ENT Manifestations in AIDS

Dr. Juveria MajeedMS ENT,SR, Bhaskar Medical College/Hospital.

HIVRetrovirus –

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

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.

CD4: disease progression

indicatorWhen 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

EPIDEMIOLOGYFirst 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

INDIAN SCENARIO OF HIV AIDS

RISK GROUPSHomosexuals.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.

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

Opportunistic infestations in AIDS

• Pneumocystis carinii• Tuberculosis• Candida albicans• Cryptococcus

neoformans• Mycobacterium

species• Toxoplasma gonidii• CMV• Herpes zoster• Histoplasmosis• Herpes simplex

ENT MANIFESTATIONS OF AIDS

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.

Kaposi's Sarcoma OF External Ear

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.

Otitis ExternaMalignant 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

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.

Herpes Zoster

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 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

Allergic Rhinitis Sinusitis

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

CandidiasisPharyngeal Laryngeal

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

Recurrent tonsillitis

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.

Infectious Processes in the NeckBacterial

lymphadenitisdeep neck infections

Tuberculous Lymphadenitis

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..

THANK YOU