ENT DISEASES IN AIDS- PLZ COMMENT FOR ENCOURAGEMENT/CORRECTIONS

1. OTOLARYNGOLOGIC
MANIFESTATIONS OF HIV-AIDS
Dr.Priyanko Chakraborty
JR2, M.S.(ENT)
IMS-BHU

2. 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.

3. HUMAN IMMUNO DEFICIENCY VIRUS

5. PATHOGENESIS OF AIDS

6.  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.

7. 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

8. 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)

9. 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

10. HAART: ANTIRETROVIRAL THERAPY

11. 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

12. AFFECTING MULTIPLE HEAD AND
NECK ANATOMIC SITES

13. 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.

14. KAPOSI’S SARCOMA

15. 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

16. 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

17. NHL

18. 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.

19. 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

20. 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.

21. 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

22. HERPES ZOSTER

23. HIV-ASSOCIATED CONDITIONS IN THE
EXTERNAL EAR

24. 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

26. 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.

27. 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.

28. MALIGNANT OTITIS EXTERNA

29. HIV-ASSOCIATED CONDITIONS IN THE
MIDDLE EAR

30. 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.

31. SEROUS OM AND ACUTE OM

32. HIV-ASSOCIATED CONDITIONS IN THE
INNER EAR

33. 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

34. 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.

35. HIV-ASSOCIATED CONDITIONS
AFFECTING THE EXTERNAL NOSE
AND FACE

36. 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.

37. 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.

38. BELL’S PALSY

39. 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.

40. CUTANEOUS LESIONS
 Kaposi’s Sarcoma
 Herpetic infection
 Seborrheic dermatitis.
 Cellulitis

41. HIV-ASSOCIATED NASAL AND
PARANASAL SINUS PROBLEMS

42. 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.

43. 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

44. VESTIBULITIS

45. 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

46. 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

47. CT SCAN- PNS

48. 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.

49.  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.

50. ORAL CAVITY

51. 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

52. ORAL THRUSH

53. ORAL THRUSH

54. 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

55. ORAL HAIRY LEUCOPLAKIA

56. 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

57. APTHOUS ULCERS

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

59. 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

60. 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

61. PHARYNX AND LARYNX

62. 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

63. 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

64. 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

65.  Kaposi's Sarcoma
 Non-Hodgkin's Lymphoma
 Acute adult epiglottitis
 Benign lymphoid hyperplasia

66. NECK

67. 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.

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

69. 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.

70. THANKS!!!