Otorhinolaryngologica lManifestations in AIDS

1. ENT Manifestations in AIDS
Dr. Juveria Majeed
MS ENT,
SR, Bhaskar Medical College/Hospital.

2. HIV
Retrovirus – Viral RNA
into DNA
Two types – Type 1 and
type 2
Type 1 - more common
and more pathogenic
Type 2 – less common
and less pathogenic

3. Once entering the host, this attacks the T-
lymphocytes and other CD4 surface markers.
With the fall of the CD4 lymphocytes(<500/cu.
mm) , the immunodeficiency is seen and many
other opportunistic and malignancy can appear.
When the CD4 cell counts appear less than 200,
death may appear in about 2-3 years.

4. CD4: disease progression indicator
When the CD4>500/mm3 essentially asymptomatic.
CD4 count 200 to 500 cells/mm the early
manifestations HIV infection.
 CD4 <200 cells/mm vulnerable to processes
associated with AIDS.
CD4 < 50 cells/mm  increasingly at risk unusual
opportunistic

5. EPIDEMIOLOGY
First case came into medical attention as early as
1980’s.
These cases were detected by retrospective
analysis to have occurred in 1978 in USA and in
late 1970’s in Equatorial Africa.
The first case was registered in 1986 in India

6. INDIAN SCENARIO OF HIV AIDS

8. RISK GROUPS
Homosexuals.
Heterosexually promiscuous individuals.
Prostitutes and truck drivers.
I. V. drug users.
Recipients of blood and its products
(haemophilia, thalassemia, dialysis).
Children born to HIV mothers.

9. Hazard to health workers is
from blood and the body fluids
such as
• Amniotic
• Pleura
• Peritoneal
• Pericardial
Risk of acquiring infections
from specimen of Urine,
sputum, stool saliva, tears,

13. Opportunistic infestations in AIDS
• Pneumocystis carinii
• Tuberculosis
• Candida albicans
• Cryptococcus neoformans
• Mycobacterium species
• Toxoplasma gonidii
• CMV
• Herpes zoster
• Histoplasmosis
• Herpes simplex

14. ENT MANIFESTATIONS OF
AIDS

15. EAR

16. Seborrheic Dermatitis
 83% of patients develop extensive
seborrheic dermatitis.
 Face, scalp and the periauricular region
 Recurrent superinfections of the
involved skin
 Treatment: Dandruff shampoo and
topical steroid

17. Kaposi's Sarcoma OF External Ear
 Either on the pinna or in the EAC
 conductive hearing loss, may arise if the tumor extends onto the tympanic
membrane (TM) or into the middle ear.
TREATMENT
 Carbon dioxide laser can excise canalicular KS.
 With TM involvement-- argon laser spare normal tissue, TM perforation less
likely.

18. Kaposi's Sarcoma OF External Ear

19. Infections of the External Ear
 Pinna cellulitis - Staphylococcus aureus
 Otitis externa - Pseudomonas aeruginosa.
 Malignant Otitis Externa: No response to standard antibiotic regimens,
suspect skull base osteomyelitis- Pseudomonas, Aspergillus (rarely)
 Extrapulmonary Infections with either Pneumocystis or Mycobacterium
tuberculosis separately can result in a tumor-like lesion in the EAC.

20. Otitis Externa
Malignant otitis externa caused
predominantly by Pseudomonas or by
Aspergillus fumigatus.
Treatment is by antibiotics for
pseudomonas or IV amphotericin B
followed by oral itraconazole for
aspergillus

21. MALIGNANT OTITIS EXTERNA

22. HIV-Associated Conditions in the Middle Ear

23. Infections of the Middle ear
• Serous otitis media and recurrent acute otitis media.
• Pathogenesis: Eustachian tube dysfunction can result from
• Nasopharyngeal lymphoid hyperplasia
• Sinusitis
• Nasopharyngeal neoplasms
• Allergies and their associated mucosal changes.
• Acute inflammation of the mastoid air cells is seen
• Coalescing suppurative mastoiditis -- rare.
• Unusual organisms- M. tuberculosis and Aspergillus.

24. SEROUS OM AND ACUTE OM

25. HIV-Associated Conditions in the Inner Ear

26. Sensorineural Hearing Loss
 May be U/L or B/L
 Sensorineural hearing loss  worsens with increasing frequencies.
 Speech discrimination  normal.
 Increased latencies on auditory brain stem testing  central demyelination consistent
with a viral infection- primary infection by HIV
 Rehabilitation with hearing aids should be considered

27. Vertigo
 It is usually concurrent with multiple other neurologic symptoms.
 Frequently a symptom of subacute encephalitis or HIV disease dementia.
 HIV may directly affect the vestibular and auditory systems.

28. HIV-Associated Conditions Affecting the External Nose and
Face

29. Facial Nerve/Central Nervous System Facial-Paralysis Syndromes
 UMN PALSY
 Unilateral or bilateral facial paralysis
 CNS toxoplasmosis is the most common identifiable cause
 HIV encephalitis and CNS lymphoma.

30. Idiopathic or Bell's Palsy
 Bell's palsy, is the single most common diagnosis given for HIV-infected patients
with seventh nerve paralysis
 The leading theory is infection of the facial nerve by herpes simplex virus (HSV).
 In the immunocompromised patient, concurrent opportunistic infections
contraindicate the use of systemic steroids. Acyclovir used alone.

31. BELL’S PALSY

32. Herpes Zoster
 Herpes zoster infection, or the Ramsey Hunt syndrome, occurs more commonly in
HIV-infected
 Results from reactivation of a chronic herpetic infection of the geniculate ganglion
 Results in painful herpetic vesicles in the distribution of the sensory component of
the facial nerve along with facial palsy, which occasionally is permanent.
 Symptoms tend to be more severe in the HIV-infected.

33. Herpes Zoster

34. Cutaneous Lesions
 Kaposi’s Sarcoma
 Herpetic infection
 Seborrheic dermatitis.
 Cellulitis

35. HIV-Associated Nasal and Paranasal Sinus Problems

36. Nasal Obstruction
 A common symptom during HIV infection
 Wide-ranging differential diagnosis
 Adenoidal hypertrophy,
 Allergic rhinitis,
 Chronic sinusitis,
 Neoplasms of the nose, paranasal sinuses, or nasopharynx.

37. RECURRENT/ PERSISTENT VESTIBULITIS
 Inflammation of nasal vestibule
 Immunosuppression
 May have fulminant course Cellulitis
 Danger area of face Cavernous sinus thrombosis
 Local and systemic antibiotics
 Early aggressive treatment

38. Vestibulitis

39. Allergic Rhinitis
• Polyclonal B-cell activation- Increased production of IgA, IgG and IgE.
• Excessive IgE production-Allergic symptoms
• Sneezing, perennial profuse thick rhinorrhea and nasal congestion.
• Rule out chronic bacterial sinusitis -- nasal endoscopy or CT imaging.
• Tx: 2nd gen Antihistaminics, topical steroids

40. Sinusitis
 Immunosupression and Changes in the mucociliary clearance
 BACTERIAL :
 Streptococcus pneumoniae, Moraxella catarrhalis, and H. influenzae
 Higher incidence of S. aureus and P. aeruginosa
 FUNGAL:
 Alternaria alternata, Aspergillus, Pseudallescheria boydii, Cryptococcus,Candida albicans
 Increasing invasive Aspergillus sinusitis.
 Incidence of rhinocerebral Mucormycosis not increased

41. Allergic Rhinitis Sinusitis

42. CT SCAN- PNS

43. Sinusitis
 Signs and symptoms: fever, headache and chronic, thick mucopurulent nasal
discharge,etc.
 Diagnosis: Plain sinus radiographs, CT scanning, Nasal endoscopic
examination
 Antral lavage and endoscope-guided culture-if symptoms persist following
medical therapy.
 CD4 <50 cells/mm with persistent sinus symptoms  invasive fungal
infection
 Endoscopic sinus surgery (ESS) if medical therapy fails.

44. KAPOSI’S SARCOMA:
 Nasal obstruction
 Intermittent epistaxis
 Rhinorrhea
NON HODGKIN’S LYMPHOMA:
 Bleeding
 Nasal obstruction
 Rhinorrhea
 Mass effect on the face, orbit, or other surrounding structures.

45. ORAL CAVITY

46. Oral Candidiasis (Thrush)
 Most Common , Recurring problem
 C/F: tender, white, pseudomembranous or plaque-like lesions with
underlying erosive erythematous mucosal surfaces
 Angular cheilitis: Angle of mouth
 KOH preparation of scrapings- diagnostic.
 Topical antifungals: Clotrimazole, Nystatin
 I.V. Amphotericin B in unresponsive cases

47. Oral thrush

48. Oral thrush

49. Oral Hairy Leukoplakia
 Almost exclusively in HIV-infected patients
 White, vertically corrugated lesion
 Anterior lateral border of the tongue
 Shows rapid progression to the advanced stage of HIV disease
 Epstein-Barr virus (EBV) is associated
 No prognostic significance
 Treatment is generally unnecessary

50. ORAL HAIRY LEUCOPLAKIA

51. Recurrent Aphthous Ulcerations
 Giant(several cms in diameter) aphthous ulcerations.
 Cause tremendous morbidity
 Severe odynophagia due to giant aphthous stomatitis produce anorexia and
dehydration.
 May lead to AIDS wasting disease
 Secondary infection further adds to the severe pain
 Local anesthetics and supportive therapy

52. APTHOUS ULCERS

53. Xerostomia
 Chronic inflammatory processsimilar to Sjögren's
syndrome
 Interfere with deglutition Nutritional Deficiency
 Potentiates dental decay
 Sialogogues, Oral saline rinse, salivary substitutes

54. PAROTID AND SALIVARY GLANDS
 Diffuse glandular swelling
 Lymphoepithelial cyst  Unique to HIV infection  Indolent swelling, Mild
tenderness
 Recurrent Parotitis: Bacterial and Viral
 Chronic lymphocytic inflammation Similar to Sjögren's syndrome

55. Other Oral Lesions
 Oral Kaposi's Sarcoma
 Oral Non-Hodgkin's Lymphoma
 Squamous Cell Carcinoma
 Gingivitis and Periodontal Disease
 Varicella Zoster in the Oral Cavity
 Oral Herpes Simplex

56. Pharynx and Larynx

57. Candidiasis
 Severe odynophagia
 Some degree of aspiration--- interference with normal laryngeal function
 Associated with advanced HIV disease and CD4
 counts less than 200
 Oesophagoscopy– Rule out oesophageal candidiasis
 Tx: systemic antifungal agents

58. Candidiasis
Pharyngeal Laryngeal

59. Herpes Simplex and Cytomegalovirus
 The clinical findings are often nonspecific;
 Biopsy with HPE and viral culture will usually confirm the diagnosis.
 Systemic antiviral agents (ganciclovir or foscarnet)
Recurrent Aphthous Ulcerations
 Giant aphthous ulcers (> 2 cm) in the oropharyngeal region

60. Recurrent tonsillitis
 Part of HIV lymphadenopathy
 Immunosuppression
 Poor Orodental hygiene
 Painful swollen tonsils, severe odynophagia
 May progress to peritonsillar abscess
 May involve deep neck spaces

61. Recurrent tonsillitis

62.  Kaposi's Sarcoma
 Non-Hodgkin's Lymphoma
 Acute adult epiglottitis
 Benign lymphoid hyperplasia

63. NECK

64. Infectious Processes in the Neck
 Bacterial lymphadenitis and deep neck infections
 Present as enlarging tender mass in neck
 Management should be surgical and aggressive
 Cultures for mycotic, mycobacterial,and bacterial organisms from all involved tissue or any inflammatory
exudate.
Mycobacterial Infections
 Extrapulmonary disease- Common
 Mycobacterium avium complex (MAC) infection is the most common mycobacterial infection
 2nd line drugs used.

65. Infectious Processes in the Neck
Bacterial lymphadenitis
deep neck infections

66. Tuberculous Lymphadenitis

67.  Pneumocystis carinii- Extrapulmonary
 Toxoplasmosis
 Fungal infections: cryptococcosis, histoplasmosis, and coccidioidomycosis
 Malignancies- Kaposi’s sarcoma, Non Hodgkin’s lymphoma

68. TAKE HOME MESSAGE
 India has the third-highest number of people living with HIV in the world
 2.1 million Indians accounting for about four out of 10 people infected with the deadly virus in the Asia—
Pacific region, according to a UN report.
 ENT surgeons encounter a varied presentation of sign and symptoms.
 There is a paradigm shift from cure to quality of life.
 High index of suspicion necessary for specific presentations.
 UNIVERSAL PRECAUTIONS a must
for every surgeon..

69. THANK YOU