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OTOLARYNGOLOGIC

MANIFESTATIONS OF HIV-AIDS
Dr.Priyanko Chakraborty
JR2, M.S.(ENT)
IMS-BHU
INTRODUCTION
 HIV is classified as retrovirus

-Once HIV enters the host (CD4) cell, it converts its


RNA (ribonucleic acid) to DNA (deoxyribonucleic acid)
via its enzyme reverse transcriptase.

 HIV is completely dependent upon CD4 cells for


replication and survival.
 When CD4 count is in normal range (500-1,600
cells/cmm or 28-50%), the immune system defends
itself against most antigens.

 As T-cell count declines with HIV disease progression,


the HIV+ patient is at increased risk for infection.
HUMAN IMMUNO DEFICIENCY VIRUS
PATHOGENESIS OF AIDS
 Actual diagnosis of AIDS is made when the
CD4 count falls below 200 cells/cmm or
when an AIDS-defining condition is
diagnosed.
 Once a diagnosis of AIDS has been made, it
remains with the patient even if his/her CD4
count returns to above 200 with
antiretroviral therapy.
AIDS DEFINING CONDITIONS
 Candidiasis of esophagus, trachea, bronchi or lungs
 Herpes simplex with mucocutaneous ulcer for > 1 month
or bronchitis, pneumonitis, esophagitis
 Cervical cancer, invasive

 Histoplasmosis, extrapulmonary

 Coccidioidomycosis, extrapulmonary

 HIV-associated dementia: disabling cognitive and/or


motor dysfunction interfering with occupation or
activities of daily living
 Cryptococcosis, extrapulmonary
CONTD.
 HIV-associated wasting: involuntary weight loss of
>10% of baseline plus chronic diarrhea (>2 loose
stools/day for >30 days) or chronic weakness and
documented enigmatic fever for > 30 days
 Cryptosporidiosis with diarrhea for > 1 month

 Isoporosis with diarrhea for >1 month

 Cytomegalovirus of any organ other than liver, spleen, or


lymph nodes

 Kaposi’s sarcoma in patient younger than 60 (or older


than 60 with positive HIV serology)
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
HAART: ANTIRETROVIRAL THERAPY
SITES
 Affecting Multiple Head and Neck Anatomic Sites
 Conditions in the Ear

 Conditions in the External nose and face

 Nose and Paranasal sinuses

 Oral cavity

 Pharynx and Larynx

 Neck
AFFECTING MULTIPLE HEAD AND
NECK ANATOMIC SITES
KAPOSI’S SARCOMA
 Most common malignancy
 Idiopathic multiple sarcoma of the skin

 Opportunistic neoplasm

 KS may be 1st clinical manifestation.

 Lesion:
• pink or purple
• non tender
• macular or slightly raised or nodular
• both cutaneous and mucosal surfaces.
 Biopsy is confirmatory.
KAPOSI’S SARCOMA
KAPOSI’S SARCOMA

 CLINICAL COURSE: Static or Aggressive


 AGGRESSIVE: Pain, disfigurement and functional
problems.
 Death is unusual: Pulmonary KS or URT obstruction.

 TREATMENT: local or systemic chemotherapy and


radiation therapy for palliation and cosmesis.
 Cure is not a realistic goal- Radical operations avoided.

 The expected benefits should outweigh the risks of


treatment of the KS lesions
NON-HODGKIN'S LYMPHOMA
 Second most common malignancy
 fever, night sweats, and significant weight loss.

 appears late in the course of HIV disease

 Diagnosis: FNAC

 Biopsy and IHC: For confirmation  Usually high


grade
 TX: Aggressive systemic chemotherapy, RCHOP
regime.
 Radiotherapy contraindicated- severe refractory
mucositis
NHL
LYMPHOID HYPERPLASIA
 Generalized proliferation of lymphoid tissue
 Affects Waldeyer's ring (adenoids,lingual tonsils
and faucial tonsils)
 Adenoidal hypertrophy in a nonpediatric setting 
alert HIV infection.
 C/F:Nasal obstruction, acute or serous otitis media
 MRI - skull base erosion and Biopsy- Rule out
Lymphoma
 Tx: Systemic antibiotics, topical steroid sprays
 Failure of Medical therapy: Surgical Tx-
Adenoidectomy and tympanotomy with tube
placement.
HIV LYMPHADENOPATHY
 The terms "persistent generalized
lymphadenopathy" and "HIV lymphadenopathy"
describe the syndrome of unexplained diffuse
lymphadenopathy involving two or more
extrainguinal sites for longer than 3 months.
 Almost 70% develop this

 Follicles are small, hypocellular, and hyalinized, but


the paracortical regions are paradoxically
hyperplastic- Follicular involution
HIV LYMPHADENOPATHY
Clinicians should perform a FNAC/Biopsy of lymph
nodes in the following situations:
 1. Marked constitutional symptoms with otherwise
negative findings on evaluation;
 2. Adenopathy--asymmetric or nongeneralized;

 3. A single disproportionately enlarging node

 4. Peripheral cytopenia with otherwise negative


findings on evaluation
 5. Other reasons for suspicion of a treatable
pathologic process.
HERPES ZOSTER
 Sign of decreasing cellular immunity- disease
progression
 Reactivation of the latent VZV
 C/F: Burning pain, dysesthesia, and vesicular eruptions
along the distribution of the affected nerve.
 Diagnosis-Clinical appearance,Tzanck smear or viral
culture.
 Medical therapy includes acyclovir and analgesics. Oral
Acyclovir ( 800 mg 5 times daily) and I.V. Acyclovir (10
to 12 mg/kg infused over 1 hour every 8 hours for 7 to
14 days)
 Steroid use is controversial  Immune-suppressed
patients.
 Postherpetic neuropathy- severe pain and pruritus
HERPES ZOSTER
HIV-ASSOCIATED CONDITIONS IN THE
EXTERNAL EAR
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


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.
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.
MALIGNANT OTITIS EXTERNA
HIV-ASSOCIATED CONDITIONS IN THE
MIDDLE EAR
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.
SEROUS OM AND ACUTE OM
HIV-ASSOCIATED CONDITIONS IN THE
INNER EAR
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
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.
HIV-ASSOCIATED CONDITIONS
AFFECTING THE EXTERNAL NOSE
AND FACE
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.
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.
BELL’S PALSY
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.
CUTANEOUS LESIONS
 Kaposi’s Sarcoma
 Herpetic infection

 Seborrheic dermatitis.

 Cellulitis
HIV-ASSOCIATED NASALAND
PARANASAL SINUS PROBLEMS
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.
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


VESTIBULITIS
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
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
CT SCAN- PNS
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.
 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.
ORAL CAVITY
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


ORAL THRUSH
ORAL THRUSH
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


ORAL HAIRY LEUCOPLAKIA
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


APTHOUS ULCERS
XEROSTOMIA
 Chronic inflammatory
processsimilar to Sjögren's
syndrome
 Interfere with
deglutition Nutritional
Deficiency

 Potentiates dental decay


 Sialogogues, Oral saline rinse,
salivary substitutes
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
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


PHARYNX AND LARYNX
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
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
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


 Kaposi's Sarcoma
 Non-Hodgkin's Lymphoma

 Acute adult epiglottitis

 Benign lymphoid hyperplasia


NECK
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.
 Pneumocystis carinii- Extrapulmonary
 Toxoplasmosis

 Fungal infections: cryptococcosis, histoplasmosis,


and coccidioidomycosis
 Malignancies- Kaposi’s sarcoma, Non Hodgkin’s
lymphoma
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.
THANKS!!!

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