Keywords
sinusitis - otitis media with effusion - candidiasis oral - HIV
Palavras-chave
sinusite - otite média com efusão - candidíase bucal - HIV
Introduction
HIV infection is a global pandemic, with an estimated 42 million among adults worldwide,
two thirds of who are in sub-Saharan Africa; 47% of cases are women and an estimated
1.3 million children less than 15 years of age[1]. The reported prevalence of ENT, head and neck manifestations of HIV/AIDS worldwide
varies from 41 to 80%[2]
[3]
[4]
[5].
In the United States, HIV sero-prevalence varied between 0.45% - 27.5% while it is
1.2% - 12% in Nigeria[6]
[7]. HIV preferentially infects cells of the nervous and lymphatic systems. The most
important cell infected is the T-helper cell, through the CD4 receptor, resulting
in both functional impairment and numeric depletion of T helper cells. The transmission
of the virus occurs through blood and its products, sexual contacts, transplacentally
in utero and via breast feeding[8].
The causes of ORL manifestations are due to infections, neoplasms and primary neurological
damage resulting from the HIV[9].
This study is to reappraise these features among HIV/AIDS patients after a preliminary
study done among 29 patients at our centre over five years ago[10].
Method
This was a prospective study of all consecutive new patients confirmed to be HIV positive
using the ELISA technique with confirmation by the Western blot assays attending the
HIV clinic of the University of Ilorin Teaching Hospital, Ilorin, Kwara state, Nigeria
between January and July, 2009. These patients were on HAART anti retroviral drug
treatment.
Informed consents from individual patient and ethical approvals were obtained from
the hospital authority. The information retrieved included the biodata, clinical presentation,
otolaryngologic clinical findings, as well as their hearing assessment with Pure tone
audiometry (using clinical diagnostic audiometer Madsen OB 822, Denmark calibrated
according to ISI). Patients with inadequate records were excluded from analysis. Data
were entered into the computers and analysed with EPI INFO 2005 version 3.
Results
A total of 100 patients were seen over the study period but 89 patients had complete
data for analysis. There were 51 males (57.3%) and 38 females (42.7%) with a sex ratio
of 1.3:1. The age range was 3 to 62 years (Mean of 36.4 yrs, SD = 2.45 ± 0.02). The
modal age range was 21-40years (59.6%), followed by 41 to 60(36%) and over sixty and
below twenty years were 2 (2.2%) each ([Table 1]).
Table 1.
Age disribution of HIV patients
|
Age range
|
Frequency
|
Percentage (%)
|
|
>20yrs
|
2
|
2.2
|
|
21-39yrs
|
53
|
59.6
|
|
40-64yrs
|
34
|
38.2
|
|
≥ 65yrs
|
0
|
0
|
|
Total
|
89
|
100
|
Majority of the patients 44 (49.4%) were self employed, 14 (15.6%) were unemployed,
12 (13.5%) were civil servants and artisans, 3 (3.4%) were security forces and 2 (2.3%)
each were either farmers or pensioners ([Table 2]). Seventy-six (85.4%) of the respondents were married while 8 (9%) were single,
4 (4.5%) were widowed and only one (1.1%) was divorced. History of smoking was found
only among 18% of the respondent while 73 (82%) do not smoke and 19 (21.3%) take alcohol.
Table 2.
Occupational distribution among HIV/AIDS patients.
|
Occupation
|
Frequency
|
Percentage (%)
|
|
Civil servant
|
12
|
13.5
|
|
Artisan
|
12
|
13.5
|
|
Farming
|
2
|
2.3
|
|
Self employed
|
44
|
49.4
|
|
Unemployed
|
14
|
15.6
|
|
Security/force
|
3
|
3.4
|
|
Pensioner
|
2
|
2.3
|
|
Total
|
89
|
100
|
The risk factors for HIV transmission included hetero-sexual contacts in 90% of cases,
blood transfusions in 5% and others were 5%. The average period between diagnosis
and commencement of anti-retroviral drugs is 3 to 6 months.
Relating to otorhinological symptoms, otological symptoms included 9 (10.1%) with
hearing loss, 14 (15.7%) cases of tinnitus and vertigo each, 12 (13.5%) with ear blockage
and 13 (14.6%) with otalgia ([Table 3]).
Table 3A.
Otorhinolaryngological manifestaions among HIV/AIDS patients : Symptoms
|
Symptoms
|
Frequency
|
|
Otological
|
|
|
|
Hearing loss
|
9
|
(10.1%)
|
|
Tinnitus
|
14
|
(15.7%)
|
|
Vertigo
|
14
|
(15.7%)
|
|
Ear blockage
|
12
|
(13.5%)
|
|
Otalgia
|
13
|
(14.6%)
|
|
Otitis Externa
|
3
|
(3.4%)
|
|
Hearing impairment
|
6
|
(6.7%)
|
|
Total
|
71
|
|
|
Nasal
|
|
|
|
Nasal blockage
|
19
|
(21.3%)
|
|
Epistaxis (Nose bleeds)
|
10
|
(11.4%)
|
|
Recurrent nasal discharge
|
58
|
(65.2%)
|
|
Sneezing
|
35
|
(39.3%)
|
|
Anosmia
|
25
|
(30.3%)
|
|
Snoring
|
4
|
(4.5%)
|
|
Total
|
151
|
|
|
Table 3B
|
|
|
|
Oral /Oropharyngeal
|
|
|
|
Recurrent aphthous ulcers
|
28
|
(20.2%)
|
|
Dysphagia/odynophagia
|
11
|
(12.4%)
|
|
Oral candidiasis
|
40
|
(44.9%)
|
|
Total
|
79
|
|
|
Neck(Cervical) Swellings
|
30
|
(33.7%)
|
|
Other constitutional symptoms
|
42
|
(47.2%)
|
|
Cough/weight loss/anorexia/diarrhoea
|
|
|
Pharyngeal symptoms included 40 (44.9%) with oral/oropharyngeal candidiasis, 18 (20.2%)
with recurrent aphthous ulcers and 11 (12.4%) with dysphagia and odynophagia.
Nasal symptoms included nasal blockage in 19 (24.3%), 10 (11.2%) had history of epistaxis,
25 (30.3%) with anosmia, 58 (65.2%) had recurrent nasal discharge (catarrh) (65.8%),
30 (33.7%) had recurrent sneezing, 4 (4.5%) with snoring ([Table 3]). Cervical swellings occured in 30 (33.7%) patients, other constitutional symptoms
occurred in 42 patients.
The duration of diagnosis ranged from 1week to 13 yrs with the modal duration of less
than 2 yrs. 68 (76.4%) of the respondents have commenced antiretroviral drugs which
ranged from less than 3 months to over 12 months. Ear examination revealed 11 had
wax impaction in either of the ears, 1 (1.1%) with otomycosis, one with chronic suppurative
otitis media, but evidence of serous otitis media (glue ear) in 58 (65.1%) but there
was no evidence of Ramsay-Hunt syndrome.
Pure tone audiometry showed conductive hearing loss (CHL) in 20 (22.5%) on the right
and 30 (33.7%) on the left ears, sensori-neural (SNHL) in 9 (10.1%) on the right,
7 (7.9%) on the left, mixed hearing loss 8 (9%) on the right, 7 (7.9%) on the left
([Table 4]). Categorization of degree of hearing showed normal hearing in 15 (16.9%) on the
right, 11 (12.4%) on the left, mild hearing loss in 22 (24.7%) on the right, 24 (27%)
on the left, moderate hearing loss in 32 (36%) on the right, 38 (42.7%) on the left,
moderately-severe hearing in 19 (21.3%) on the right, 16 (18%) on the left, severe
hearing loss only in 1 (1.1%) right ear. The nasal examination revealed engorged inferior
turbinates on anterior rhinoscopy in 82 (92.1%) of the patients, oropharyngeal examination
revealed amputated uvula in 14 (15.7%), hypertrophied and atrophied tonsils in 3 (3.4%)
and 9 (10.1%) patients respectively. There was evidence of chronic pharyngitis (granular
posterior pharyngeal wall) in 74 (83.1%), hyperaemia in 4 (4.5%) and normal in 11
(12.4%) patients.
Table 4.
Pure tone audiometric outcome among HIV patients.
|
Frequency
|
Frequency
|
|
Right
|
Left
|
|
Conductive hearing loss(CHL)
|
24 (27%)
|
33 (37.1%)
|
|
Mixed hearing loss
|
8 (9.0%)
|
7 (7.9%)
|
|
Sensori-neural hearing loss(CHL)
|
13 (14.6%)
|
11 (12.4%)
|
|
Normal hearing
|
15 (16.9%)
|
11 (12.4%)
|
|
Total
|
89
|
(100%)
|
Discussion
Since the infective agent responsible for HIV/AIDS was discovered in 1983, the spectrum
of manifestations has become well defined with nearly 84% of infected individuals
having otorhinolaryngological symptoms or signs[11]. Various studies reported varied prevalences, Marusann \and Soy
[6], in their study of 399 patients with AIDS, found that 165 (41%) had symptoms related
to otolaryngology. Williams
[12], in his study of 50 patients with diagnosis of pediatric AIDS, reported otolaryngological
manifestation to occur in more than 80% of patients. Chandra Prasad et al reported a prevalence of 79% among 968 patients with HIV[13], earlier report by Alabi \et al in Ilorin, Nigeria (2004) reported a prevalence of 78% among 29 patients[10].
Although the ENT manifestations in this population (82.8%) are certainly higher than
in the general population, not all of them could be solely attributed to the HIV sero-positiveness.
It is known that HIV infections are generally symptomless and once AIDS is established
this figure changes dramatically.
The modal age of between 21-39 yr which differ from other studies with age range 20-49
yrs[14] still fall within age group found by most studies; however our study found a lower
value compared to somefun et al in Nigeria and a lower age group of 3 yrs which was
limited to few studies[15]
[16]. Our study showed a higher prevalence among the males compared to the females which
is similar to most studies in different part of the world[3]
[4]
[5]
[6]
[17]
[18].
Majority of the patients were self employed in 49.4% most of whom are involved in
trading and small scale business followed by unemployed ,this indicated that HIV is
still most prevalent among the lower socio-economic class similar to a study in some
parts of Africa[14].
The study showed that more than three-quarter of the respondents were married but
this does not indicate the source of the infection with the least among the divorcee,
most studies does not highlight the marital status of the respondents. Incidence of
alcohol ingestion and smoking have been found to be very low among the respondents
which most literatures are silent about as it is not a high risk and majority of those
involved in the habit of either smoking or alcohol consumptions have been doing so
for between 6 months to 20 yrs duration.
Chronic rhinosinusitis was found to be the commonest manifestation in our series ,evidenced
by clinical presentation of recurrent nasal discharge and obstruction, sneezing,epistaxis,
supported by the examination findings of engorged turbinate which is similar to findings
in other part of the world[11]
[12]
[19]
[20]. Rhinosinusitis is common in HIV-infected patients, with a reported prevalence between
20% and 68%[21]. The reasons adduced included changes in the mucociliary clearance, a primary local
defense mechanism for the sinuses. The bacteriology of acute sinusitis in this population
includes the same organisms normally considered in the immunocompetent patient however,
In late stages of HIV infection, atypical opportunistic fungal sinusitis is the rule.
Oral and oropharyngeal symptoms were the second commonest in our study with oral candidiasis
and recurrent sore throat with aphthous ulcers being the commonest oropharyngeal symptoms
, this is similar to studies in other part of the world that found oropharyngeal candidiasis
to be the commonest presentations[18]
[22].
The commonest otological symptoms were tinnitus and vertigo in 15.7% each followed
by otalgia and ear blockage in 14.6% and 13.5% respectively, the least was hearing
loss of which serous otitis media was the commonest. The most common otologic problems
reported in HIV-infected patients are serous otitis media due usually to eustachian
tube dysfunction and recurrent acute otitis media[23].
Eustachian tube dysfunction can result from nasopharyngeal lymphoid hyperplasia, sinusitis,
nasopharyngeal neoplasms, or allergies and their associated mucosal changes. This
is at variance with study in other part of the world that reported sudden sensorineural
hearing loss, chronic and recurrent otitis media to be the commonest otological manifestation[17]
[18]
[19], tympanic membrane perforation in only one of the respondent this is an unusual
finding compared to other studies where chronic otitis media was one of the commonest
ENT findings and may also be a hallmark in some reports[13]
[17]. Audiological evaluations showed conductive hearing loss in 27-37% of the respondents,
sensorineural in 12-14.6% while normal hearing was found only among 12-17% of the
respondents this was at variance with study done by somefun et al who found sensorineural
hearing loss to be the commonest[5] although the pure tone audiometry is a subjective test but it has been supported
by earlier clinical findings.
Other studies elsewhere have reported that most otological problems are caused by
routine organisms that respond to standard therapy[4] or may be as a result of direct consequence of virus or secondary to the pharmacological
treatment[21]. The cause of the hearing loss cannot be substantiated by our study as the hearing
assessment was not done before the commencement of the anti-retroviral drugs which
is an area of challenge to focus in future studies to compare the hearing assessment
before and after commencement of anti-retroviral therapies.
Due to the involvement of central nervous system in HIV infection, the most direct
consequence to the auditory system is central auditory nervous system abnormalities
similar extrapolation can be drawn to the effect on the olfactory nerve of smell as
it affects almost one-third of the respondents[24]. Cervical adenopathy was the fourth commonest, however other studies have found
cervical manifestation to be the most frequent symptoms of presentation[25]
[26]
[27]
[28]
[29]. There was no either Kaposi sarcoma or non Hodgkin's lymphoma in our series as compared
to study in the developed world
Conclusion
In conclusion, ENT manifestation of HIV occurred in over four-fifth of the patients
with leading features of chronic rhinosinusitis,oropharyngeal candidiasis,serous otitis
media and cervical adenopathy.Often, the otolaryngologist is the primary physician
who diagnoses the HIV infection. He should be aware and vigilant for its symptoms
and unusual presentations. With more people coming forward for voluntary counselling
and testing for HIV,it is important for otolaryngologists to be aware of otolaryngological
manifestations so early diagnosis and timely intervention alongside appropriate anti-retroviral
therapy be instituted to improve survival rates.
