ent manifestations in aids
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ENT Manifestations in AIDS
Dr. Juveria MajeedMS ENT,SR, Bhaskar Medical College/Hospital.
HIVRetrovirus –
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
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.
CD4: disease progression
indicatorWhen 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
EPIDEMIOLOGYFirst 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
INDIAN SCENARIO OF HIV AIDS
RISK GROUPSHomosexuals.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.
Hazard to health workers is from blood and the body fluids such as• Amniotic • Pleura• Peritoneal• PericardialRisk of acquiring infections from specimen of Urine, sputum, stool saliva, tears, sweat and vomitus is negligible.
Opportunistic infestations in AIDS
• Pneumocystis carinii• Tuberculosis• Candida albicans• Cryptococcus
neoformans• Mycobacterium
species• Toxoplasma gonidii• CMV• Herpes zoster• Histoplasmosis• Herpes simplex
ENT MANIFESTATIONS OF AIDS
EAR
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
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.
Kaposi's Sarcoma OF External Ear
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.
Otitis ExternaMalignant 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
MALIGNANT OTITIS EXTERNA
HIV-Associated Conditions in the Middle Ear
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.
SEROUS OM AND ACUTE OM
HIV-Associated Conditions in the Inner Ear
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
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.
HIV-Associated Conditions Affecting the External Nose and
Face
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.
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.
BELL’S PALSY
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.
Herpes Zoster
Cutaneous Lesions Kaposi’s Sarcoma Herpetic infection Seborrheic dermatitis. Cellulitis
HIV-Associated Nasal and Paranasal Sinus Problems
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.
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
Vestibulitis
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
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
Allergic Rhinitis Sinusitis
CT SCAN- PNS
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.
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.
ORAL CAVITY
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
Oral thrush
Oral thrush
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
ORAL HAIRY LEUCOPLAKIA
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
APTHOUS ULCERS
Xerostomia Chronic inflammatory
processsimilar to Sjögren's syndrome
Interfere with deglutition Nutritional Deficiency
Potentiates dental decay Sialogogues, Oral saline
rinse, salivary substitutes
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
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
Pharynx and Larynx
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
CandidiasisPharyngeal Laryngeal
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
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
Recurrent tonsillitis
Kaposi's Sarcoma Non-Hodgkin's Lymphoma Acute adult epiglottitis Benign lymphoid hyperplasia
NECK
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.
Infectious Processes in the NeckBacterial
lymphadenitisdeep neck infections
Tuberculous Lymphadenitis
Pneumocystis carinii- Extrapulmonary Toxoplasmosis Fungal infections: cryptococcosis, histoplasmosis,
and coccidioidomycosis Malignancies- Kaposi’s sarcoma, Non Hodgkin’s
lymphoma
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..
THANK YOU
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