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 otitismedia.

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 NASAL AND

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 mucociliaryclearance

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

processsimilar 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!!!