ENT Manifestations of

HIV/AIDS
DR SHAHINA ATHER
 HIV and ENT
Ithas been well documented that 70 - 90% of
patients with HIV will at some stage present with
an ENT manifestation of the disease.
HIV patients can be grouped into 4 stages of HIV
infection, AIDS itself representing only the very
last stages of this infection.
 CD4 count
 Using the CD4 count, patients are grouped into four stages of HIV
infection
When the CD4 count:
 is over 500 cells/mm3, most patients are essentially asymptomatic
 drops to 200 to 500 cells/mm3, the early manifestations of HIV infection start
to appear
 drops below 200 cells/mm3, patients become vulnerable to many of the
processes associated with AIDS
 drops below 50 cells/mm3, patients become increasingly at risk for the unusual
opportunistic infections
Otolaryngologic manifestations of HIV
disease can be
Infections
Neoplasms
Primary neurologic damage caused by HIV
 Region wise manifestations

Oral Cavity
Sino-nasal
Neck
Otologic
 Oral Cavity: Oral Candidiasis
 Earliest and most common finding. Cottage cheese
inflammatory appearance
 Four different types :
 Pseudomembranous candidiasis
 Hyperplastic candidiasis
 Atrophic candidiasis
 Angular cheilitis
 Oesophageal or pharyngeal candidiasis is more common
and should be suspected in patients with oral candidiasis
who develop a severe sore throat or difficulty in
swallowing
 Oral Candidiasis: Treatment
 Topical agents are usually effective in the early stages of HIV
infection (Nystatin, Clotrimazole)
 Systemic therapy with ketoconazole (200 to 400 mg daily) often
dramatically improves thrush that is unresponsive to topical
regimens
 With increasing immune deficiency, systemic therapy (with
fluconazole and rarely amphotericin B)
 Oral hairy leukoplakia
 Almost pathognomonic of HIV
infection and often indicates
progression to AIDS
 The lesion most frequently appears on
the lateral aspect of the tongue
 A thick, vertically correlated (‘hairy’)
whitish plaque, looks like hyperplastic
type of oral candidiasis (KOH test)
 The Epstein-Barr virus has been
identified as the most likely causative
agent
Oral hairy leukoplakia: Treatment

 Typically asymptomatic and does not usually require any

treatment
 The lesions have been successfully treated with aciclovir
(2 g/day), sulpha drugs, zidovudine or topical retinoic
acid
 Oral Herpes Simplex
• Frequently associated with HIV disease

• While HSV-1 is the usual strain, HSV-2 has also

occurred orally

• Herpes labialis is the most common

presentation

• Crops of "fever blisters" occur on the palate,

gingiva, or other oral mucosal surfaces

• Although similar to infection in non-HIV-

infected patients, these lesions tend to be larger
and more numerous, recur more frequently, and
often persist longer
Oral Kaposi's Sarcoma
 By far the most common oral
malignancy in HIV disease
 Can occur anywhere in the oral cavity,
nearly 95% are found on the palate
 At first, these lesions are usually flat
and asymptomatic, Often become
exophytic and ulcerated
 Secondary infection often occurs
producing severe, increasing pain,
difficulty with mastication and
swallowing
Oral Kaposi's Sarcoma

 KS is very radiosensitive and localised tumours respond well

to low dose radiotherapy with a good palliative result
 HIV-positive patients more susceptible to radiation-induced
mucositis and cannot tolerate wide-field radiation
 Alternative treatment options include intralesional
chemotherapy for solitary lesions and systemic chemotherapy
for disseminated disease.
Oral Non-Hodgkin's Lymphoma
 NHL is a malignancy occurring with
increased frequency in patients with
HIV disease
 These lymphomas can occur anywhere
in the mouth; frequent sites include the
gingiva and the palate, with extension
onto or from Waldeyer's ring,
especially the tonsils.
 NHL generally is a grim prognostic
sign.
 Confirmed by Biopsy
HIV SINONASAL
MANIFESTATIONS
 Between 40% and 70% of patients with AIDS will present with
allergic rhinitis, sinusitis, a blocked nose or symptoms suggesting
a malignancy
 The most common sinonasal complaint is that of a blocked nose,
the most likely causes being adenoidal hypertrophy and allergic
rhinitis
 HIV-infected individuals often suffer from other common
illnesses, such as TB, which can present with unusual
manifestations of the disease
 Adenoid Hypertrophy

 Presents as persistent nasal obstruction

 Inthe adult patient this demands further investigation and the
possibility of HIV infection must be entertained
 InHIV positive patients enlarged adenoids are most commonly
due to lymphoid hyperplasia and generalised lymphadenopathy
and enlarged tonsils are frequently part of the clinical picture.
 The aetiology is thought to be related to B-cell activation by HIV,
Epstein-Barr virus or cytomegalovirus.
 Adenoid Hypertrophy
 Otitismedia with effusion (OME), causing a conductive
hearing loss, often follows owing to obstruction of the
Eustachian tubes by the lymphoid mass in the postnasal
space
 For lymphoid hyperplasia, an adenoidectomy is
frequently done to relieve symptoms of nasal obstruction
and OME
 Lymphoma is treated with systemic chemotherapy, and
radiotherapy is given if the tumour causes any mass
effect
 Allergic rhinitis
Very common in the HIV-positive population
Patients have increased levels of IgE
These high levels of IgE then lead to increased IgE-
mediated allergic symptoms
Treatment consists of allergen avoidance, topical
steroids and oral antihistamines
 Rhinosinusitis
 Occurs in 20 - 68% of HIV infected patients
 Predisposing factors include allergic rhinitis, with the oedematous mucosa
leading to obstruction of the sinus ostia, and decreased local and systemic
immunity
 The microbiology is similar to that found in the HIV negative population,
with the exception of two atypical opportunistic organisms, Pseudomonas
aeruginosa and Aspergillus fumigatus
 Initial management should be restricted to the use of first-line drugs such as
amoxicillin or amoxiclav
 NECK MANIFESTATIONS
 Enlarging neck masses frequently occur in the HIV-infected population
 Up to 90% of patients with an ENT manifestation will present with a neck
mass as well
 The differential diagnosis of a neck mass in the HIV-positive patient can be
broadly divided into the following categories:
 HIV lymphadenopathy
 Parotid disease
 Infections
 Neoplasms
Parotid gland enlargement
 Commonly encountered in HIV-infected adults and
children who are not on antiretroviral therapy
 Etiology is thought to be related to a lymphoid
response to HIV infection
 Patients usually present with bilateral, painless
parotomegaly
 Treatment is guided by the severity of the cosmetic
deformity and includes antiretroviral therapy,
aspiration of the cysts with tetracycline sclerosis and
low-dose radiotherapy.
OTOLOGICAL
MANIFESTATIONS
 The incidence of OME is higher in the HIV population than in the general
population
 The most common otologic problems reported in HIV-infected patients are
serous otitis media and recurrent acute otitis media
 Sensorineural hearing loss, both unilateral and bilateral, occurs in 21 to 49%
of HIV-infected patients
 Vertigo can occur in the HIV-infected patient. Vertigo is frequently a
symptom of subacute encephalitis
 HIV may directly affect the vestibular and auditory systems
 To sum up
 Multiple oral lesions can be present simultaneously
 Oral
candidiasis and rhinosinusitis are the commonest
ENT manifestations of HIV
 Oesophageal candidiasis must be suspected in patients
with increasing dysphagia and odynophagia
 Oralhairy leukoplakia is a condition almost
pathognomonic of HIV infection and often indicates
progression to AIDS
 To sum up
 Kaposi’s sarcoma is the most common HIV-
associated oral tumour and predominantly occurs on
the palate.
 HIV-associated cystic lympho-epithelial disease of
the parotid is a disease process unique to HIV-
infected individuals.
 OME in the adult patient must be investigated and the
HIV status of the patient ascertained.