MANIFESTATIONS OF HIV-AIDS
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.
Actual diagnosis of AIDS is made when the
CD4 count falls below 200 cells/cmm or
when an AIDS-defining condition is
Once a diagnosis of AIDS has been made, it
remains with the patient even if his/her CD4
count returns to above 200 with
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
HIV-associated dementia: disabling cognitive and/or
motor dysfunction interfering with occupation or
activities of daily living
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
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
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
Affecting Multiple Head and Neck Anatomic Sites
Conditions in the Ear
Conditions in the External nose and face
Nose and Paranasal sinuses
Pharynx and Larynx
AFFECTING MULTIPLE HEAD AND
NECK ANATOMIC SITES
Most common malignancy
Idiopathic multiple sarcoma of the skin
KS may be 1st clinical manifestation.
• pink or purple
• non tender
• macular or slightly raised or nodular
• both cutaneous and mucosal surfaces.
Biopsy is confirmatory.
CLINICAL COURSE: Static or Aggressive
AGGRESSIVE: Pain, disfigurement and functional
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
Second most common malignancy
fever, night sweats, and significant weight loss.
appears late in the course of HIV disease
Biopsy and IHC: For confirmation Usually high
TX: Aggressive systemic chemotherapy, RCHOP
Radiotherapy contraindicated- severe refractory
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
Tx: Systemic antibiotics, topical steroid sprays
Failure of Medical therapy: Surgical Tx-
Adenoidectomy and tympanotomy with tube
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
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
Sign of decreasing cellular immunity- disease
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
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
Steroid use is controversial Immune-suppressed
Postherpetic neuropathy- severe pain and pruritus
83% of patients develop extensive seborrheic
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.
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.
INFECTIONS OF THE MIDDLE EAR
Serous otitis media and recurrent acute otitis
Pathogenesis: Eustachian tube dysfunction can
• Nasopharyngeal lymphoid hyperplasia
• 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
SENSORINEURAL HEARING LOSS
May be U/L or B/L
Sensorineural hearing loss worsens with
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
It is usually concurrent with multiple other
Frequently a symptom of subacute encephalitis or
HIV disease dementia.
HIV may directly affect the vestibular and auditory
AFFECTING THE EXTERNAL NOSE
FACIAL NERVE/CENTRAL NERVOUS SYSTEM
Unilateral or bilateral facial paralysis
CNS toxoplasmosis is the most common
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
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.
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
Symptoms tend to be more severe in the HIV-
HIV-ASSOCIATED NASAL AND
PARANASAL SINUS PROBLEMS
A common symptom during HIV infection
Wide-ranging differential diagnosis
• Adenoidal hypertrophy,
• Allergic rhinitis,
• Chronic sinusitis,
• Neoplasms of the nose, paranasal sinuses, or nasopharynx.
Inflammation of nasal vestibule
May have fulminant course Cellulitis
Danger area of face Cavernous sinus thrombosis
Local and systemic antibiotics
Early aggressive treatment
Polyclonal B-cell activation- Increased production of
IgA, IgG and IgE.
Excessive IgE production-Allergic symptoms
Sneezing, perennial profuse thick rhinorrhea and
Rule out chronic bacterial sinusitis -- nasal
endoscopy or CT imaging.
Tx: 2nd gen Antihistaminics, topical steroids
Immunosupression and Changes in the mucociliary
Streptococcus pneumoniae, Moraxella catarrhalis, and
Higher incidence of S. aureus and P. aeruginosa
Alternaria alternata, Aspergillus, Pseudallescheria
boydii, Cryptococcus,Candida albicans
Increasing invasive Aspergillus sinusitis.
Incidence of rhinocerebral Mucormycosis not increased
ORAL CANDIDIASIS (THRUSH)
Most Common , Recurring problem
C/F: tender, white, pseudomembranous or plaque-
like lesions with underlying erosive erythematous
Angular cheilitis: Angle of mouth
KOH preparation of scrapings- diagnostic.
Topical antifungals: Clotrimazole, Nystatin
I.V. Amphotericin B in unresponsive cases
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
Epstein-Barr virus (EBV) is associated
No prognostic significance
Treatment is generally unnecessary
RECURRENT APHTHOUS ULCERATIONS
Giant(several cms in diameter) aphthous
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
Some degree of aspiration--- interference with
normal laryngeal function
Associated with advanced HIV disease and CD4
counts less than 200
Oesophagoscopy– Rule out oesophageal
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
Part of HIV lymphadenopathy
Poor Orodental hygiene
Painful swollen tonsils, severe odynophagia
May progress to peritonsillar abscess
May involve deep neck spaces
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
Extrapulmonary disease- Common
Mycobacterium avium complex (MAC) infection is
the most common mycobacterial infection
2nd line drugs used.
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
UNIVERSAL PRECAUTIONS a must for every