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Otolaryngologic manifestations of HIV AIDS

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ENT DISEASES IN AIDS- PLZ COMMENT FOR ENCOURAGEMENT/CORRECTIONS

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Otolaryngologic manifestations of HIV AIDS

  1. 1. OTOLARYNGOLOGIC MANIFESTATIONS OF HIV-AIDS Dr.Priyanko Chakraborty JR2, M.S.(ENT) IMS-BHU
  2. 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. 3. HUMAN IMMUNO DEFICIENCY VIRUS
  4. 4. PATHOGENESIS OF AIDS
  5. 5.  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.
  6. 6. 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
  7. 7. 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)
  8. 8. 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
  9. 9. HAART: ANTIRETROVIRAL THERAPY
  10. 10. 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
  11. 11. AFFECTING MULTIPLE HEAD AND NECK ANATOMIC SITES
  12. 12. 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.
  13. 13. KAPOSI’S SARCOMA
  14. 14. 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
  15. 15. 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
  16. 16. NHL
  17. 17. 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.
  18. 18. 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
  19. 19. 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.
  20. 20. 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
  21. 21. HERPES ZOSTER
  22. 22. HIV-ASSOCIATED CONDITIONS IN THE EXTERNAL EAR
  23. 23. 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
  24. 24. 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.
  25. 25. 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.
  26. 26. MALIGNANT OTITIS EXTERNA
  27. 27. HIV-ASSOCIATED CONDITIONS IN THE MIDDLE EAR
  28. 28. 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.
  29. 29. SEROUS OM AND ACUTE OM
  30. 30. HIV-ASSOCIATED CONDITIONS IN THE INNER EAR
  31. 31. 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
  32. 32. 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.
  33. 33. HIV-ASSOCIATED CONDITIONS AFFECTING THE EXTERNAL NOSE AND FACE
  34. 34. 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.
  35. 35. 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.
  36. 36. BELL’S PALSY
  37. 37. 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.
  38. 38. CUTANEOUS LESIONS  Kaposi’s Sarcoma  Herpetic infection  Seborrheic dermatitis.  Cellulitis
  39. 39. HIV-ASSOCIATED NASAL AND PARANASAL SINUS PROBLEMS
  40. 40. 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.
  41. 41. 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
  42. 42. VESTIBULITIS
  43. 43. 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
  44. 44. 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
  45. 45. CT SCAN- PNS
  46. 46. 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.
  47. 47.  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.
  48. 48. ORAL CAVITY
  49. 49. 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
  50. 50. ORAL THRUSH
  51. 51. ORAL THRUSH
  52. 52. 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
  53. 53. ORAL HAIRY LEUCOPLAKIA
  54. 54. 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
  55. 55. APTHOUS ULCERS
  56. 56. XEROSTOMIA  Chronic inflammatory processsimilar to Sjögren's syndrome  Interfere with deglutition Nutritional Deficiency  Potentiates dental decay  Sialogogues, Oral saline rinse, salivary substitutes
  57. 57. 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
  58. 58. 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
  59. 59. PHARYNX AND LARYNX
  60. 60. 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
  61. 61. 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
  62. 62. 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
  63. 63.  Kaposi's Sarcoma  Non-Hodgkin's Lymphoma  Acute adult epiglottitis  Benign lymphoid hyperplasia
  64. 64. NECK
  65. 65. 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.
  66. 66.  Pneumocystis carinii- Extrapulmonary  Toxoplasmosis  Fungal infections: cryptococcosis, histoplasmosis, and coccidioidomycosis  Malignancies- Kaposi’s sarcoma, Non Hodgkin’s lymphoma
  67. 67. 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.
  68. 68. THANKS!!!

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