This document discusses ENT manifestations of AIDS. It begins by providing background on HIV, noting that it attacks CD4 cells. When CD4 counts fall below 200, opportunistic infections and malignancies can develop. ENT issues are then reviewed, including candidiasis, Kaposi's sarcoma, herpes zoster, Bell's palsy, sinusitis, oral thrush, hairy leukoplakia, and recurrent tonsillitis. Neck lymphadenopathy can indicate bacterial or mycobacterial infections, P. carinii, toxoplasmosis or fungal infections. Overall, the document outlines the varied ENT presentations associated with HIV/AIDS and emphasizes the need for a high index of suspicion to properly

1. ENT Manifestations in AIDS
Dr. Juveria Majeed
MS ENT,
SR, Bhaskar Medical College/Hospital.

2. HIV
Retrovirus – 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

3. 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.

4. 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

5. EPIDEMIOLOGY
First 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

6. INDIAN SCENARIO OF HIV AIDS

8. RISK GROUPS
Homosexuals.
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.

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

13. Opportunistic infestations in AIDS
• Pneumocystis carinii
• Tuberculosis
• Candida albicans
• Cryptococcus neoformans
• Mycobacterium species
• Toxoplasma gonidii
• CMV
• Herpes zoster
• Histoplasmosis
• Herpes simplex

14. ENT MANIFESTATIONS OF
AIDS

15. EAR

16. 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

17. 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.

18. Kaposi's Sarcoma OF External Ear

19. 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.

20. Otitis Externa
Malignant 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

21. MALIGNANT OTITIS EXTERNA

22. HIV-Associated Conditions in the Middle Ear

23. 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.

24. SEROUS OM AND ACUTE OM

25. HIV-Associated Conditions in the Inner Ear

26. 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

27. 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.

28. HIV-Associated Conditions Affecting the External Nose and
Face

29. 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.

30. 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.

31. BELL’S PALSY

32. 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.

33. Herpes Zoster

34. Cutaneous Lesions
 Kaposi’s Sarcoma
 Herpetic infection
 Seborrheic dermatitis.
 Cellulitis

35. HIV-Associated Nasal and Paranasal Sinus Problems

36. 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.

37. 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

38. Vestibulitis

39. 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

40. 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

41. Allergic Rhinitis Sinusitis

42. CT SCAN- PNS

43. 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.

44. 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.

45. ORAL CAVITY

46. 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

47. Oral thrush

48. Oral thrush

49. 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

50. ORAL HAIRY LEUCOPLAKIA

51. 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

52. APTHOUS ULCERS

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

54. 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

55. 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

56. Pharynx and Larynx

57. 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

58. Candidiasis
Pharyngeal Laryngeal

59. 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

60. 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

61. Recurrent tonsillitis

62.  Kaposi's Sarcoma
 Non-Hodgkin's Lymphoma
 Acute adult epiglottitis
 Benign lymphoid hyperplasia

63. NECK

64. 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.

65. Infectious Processes in the Neck
Bacterial lymphadenitis
deep neck infections

66. Tuberculous Lymphadenitis

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

68. 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..

69. THANK YOU