part of the illness.

Snoring is a common symptom. Child can have sleep disturbance and cessation of sleep for a brief period (Sleep Apnea)

If persistent it can lead to sinusitis and most importantly otitis media causing ear ache, fever and hearing loss.
Adenoid-Treatment

Symptomatic- usually base their treatment on the nature of the clinical symptoms. Antibiotics, Nasal decongestant, Systemic decongestants are given for 5-7 days. A small and short course of steroid will be very good to relive the symptoms

Surgery – Adenoidectomy
Surgical removal of the adenoids is appropriate when the adenoids are so enlarged that your child consistently has difficulty breathing through the nose, and the condition is not substantially improved by antibiotic treatment.

Removal of the adenoids is also appropriate in children who have had persistent otitis media (infection or fluid in the middle-ear), even after having surgery to place grommets in the ears.

Conclusion

In my experience of 35 years of ENT practice, must have removed thousands of Tonsils and Adenoid. I have operated in 3 Generation of people. I haven’t seen any one who were adversely affected by its removal. So why keep on having a miserable life with horrible Tonsils, go for Surgery. Its simple and nothing to worry about.

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What is Sleep Apnoea?

Sleep apnoea is a condition that interrupts your breathing when you are asleep. This is usually caused by an obstruction blocking the back of the throat so that the air cannot reach your lungs. The cessation of breathing automatically forces you to wake up in order to start breathing again. This can happen many times during the night, making it hard for your body to get enough oxygen, and preventing you from obtaining enough good quality sleep.

Obstructive Sleep Apnoea (OSA)

This is a common feature in middle aged, overweight men. OSA can range from being very mild to severe. Sleep apnoea is usually defined as cessation of air flow into the lungs which lasts for more than 10 seconds.

This definition however is rather artificial as some apnoeas which last for more than 10 seconds during sleep are perfectly normal. It is quite common for intervals between breaths to last for 10-20 seconds without there being any underlying sleep or respiratory disorder.

How Do one Know that he or she Has Sleep Apnoea?

Sleep Study

A common situation in which breathing may stop for more than 10 seconds is when the stage of sleep changes. We can determine the severity of sleep apnoea by two indices. The apnoea index (AI) (the number of apnoeas occuring per hour), and the apnoea/hypopnoea index (AHI) (significant drop in oxygen saturation of 4% or more per hour due to the cessation of breathing). An AHI of less than 10 is not likely to be associated with clinical problems.

To determine whether you are suffering from sleep apnoea you must first undergo a specialist “sleep study”. This will usually involve a night in hospital where equipment will be used to monitor the quality of your sleep and the amount of oxygen your body is getting. This information will enable a specialist to diagnose whether or not you have sleep apnoea and decide on your best course of treatment. The ultimate investigation is polysomnography which will include:

  • Electro-encephalography (EEG) – brain wave monitoring
  • Electromyography (EMG) – muscle tone monitoring
  • Recording thoracic-abdominal movements – chest and abdomen movements
  • Recording oro-nasal flow – mouth and nose air flow
  • Pulse oximetry – heart rate and blood oxygen level monitoring
  • Electrocardiography(ECG) – heart monitoring

Obstructive Sleep Apnoea OSA is the most common form of sleep apnoea, This is when the airway is blocked but the respiratory effort continues.

But there is also a condition called Central Sleep Apnoea (CSA). This is a condition when the brain does not send the right signals to tell you to breathe when you are asleep causing a lack of reparatory activity. In other words the brain “forgets” to make you breathe. It can also be associated with weakness of the breathing muscles. CSA is less common than OSA, and needs to be investigated by a specialist. The assessment is often more complicated than for patients with OSA and the treatment has to be carefully matched to the patient’s requirements.

There is also a condition called Mixed Sleep Apnoea which is a combination of both OSA and CSA. The cause of Silent death in some patients are due to this.