CO2 laser cryptolysis by coagulation for the treatment of halitosis

FEATURES OF THE CONNECTIVE TISSUE COMPONENT OF THE PALATINE TONSILS IN PATIENTS WITH RECURRENT TONSILLITIS

OBJECTIVE

The aim: To explore the morphological changes of palatine tonsil at the levels of the epithelial layer and connective tissue; to determine the relative area of the connective tissue component in the tonsillar tissue (fibrosis) in patients with recurrent tonsillitis compared to the control.

PATIENTS AND METHODS

Materials and methods: This study presents a morphological assessment of the palatine tonsils of 10 people. Tonsils' material with surrounding tissue was fixed in 10% formalin solution. The samples were dehydrated in increasing ethanol concentrations, cleared in xylol, impregnated with paraffin. Microscopy was then performed with samples stained beforehand.

RESULTS

Results: In the samples of patients with recurrent tonsillitis pericapsular sclerosis was noted, along with thickening of interlobular septa and pronounced subepithelial fibrosis. A ratio of the dense connective tissue surface area to the total surface area of tonsil tissue was determined. The control group showed a statistically significant decrease in the degree of sclerosis of the tonsil stroma.

CONCLUSION

Conclusions: Multiple changes were found in the tonsils of patients with recurrent tonsillitis at the level of the epithelial layer that manifested in structural alterations. Significant and irreversible changes were also observed in the connective stroma of the tonsil - pericapsular sclerosis, thickening of interlobular septa, and pronounced subepithelial fibrosis. A statistically significant increase in the relative surface area of the connective tissue component of the tonsil (fibrosis) by a factor of 1,26 was noted in patients with recurrent tonsillitis compared to the results of the control group of patients.

Coblation cryptolysis method in treatment of tonsil caseum-induced halitosis

PURPOSE

Halitosis, is a social problem affecting many patients seeking help from clinicians. Tonsil stones can cause halitosis and especially occur in crypts of palatine tonsils. Coblation cryptolysis is an alternative method for tonsil caseum treatment. The coblation technology includes passing a radiofrequency bipolar electrical current through a medium of normal saline which results in the production of a plasma field of sodium ions. In this study, our aim was to investigate the effectiveness of coblator cryptolysis treatment method in chronic caseous tonsillitis-induced halitosis.

METHODS

We included in our study 28 patients who underwent coblator cryptolysis surgery for halitosis due to chronic caseous tonsillitis. The efficacy of treatment and the presence of caseoma were evaluated with the Finkelstein test, organoleptic test and VAS before the procedure and at the 6th month control after the treatment was completed.

RESULTS

At the 6th month follow-up after the procedure (a single coblation cryptolysis) we found that 23 of the patients (82.1%) had no caseum. There was a statistically significant change in Finkelstein measurements before and after the procedure (p < 0.001). Organoleptic measurements demonstrated that 21 patients had no halitosis postoperatively and the mean organoleptic test score was calculated as 0.39 ± 0.79 after the procedure. The recovery was statistically significant (p < 0.001). The mean VAS score before coblation cryptolysis was 8.0 ± 1.33 (range 5-10). On the other hand 6 months after a single coblation cryptolysis session, the mean VAS score was 1.25 ± 1.78 (range: 0-6). This difference was statistically significant (p < 0.001).

CONCLUSIONS

Our results suggest that coblation crptolysis is an effective, safe, minimally invasive and practical alternative method in treatment of halitosis due to tonsil caseums. We did not observe any complication after the procedure.

Assessment of Volatile Sulfur Compounds in Adult and Pediatric Chronic Tonsillitis Patients Receiving Tonsillectomy

OBJECTIVES

To study the volatile sulfur compound (VSC) concentration profile in chronic tonsillitis patients before and after tonsillectomy, and to evaluate the difference between adult and pediatric (children and adolescents) patients.

METHODS

Thirty adult patients (older than 20 years old) and 30 pediatric patients (younger than 20 years old) who were assigned to get tonsillectomy due to chronic tonsillitis were enrolled in this prospective nonrandomized clinical study. The concentrations of the three main VSCs related to halitosis (hydrogen sulfide, methyl mercaptan, and dimethyl sulfide) were assessed in each patient using a portable chromatograph (Oral Chroma^TM) at 1 day before operation, postoperative 1 day, 1 week, and 2 weeks.

RESULTS

Average concentration of hydrogen sulfide, methyl mercaptan, and dimethyl sulfide preoperatively were 99.5 ppb, 24.6 ppb, and 9.45 ppb in adult patients, and 97.4 ppb, 26 ppb, and 10.5 ppb in pediatric patients, respectively. The concentrations of the three VSCs in both groups were highest in first day after surgery, and decreased signigicantly after 2 weeks compared to preoperative values (P<0.001). There was no significant difference of the concentration of the three VSCs between adult and pediatric patients in any time point.

CONCLUSION

The concentrations of hydrogen sulfide, methyl mercaptan, and dimethyl sulfide decreased significantly after tonsillectomy in chronic tonsillitis patients. The concentrations of the three VSCs were not significantly different between pediatric and adult patients before and after tonsillectomy.

Immediate results of photodynamic therapy for the treatment of halitosis in adolescents: a randomized, controlled, clinical trial

Light with or without chemical agents has been used to induce therapeutic and antimicrobial effects. With photodynamic therapy, the antimicrobial effect is confined to areas covered by a photosensitive dye and irradiated with light. The aim of the present study was to evaluate the effect of photodynamic therapy for the treatment of halitosis in adolescents through the analysis of volatile sulfur compounds, especially sulfide. A controlled, clinical trial was conducted with 45 adolescents randomly allocated to three groups: group 1, photodynamic therapy administered to the dorsum of the tongue; group 2, treatment with a tongue scraper; and group 3, treatment with a tongue scraper combined with photodynamic therapy. The diagnosis of halitosis was performed using gas chromatography before and after treatment. Comparisons were made using the Kruskal-Wallis test followed by the Student-Newman-Keuls test, with the level of significance set at 5 % (p < 0.05). After treatment, a statistically significant reduction in halitosis was found in all groups (p < 0.001). The greatest reduction in total sulfides (median = 0) occurred with the combination of tongue scraper and photodynamic therapy. The present study describes a novel option for the treatment of halitosis in adolescents with an immediate effect that does not involve the mechanical aggression of the lingual papillae that occurs with conventional treatment.

TRIAL REGISTRATION

Photodynamic Therapy in Adolescents Halitosis ( https://clinicaltrials.gov/ct2/show/NCT02007993?term=NCT02007993&rank=1 )Number: NCT02007993FUNDING:FAPESPNumber: 2013/13032-8.

Tonsillitis and sore throat in children

Surgery of the tonsils is still one of the most frequent procedures during childhood. Due to a series of fatal outcomes after hemorrhage in children in Austria in 2006, the standards and indications for tonsillectomy have slowly changed in Germany. However, no national guidelines exist and the frequency of tonsil surgery varies across the country. In some districts eight times more children were tonsillectomized than in others. A tonsillectomy in children under six years should only be done if the child suffers from recurrent acute bacterially tonsillitis. In all other cases (i.e. hyperplasia of the tonsils) the low risk partial tonsillectomy should be the first line therapy. Postoperative pain and the risk of hemorrhage are much lower in partial tonsillectomy (=tonsillotomy). No matter whether the tonsillotomy is done by laser, radiofrequency, shaver, coblation, bipolar scissor or Colorado needle, as long as the crypts are kept open and some tonsil tissue is left behind. Total extracapsular tonsillectomy is still indicated in severely affected children with recurrent infections of the tonsils, allergy to antibiotics, PFAPA syndrome (periodic fever, aphthous stomatitis, pharyngitis, and cervical adenitis) and peritonsillar abscess. With regard to the frequency and seriousness of the recurrent tonsillitis the indication for tonsillectomy in children is justified if 7 or more well-documented, clinically important, adequately treated episodes of throat infection occur in the preceding year, or 5 or more of such episodes occur in each of the 2 preceding years (according to the paradise criteria). Diagnosis of acute tonsillitis is clinical, but sometimes it is hard to distinguish viral from bacterial infections. Rapid antigen testing has a very low sensitivity in the diagnosis of bacterial tonsillitis and swabs are highly sensitive but take a long time. In all microbiological tests the treating physician has to keep in mind, that most of the bacterials, viruses and fungi belong to the healthy flora and do no harm. Ten percent of healthy children even bear strepptococcus pyogenes all the time in the tonsils with no clinical signs. In these children decolonization is not necessary. Therefore, microbiological screening tests in children without symptoms are senseless and do not justify an antibiotic treatment (which is sometimes postulated by the kindergartens). The acute tonsillitis should be treated with steroids (e.g. dexamethasone), NSAIDs (e.g. ibuprofene) and betalactam antibiotics (e.g. penicillin or cefuroxime). With respect to the symptom reduction and primary healing the short-term late-generation antibiotic therapy (azithromycin, clarithromycin or cephalosporine for three to five days) is comparable to the long-term penicilline therapy. There is no difference in the course of healing, recurrence or microbiological resistance between the short-term penicilline therapy and the standard ten days therapy. On the other hand, only the ten days antibiotic therapy has proven to be effective in the prevention of rheumatic fever and glomerulonephritic diseases. The incidence of rheumatic heart disease is currently 0.5 per 100,000 children of school age. The main morbidity after tonsillectomy is pain and the late haemorrhage. Posttonsillectomy bleeding can occur till the whole wound is completely healed, which is normally after three weeks. Life-threatening haemorrhages occur often after smaller bleedings, which can spontaneously cease. That is why every haemorrhage, even the smallest, has to be treated properly and in ward. Patients and parents have to be informed about the correct behaviour in case of haemorrhage with a written consent before the surgery. The handout should contain important addresses, phone numbers and contact persons. Almost all cases of fatal outcome after tonsillectomy were due to false management of haemorrhage. Haemorrhage in small children can be especially life-threatening because of the lower blood volume and the danger of aspiration with asphyxia. A massive haemorrhage is an extreme challenge for every paramedic or emergency doctor because of the difficult airway management. Intubation is only possible with appropriate inflexible suction tubes. All different surgical techniques have the risk of haemorrhage and even the best surgeon will experience a postoperative haemorrhage. The lowest risk of haemorrhage is after cold dissection with ligature or suturing. All "hot" techniques with laser, radiofrequency, coblation, mono- or bipolar forceps have a higher risk of late haemorrhage. Children with a hereditary coagulopathy have a higher risk of haemorrhage. It is possible, that these children were not identified before surgery. Therefore it is recommended by the Society of paediatrics, anaesthesia and ENT, that a standardised questionnaire should be answered by the parents before tonsillectomy and adenoidectomy. This 17-point-checklist questionnaire is more sensitive and easier to perform than a screening with blood tests (e.g. INR and PTT). Unfortunately, a lot of surgeons still screen the children preoperatively by coagulative blood tests, although these tests are inappropriate and incapable of detecting the von Willebrand disease, which is the most frequent coagulopathy in Europe. The preoperative information about the surgery should be done with the child and the parents in a calm and objective atmosphere with a written consent. A copy of the consent with the signature of the surgeon and both custodial parents has to be handed out to the parents.

Photodynamic therapy as a novel treatment for halitosis in adolescents: study protocol for a randomized controlled trial

Background

Halitosis is a common problem that affects a large portion of the population worldwide. The origin of this condition is oral in 90% and systemic in 10% of cases. The unpleasant odor is mainly the result of volatile sulfur compounds produced by Gram-negative bacteria. However, it has recently been found that anaerobic Gram-positive bacteria also produce hydrogen sulfide (H₂S) in the presence of amino acids, such as cysteine. Light, both with and without the use of chemical agents, has been used to induce therapeutic and antimicrobial effects. In photodynamic therapy, the antimicrobial effect is confined to areas covered by photosensitizing dye. The aim of the present study is to evaluate the antimicrobial effect of photodynamic therapy on halitosis in adolescents through the analysis of volatile sulfur compounds measured using gas chromatography and microbiological analysis of coated tongue.

Methods/Design

A quantitative clinical trial will be carried out involving 60 adolescents randomly divided into the following groups: group 1 will receive treatment with a tongue scraper, group 2 will receive photodynamic therapy applied to the posterior two-thirds of the dorsum of the tongue, and group 3 will receive combined treatment (tongue scraper and photodynamic therapy). Gas chromatography (OralChroma^TM) and microbiological analysis will be used for the diagnosis of halitosis at the beginning of the study. Post-treatment evaluations will be conducted at one hour and 24 hours after treatment. The statistical analysis will include the Shapiro-Wilk test for the determination of the distribution of the data. If normal distribution is demonstrated, analysis of variance followed by Tukey’s test will be used to compare groups. The Kruskal-Wallis test followed by the Student-Newman-Keuls test will be used for data with non-normal distribution. Either the paired t-test or the Wilcoxon test will be used to compare data before and after treatment, depending on the distribution of the data.

Discussion

The results of this trial will determine the efficacy of using photodynamic therapy alone or in combination with a tongue scraper to treat bad breath in adolescents.

Trial registration

The protocol for this study was registered with Clinical Trials (registration number NCT02007993) on 10 December 2013.

Halitosis and the Tonsils

Objective

Halitosis secondary to pathology of the palatine tonsils is considered airway (type 2) halitosis in the etiologic classification. Reports differ as to the proportion of objective halitosis complaints that have tonsillar etiology, with some giving this figure as 3%. Due to their immunologic role, even healthy tonsils usually possess some subclinical inflammation. The tonsil crypt system is also the most ideal environment for anaerobic bacterial activity in the upper respiratory tract. Tonsillar halitosis is thought to occur mainly because of chronic caseous tonsillitis and tonsillolithiasis (tonsil stones). Tonsillectomy and various cryptolysis techniques are reported to improve halitosis in such cases. In this article, diagnostic methods and evidence for interventions are reviewed.

Data Source

Medline search.

Review Methods

Studies reporting the efficacy of any intervention (medical or surgical) on tonsillar halitosis were included, whether halitosis was the focus or one of several measures.

Conclusions

There are insufficient high-quality studies on this topic. Improved methodology, for example, use of control groups and utilization of more accurate halitosis detection/quantification techniques, are required.

Implications for Practice

Lack of evidence currently prevents firm conclusions, but the following is recommended: (1) Use reliable methods for halitosis diagnosis and confirmation of tonsillar etiology. Initial treatment such as tongue scraping is useful to rule out oral halitosis. (2) Tonsillar procedures are contraindicated in: subjective halitosis, non-tonsillar etiology, or if medical management resolves halitosis. (3) Where indicated and where facilities permit, less invasive techniques such as laser cryptolysis may be preferable to tonsillectomy in adults, potentially avoiding general anesthetic and the higher risk associated with tonsillectomy in this group.

Effectiveness of radiofrequency cryptolysis for the treatment of halitosis due to caseums

OBJECTIVE

To evaluate the effectiveness of radiofrequency (RF) cryptolysis for caseum-induced halitosis.

STUDY DESIGN

Clinical retrospective study.

SETTING

Otorhinolaryngology Head and Neck Surgery Department of Konya Training and Research Hospital in Turkey.

SUBJECTS AND METHODS

Thirty-four patients with caseum-induced halitosis were included. Eight were male (23.5%) and 26 were female (76.5%). Their mean age was 28.29 ± 9.3 (range: 17-48) years. The mean duration of complaint of halitosis before RF cryptolysis was 53.41 ± 42.6 months (range: 6-182 months). The Finkelstein test, organoleptic measurements, and visual analog scale (VAS) were performed before and 12 months after RF cryptolysis.

RESULTS

Before RF cryptolysis, all patients had a positive Finkelstein's test result, organoleptic measurements revealed that three (8.82%) had serious halitosis, 24 (70.58%) had average halitosis, and seven (20.58%) had mild halitosis, and the mean VAS score was 6.82 ± 1.45. The follow-up period after RF cryptolysis was 12 months. After the single RF cryptolysis session, 26 patients (76.47%) were negative for Finkelstein's test, organoleptic assessments revealed that 26 (76.47%), six (17.64%), and two (5.88%) showed complete, partial, and no recovery, respectively, (p<0.001), and the mean VAS score was significantly better at 1.88 ± 2.5 (p<0.001). Thirty-two patients (94.1%) exhibited a decrease in VAS score.

CONCLUSION

RF cryptolysis is a cost-effective, safe, and easily applicable modality for the treatment of halitosis due to caseums in the crypts of the palatine tonsils.

Laser tonsil cryptolysis: in-office 500 cases review

OBJECTIVES

Tonsilloliths, proven to be tonsillar biofilms cause symptoms of halitosis, foreign body sensation and recurrent sore throats. Laser Tonsil Cryptolysis (LTC) performed in the office may represent an alternative to tonsillectomy in selected cases of persistent tonsilloliths with cryptic infections.

STUDY DESIGN

A retrospective chart analysis using CPT codes.

SETTING

Office and hospital.

METHODS

A retrospective complications review consisting of bleeding, the need for an additional procedure, patient satisfaction and conversion rate to complete tonsillectomy was documented.

RESULTS

Five hundred consecutive LTCs performed in the office under local anesthesia with a CO2 or diode laser were identified. Energy delivery was in continuous mode with power settings of 18W and 10W respectively. Bleeding occurred in 6 patients requiring unscheduled return office visit for evaluation. Eighty patients required a second procedure, comprising total of 1.16 procedures per patient. Eighteen (3.6%) patients underwent complete tonsillectomy. Patient satisfaction was high with an overall incidence of 0-2 days of work absence. Follow-up was 1-8 years.

CONCLUSIONS

With a small tonsil size, controllable gag reflex and cooperative adult patient LTC allows several advantages compared to conventional tonsillectomy. Benefits of LTC include avoidance of general anesthesia and limited ablation of cryptic pockets, resulting in reduced post-operative pain, bleeding, shorter recovery time and the convenience and cost advantage of an office procedure. With 1.16 sessions required per patient, low conversion rate to standard tonsillectomy and minimal complication rate LTC can be considered an alternative option to a patient suffering from recurrent cryptic tonsillitis with or without tonsilloliths.

Halitosis: the multidisciplinary approach

Halitosis, bad breath or oral malodour are all synonyms for the same pathology. Halitosis has a large social and economic impact. For the majority of patients suffering from bad breath, it causes embarrassment and affects their social communication and life. Moreover,halitosis can be indicative of underlying diseases. Only a limited number of scientific publications were presented in this field until 1995. Ever since, a large amount of research is published, often with lack of evidence. In general, intraoral conditions, like insufficient dental hygiene, periodontitis or tongue coating are considered to be the most important cause (85%) for halitosis. Therefore, dentists and periodontologists are the first-line professionals to be confronted with this problem. They should be well aware of the origin, the detection and especially of the treatment of this pathology. In addition, ear-nose-throat-associated (10%) or gastrointestinal/endocrinological (5%) disorders may contribute to the problem. In the case of halitophobia, psychiatrical or psychological problems may be present. Bad breath needs a multidisciplinary team approach: dentists, periodontologists, specialists in family medicine, ear-nose-throat surgeons, internal medicine and psychiatry need to be updated in this field, which still is surrounded by a large taboo.Multidisciplinary bad breath clinics offer the best environment to examine and treat this pathology that affects around 25% of the whole population. This article describes the origin, detection and treatment of halitosis, regarded from the different etiological origins.

Coblation Cryptolysis to Treat Tonsil Stones: A Retrospective Case Series

We introduce a novel and potentially effective approach in the treatment of tonsil stones using Coblation technology. A retrospective pilot case series was performed demonstrating the effectiveness of a technique that we call Coblation tonsil cryptolysis. This technique is unique in that it can be performed in adult patients without sedation using only local anesthesia, much like laser tonsil cryptolysis. As with laser cryptolysis, pain is significant for only a few days and most adults can resume normal diet and activity within 1 week. In contrast, tonsillectomy entails significant morbidity for several weeks. However, Coblation avoids the significant disadvantages of laser use, including the potential for airway fire, retinal damage from reflected scatter, dealing with plume from vaporized tissues, oral/facial burns, and the high cost of purchasing and maintaining laser equipment. After a single session of Coblation tonsil cryptolysis, a significant decrease and even elimination of tonsil stones can potentially be achieved.

Relationship between tonsil odor and oral malodor: a clinical study on 48 Iranian patients

The objective of this study is to evaluate tonsil odor as a contributor to halitosis and to study the reduction of oral malodor by mouth rinsing, without tonsil treatment. In 48 halitosis patients, tonsil odor and oral malodor were assessed through the 0-5 scale. In tonsil odor assessment, a dental burnisher was inserted into the tonsilar crypts and was sniffed by an odor judge. Oral malodor was analyzed through a plastic straw using the same scale by the same judge. The concentrations of H(2)S, CH(3)SH and (CH(3))(2)S were measured by a portable gas chromatograph (GC) (OralChroma) in ppb. After the baseline evaluations the subjects were instructed to scrape the surface of the tongue daily and rinse with a zinc-containing mouthwash twice daily for 1 month. After this period the same evaluations were repeated. Data were analyzed by SPSS software, paired t-test and Pearson correlation. Before mouthwash test: mean values of oral malodor scores and tonsil odor scores were 4.2 and 3.7, respectively. Pearson correlation analysis showed that oral malodor scores and tonsil odor scores had a significant correlation (p = 0.025). Oral malodor scores were correlated with the concentrations of H(2)S (p = 0.0001), CH(3)SH (p = 0.041) but not with (CH(3))(2)S concentration. After mouthwash test: mean values of oral malodor scores and tonsil odor scores were 2.2 and 3.0, respectively. Tonsil odor scores and oral malodor scores were not correlated. Also the paired t-test results showed that the effect of the mouthwash on the reduction of oral malodor and tonsil odor was not the same. Since oral malodor was successfully reduced while tonsil odor remained with a little reduction, it is concluded that tonsilar treatment such as tonsillectomy and laser cryptolysis might be considered only after the failure of mechanochemical therapy.