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ENT
Manifestations of
HIV/AIDS
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HIV and ENT

 It has 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 stages of
HIV infection, AIDS itself representing only the
very last stages of this infection.
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CD4 count

 Using the CD4 count, patients can be generally 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/mm 3, 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
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Causes of most otolaryngologic
manifestations of HIV disease

 Infections
 Neoplasms
 Primary neurologic damage caused by HIV
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Region wise manifestations

 Oral Cavity
 Sino-nasal
 Neck
 Otologic
 Oral Cavity: Oral Candidiasis
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 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
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 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
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 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
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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
 z 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
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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
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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.
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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.
 Biopsy
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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
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Adenoid Hypertrophy

 Presents as persistent nasal obstruction

 In the adult patient this demands further investigation and the

possibility of HIV infection must be entertained
 In HIV 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
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 Otitis media 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
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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
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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
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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
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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.
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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
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 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
 Oral hairy leukoplakia is a condition almost
pathognomonic of HIV infection and often indicates
progression to AIDS
 To sum up
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 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.