Ear, Nose, Sinus, Mouth

July 2006

Chapter Contents

Background

Ears

Nose and Sinuses

Mouth and Throat

References

Background

HIV-infected individuals frequently experience infections and neoplasms that affect the ears, nose, sinuses, and mouth. The degree of immunosuppression, as reflected by a patient's CD4 cell count, can affect the severity, likelihood of recurrence, and response to therapy for various infections and neoplasms.

Patients may present with ear, nose, sinus, or mouth complaints early in the course of HIV infection, perhaps even before they are aware of their infection. Some conditions arise more commonly in patients with advanced HIV infection. Certain complaints (eg, oral candidiasis) should prompt consideration of HIV testing in patients without known infection.

Ears

HIV-infected patients may experience recurrent acute otitis media and serous otitis media. Nasopharyngeal lymphoid hyperplasia, sinusitis, or allergies may contribute to dysfunction of the eustachian tubes. Unilateral and bilateral sensorineural hearing loss has been reported and may be caused by HIV infection involving the central nervous system (CNS) or the auditory nerve. Hearing loss may also be due to syphilis, other CNS infections, chronic otitis media, neoplasms, and certain medications (including some nucleoside analogues in rare cases). The pathophysiology, causative organisms, and incidence of external-ear infections appear to be the same in HIV-infected patients as in HIV-uninfected individuals.

S: Subjective

The patient may complain of ear pain, decreased hearing or hearing loss, a feeling of fullness in the ear, vertigo, or a popping or snapping sensation in the ear.

Obtain the following information during the history:

• Medications (prescription and over-the-counter) and herbal supplements, current and past
• Current or recent sinus infection
• Associated symptoms
• Drainage or blood from the ear
• Head or ear trauma

O: Objective

Recent CD4 count and HIV viral load are important measures of immunosuppression to determine whether the patient is at risk for opportunistic infections as causes of ear complaints.

Perform visual and otoscopic inspection, including evaluation for skin abnormalities, lesions, cerumen impaction or foreign body, lymphadenopathy, adenotonsillar hypertrophy.

Evaluate hearing and refer for an audiogram. Perform a neurologic examination and draw rapid plasma reagin (RPR) or Venereal Disease Research Laboratory (VDRL) test.

A: Assessment and Plan

Otitis Externa/Interna

Proceed with care as with an immunocompetent patient. A chronic or atypical presentation in an HIV-infected patient warrants a thorough evaluation, including cultures, biopsy, radiographic scans, and referral to an ear, nose, and throat (ENT) specialist.

Hearing Loss

A patient with hearing loss should be referred for evaluation or treated depending on the cause. Avoid ototoxic medications (eg, furosemide, aminoglycosides).

Nose and Sinuses

Nasal and paranasal sinus conditions occur frequently in HIV-infected patients. Nasal obstruction, allergic rhinitis, nasal lesions, and sinusitis are common. Epistaxis can occur in patients with platelet disorders (eg, idiopathic thrombocytopenic purpura [ITP]).

S: Subjective

The patient may complain of "stuffy nose", rhinorrhea, epistaxis, frontal or maxillary headaches (worse at night or early morning), pain in the nostrils, persistent postnasal drip, mucopurulent nasal discharge, general malaise, aching or pressure behind the eyes, or toothache-like pain.

Obtain the following information during the history:

• Medications (prescription and over-the-counter) and herbal supplements, current and past
• Current or recent sinus infection
• Previous sinus surgery
• Recent or current upper respiratory infection (URI)
• Nasal bleeding or discharge
• Facial trauma
• Allergic rhinitis
• Positional pain; worse when patient bends forward?
• Tobacco use
• Fever
• Headache
• Mucopurulent nasal drainage

O: Objective

Recent CD4 count and HIV viral load are important measures of immunosuppression to determine whether the patient is at risk for opportunistic infections as causes of nasal and sinus complaints.

Examine the nose and sinuses. Check the nasal mucosa with a light and a speculum, looking for areas of bleeding, purulent drainage, ulcerated lesions, or discolored areas. Palpate or percuss the sinuses for areas of tenderness, look for areas of swelling over the sinuses, and visualize the posterior pharynx for mucopurulent drainage. Transillumination may be helpful. Examine the teeth and gums for caries and inflammation of the gingivae. Check maxillary teeth with the use of a tongue blade (5-10% of maxillary sinusitis is due to dental root infection). Refer to a dentist for tooth sensitivity or caries.

A: Assessment

Possible causes of epistaxis include coagulopathy, ITP, tumor, lesions of herpes simplex virus (HSV), and Kaposi sarcoma (KS). Suspect ITP if the platelet count is low and bleeding is difficult to control. HSV appears as painful, ulcerated vesicles in the nasal mucosa. Tumors may be caused by KS, squamous papilloma, or lymphoma; biopsy is necessary to determine the cause.

Acute infection of 1 or more of the paranasal sinuses is common. Streptococcus pneumoniae , Haemophilus influenzae , and Moraxella catarrhalis are seen in both HIV-uninfected and HIV-infected patients, whereas Staphylococcus aureus and Pseudomonas aeruginosa are found more often in HIV-infected patients. Fungi may be the causative agents, especially in patients with severe immunosuppression.

Chronic sinusitis occurs frequently in patients with HIV infection and may be polymicrobial or anaerobic. In patients with low CD4 cell counts, fungal sinusitis may occur.

Nasal obstruction may be caused by adenoidal hypertrophy, chronic sinusitis, allergic rhinitis, or neoplasm.

P: Plan

Epistaxis

Epistaxis caused by coagulopathy or tumor is managed the same as in the immunocompetent patient with these conditions. Cauterization of an identified bleeding point or packing may be necessary. ITP may be treated with antiretroviral therapy (ART) as chronic management, or with corticosteroids for acute management. Refer to a hematologist.

Acute Sinusitis

Combination therapy with antibiotics, decongestants, mucolytics, saline nasal spray, and topical nasal steroids may be effective. See chapter Sinusitis for details. Note: Avoid fluticasone (Flonase) and budesonide (Rhinocort Aqua) nasal spray in patients taking ritonavir or ritonavir-boosted protease inhibitors (eg, Kaletra), because significant increases in serum levels of these glucocorticoids may occur.

Chronic Sinusitis

Treat with a systemic decongestant (guaifenesin), saline nasal spray twice daily, and topical nasal saline spray. Patients with exacerbations of sinusitis should be treated as for acute sinusitis. For more detailed information, see chapter Sinusitis . Note: Avoid fluticasone (Flonase) and budesonide (Rhinocort Aqua) nasal spray in patients taking ritonavir or ritonavir-boosted protease inhibitors (eg, Kaletra), because significant increases in serum levels of these glucocorticoids may occur.

Nasal Obstruction

Perform magnetic resonance imaging (MRI) or computed tomography (CT) scan with biopsy for mass lesions or asymmetric nasal lymphoid tissue. Refer to an ENT specialist.

Mouth and Throat

The oral cavity is one of the most common areas of symptoms in patients with HIV infection. Conditions that arise in the oral cavity may be infectious, benign inflammatory, neoplastic, or degenerative processes.

S: Subjective

The patient may complain of white patches and red areas on the dorsal surface of the tongue and the palate, decreased taste sensation, white lesions along the lateral margins of the tongue, ulcerated lesions, nonhealing lesions at the corners of the mouth, sore gums, loose teeth, dysphagia, or odynophagia.

Obtain the following information during the history:

• Medications (prescription and over-the-counter) and herbal supplements (note that zalcitabine, dapsone, and other drugs may cause aphthous ulcers)
• Usual oral hygiene (toothbrushing, tongue brushing or scraping, flossing, use of mouthwash)
• Date of last dental examination
• Involuntary weight loss

O: Objective

Recent CD4 count and HIV viral load are important measures of immunosuppression to determine whether the patient is at risk for opportunistic infections as causes of oral complaints.

Thorough examination of the mouth and throat with a tongue depressor and a good light is mandatory. Observe for white patches or plaques on the mucous membranes that can be partially removed by scraping with a tongue blade (candidiasis). Examine the dorsal surface of the tongue and hard and soft palates for red, flat, subtle lesions (erythematous candidiasis). Check for ulcerations, inflamed gums, and loose teeth. Look for discoloration or nodular lesions on the hard palate (Kaposi sarcoma). Look for ribbed, whitish lesions on the lateral aspects of the tongue that cannot be scraped off (oral hairy leukoplakia). Check the pharynx for adenotonsillar hypertrophy. Rule out HIV-unrelated causes of pharyngitis, including streptococci or respiratory viruses.

A: Assessment and Plan

Perform biopsy, culture, and potassium hydroxide (KOH) preparation of lesions as indicated.

Oral Candidiasis (Thrush)

Oral candidiasis is most likely to occur when the CD4 count is <300 cells/µL, but it can occur at any CD4 level and in HIV-uninfected individuals. It may appear as creamy white plaques on the tongue or buccal mucosa or as erythematous lesions on the dorsal tongue or the palate. The most common treatment strategy is empiric therapy with topical or systemic antifungal agents. For more details, see chapter Candidiasis, Oral and Esophageal .

Angular Cheilitis

Angular cheilitis is also caused by Candida species, and is characterized by fissuring at the corners of the mouth. For treatment, see chapter Candidiasis, Oral and Esophageal .

Oral Hairy Leukoplakia

Oral hairy leukoplakia (OHL) is caused by Epstein-Barr virus and appears as raised, ribbed, "hairy" white lesions along the lateral margins of the tongue. Lesions are primarily asymptomatic, and treatment is generally not needed. Lesions often resolve with successful ART. For more details, see chapter Oral Hairy Leukoplakia .

Kaposi Sarcoma

Kaposi sarcoma appears as red, blue, or purplish lesions that are flat or nodular, and solitary or multiple. Lesions appear most commonly on the hard palate but may also occur on the gingival surfaces and elsewhere in the mouth. A definitive diagnosis requires biopsy and histologic examination. KS often resolves with ART and successful immune reconstitution. If lesions do not respond to ART or are severe or numerous, refer to an oncology specialist for chemotherapy. For more details, see chapter Kaposi Sarcoma .

Gingivitis

See chapters Linear Gingival Erythema and Necrotizing Ulcerative Periodontitis and Gingivitis for more details.

Herpes Simplex Virus

HSV lesions occur on the palate, gingivae, or other mucosal surfaces. They appear as single or clustered vesicles and may extend onto adjacent skin of the lips and face to form a large herpetic lesion. Lesions tend to be more common, persist longer, recur more often, and be larger and more numerous in HIV-infected patients, especially those with significant immunosuppression, than in healthy individuals. Empiric treatment with famciclovir, valacyclovir, or acyclovir is appropriate. For more details, see chapter Herpes Simplex, Mucocutaneous .

Aphthous Ulcers

Aphthous ulcers are eroded, well-defined lesions surrounded by erythema, ranging in size from <6 mm to several centimeters in diameter. The ulcers can appear anywhere in the oral cavity or pharynx and may be recurrent; they are extremely painful. Treatment may involve topical steroids or other methods. For more details, see chapter Oral Ulceration .

Oral Warts (human papillomavirus)

Oral warts may appear as solitary or multiple nodules. The lesions may be smooth, raised masses resembling focal epithelial hyperplasia, or small papuliferous or cauliflower-like projections. See chapter Oral Warts .

Other Conditions

Most of these complications also can occur in the esophagus. See chapters Esophageal Problems , Candidiasis, Oral and Esophageal , and Cytomegalovirus Disease .

If patient is having mouth pain, anorexia, or problems with taste, treat the condition appropriately and refer to an HIV-experienced dentist for evaluation and further treatment as needed. Refer to a dietitian for assistance with dietary needs (eg, nutritional supplements).

References

• Greenspan JS, Greenspan D. Oral Complications of HIV Infection. In: Sande MA, Volberding PA, eds. Medical Management of AIDS, 6th ed . Philadelphia: WB Saunders; 1999:157-169.
• Gurney TA, Murr AH. Otolaryngologic manifestations of human immunodeficiency virus infection . Otolaryngol Clin North Am. 2003 Aug;36(4):607-24.
• Lee K, Tami T. Otolaryngologic Manifestations of HIV . In: Peiperl L, Coffey S, Volberding PA, eds. HIV InSite Knowledge Base [textbook online]; San Francisco: UCSF Center for HIV Information; August 1998. Available online at hivinsite.ucsf.edu/InSite?page=kb-04-01-13. Accessed February 7, 2006.
• Sande MA, Eliopoulos GM, Moellering RC, et al. The Sanford Guide to HIV/AIDS Therapy, 14th ed. Hyde Park, VT: Antimicrobial Therapy, Inc.; 2005.
• Simdon J, Watters D, Bartlett S, et al. Ototoxicity associated with use of nucleoside analog reverse transcriptase inhibitors: a report of 3 possible cases and review of the literature . Clin Infect Dis. 2001 Jun 1;32(11):1623-7.
• Uphold CR, Graham MV. Clinical Guidelines in Family Practice, 3rd ed. Gainesville, FL: Barmarrae Books, Inc.; 1998.