Halitosis

Halitosis is a relatively infrequent pediatric chief complaint; however, it frequently emerges as part of the HPI. Acute causes are usually upper respiratory infections (such as stomatitis, tonsillitis, or sinusitis), whereas chronic halitosis is more likely to be due to dental issues. However, chronic sinusitis may cause halitosis either from the presence of bacterial colonies or from secondary mouth breathing.

Differential Diagnosis

• Upper respiratory
  –Stomatitis: Painful ulcerated lesions on oral mucosa and gingiva; coxsackie virus is commonly called hand-foot-and-mouth disease; herpangina refers to herpetic lesions on the soft palate and posterior pharynx; trench mouth refers to necrotizing gingivostomatitis with pseudomembrane caused by spirochetes or fusiform bacteria
  –Sinusitis: Acute or chronic; pathogens are Streptococcus pneumoniae, β-hemolytic strep, Haemophilus influenzae, and Moraxella catarrhalis; maxillary sinuses are most frequently involved
  –Pharyngitis/tonsillitis/tonsillar abscess: Group A strep

• Pulmonary disorders
  –Pulmonary abscess
  –Bronchiectasis
• Gastric disorders
  –GERD
  –Bezoar

• Dental etiologies
  –Poor oral hygiene: Bacterial accumulation on the teeth or tongue; gingival inflammation; food concretions within tonsillar crypts
  –Dental abscess: May be sequela of baby-bottle tooth decay, untreated dental caries, dental fracture, or poor hygiene
  –Orthodontic devices

• Chronic mouth breathing
  –Seen in children with nasal polyps, adenoid hypertrophy, allergic rhinitis, and chronic sinusitis
  –Rarely due to a nasopharyngeal tumor such as a hemangioma or fibromas
  –Resultant dryness causes alteration of the oral mucosa and resultant bad breath; taste and smell may be affected

• Nasal foreign body
  –Seen most often in the toddler/preschool age group
  –History of foreign body placement is not always forthcoming
  –Usually accompanied by unilateral nasal discharge

Workup and Diagnosis

• History
  –Onset, duration, severity of symptoms
  –Accompanying signs and symptoms, especially fever, nasal congestion, nasal discharge, sore throat, cough, tachypnea
  –History of recurrent pneumonia
  –History of GI upset, digestive problems
  –Dental history and frequency of dental care

• Physical exam
  –Examination of the oral cavity for dental hygiene, dental caries, gingival swelling, orthodontic devices that are poorly fitting or poorly maintained
  –HEENT examination including nasal cavity, oral lesions, tonsillar hypertrophy, asymmetry, exudate, or concretions
  –General medical evaluation including respiratory and GI systems

• Labs
  –Throat culture if streptococcal pharyngitis is suspected
• Radiology
  –X-ray or CT of sinuses for mucosal thickening or air-fluid levels
  –Lateral X-ray for adenoid hypertrophy
  –Chest X-ray if pulmonary lesion is suspected
• Studies
  –Endoscopy may be required for suspicion of GERD or bezoar

Treatment

• Scrupulous oral hygiene
• Stomatitis is usually treated supportively with acetaminophen and oral hydration (Popsicles)
  –Viscous lidocaine should be used sparingly, if ever
  –Herpetic lesions may be treated with oral acyclovir
  –Trench mouth is treated with penicillin
• Streptococcal pharyngitis is treated with penicillin
• Sinusitis requires longer duration of antibiotic therapy
• Bronchiectasis and pulmonary abscess are treated with systemic antibiotics and nonsurgical or surgical drainage
• Adenoidectomy and treatment of concurrent allergies and sinusitis rectifies most mouth breathing
• GERD is treated with H2 blockers and promotility agents
• Endoscopy may be therapeutic and diagnostic for bezoar
• Removal of nasal foreign body is usually sufficient treatment

Book Source Details

• Book Title: In A Page: Pediatric Signs and Symptoms
• Author(s): Jonathan E. Teitelbaum, Kathleen O. Deantonis, Scott Kahan
• Year of Publication: 2007
• Copyright Details: In A Page: Pediatric Signs and Symptoms, Copyright © 2007 Lippincott Williams & Wilkins.

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Copyright Details: In A Page: Pediatric Signs and Symptoms, Copyright © 2008 Williams & Wilkins.

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More About This Book: Title: In A Page: Pediatric Signs and Symptoms Authors: Jonathan E. Teitelbaum, Kathleen O. Deantonis, Scott Kahan Publisher: Lippincott Williams & Wilkins Copyright: 2007 ISBN: 1-4051-0427-9

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