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A study on otorhinolaryngologic manifestations in human immunodeficiency virus infected patients

Acquired immunodeficiency syndrome (AIDS), caused by the human immunodeficiency virus (HIV) is a major public health problem and is a major killer throughout the world. It is the biggest challenge for the medical community to treat and effectively cure the disease. The ear, nose, and throat (ENT) and head and neck surgeons have the main responsibility in the earlier recognition of head and neck manifestations of HIV infection and to treat accordingly so that these patients are diagnosed early and receive appropriate care. It was reported initially that 41 percent of patients with AIDS had head and neck manifestations. As awareness has increased, however, recognition of these lesions has also increased, until now it seems that nearly all patients with AIDS have head and neck manifestations.

mucocutaneous herpes simplex, oral hairy leukoplakia and oral or aural Kaposi's sarcoma. [2][3][4] Of these, oral hairy leukoplakia is virtually pathognomonic of HIV disease. 5 Though kaposi's sarcoma is rare in our country, it is an AIDS defining illness and we should suspect HIV infection in those individuals with Kaposi's sarcoma. It is very common in African homosexual men. It has to be noted that the studies regarding the prevalence of these AIDS defining ENT manifestations among Indian population has been very meagre. With these in mind our main aim of this study was to find out the ENT manifestations in a selected regional population of 100 HIV infected patients, to identify the commoner ENT manifestations among them and to make these manifestations, a guide for regional ENT surgeons, to diagnose HIV/AIDS patients early and to treat them accordingly.

METHODS
The study was an observational study which was conducted for a period of five years from January 2015 to January 2019 after approval from institutional Ethical committee. The study included 100 HIV seropositive patients, among the patients attending the Outpatient Department of the Otorhinolaryngology and antiretroviral therapy (ART) centre across five Government Hospitals in South India, details of each institution with duration of study carried out in that institution has been shared in Table 1. Detailed ENT clinical examination as well as laboratory investigations were carried out to evaluate the nature of ENT presentations of HIV infection. Patients included in our study were previously proved seropositive HIV infected patients of age group 20 to 50 years of both sexes with some form of ENT symptoms like oral white patches, painful oral ulcers, neck swelling, headache, nasal obstruction, nasal discharge, ear pain/ discharge, dysphonia, throat pain, swelling in mouth or difficulty in swallowing. HIV infected patients with no obvious ENT symptoms, HIV infected patients with coexisting diabetes mellitus, HIV infected patients received or receiving steroids or any other immunosuppressive therapy and HIV infected patients with past history of hard of hearing and those patients who were previously diagnosed to have chronic suppurative otitis media and chronic sinusitis were excluded from our study. Detailed history was taken and physical examination was done for each patient as shown in proforma. All patients underwent the following investigations i.e. blood total count, differential count, erythrocyte sedimentation rate, haemoglobin, chest X ray PA view, ELISA for HIV and CD4+ T cell count. Selected patients underwent following investigations like gram stain for oral candidiasis, biopsy for histopathological examination for oral hairy leukoplakia, Tzanck smear for oral herpes simplex infection, fine needle aspiration cytology for neck nodes, biopsy for histopathological examination for swelling in oral cavity and for suspected tuberculous laryngitis, pure tone audiogram for patients with hard of hearing, pus for culture and sensitivity (C/S) from pus in ear or middle meatus or nasal cavity through DNE and sputum AFB for suspected tuberculous laryngitis. Diagnostic nasal endoscopic examination and videolaryngoscopic examination too were carried out for all selected patients. Universal barrier precautions were followed by all health care workers and all equipments involved in our study to prevent them from getting exposed to infection.

Statistical analysis
Data was compiled and analysed Microsoft excel for windows. The results were presented as percentages out of total HIV patients included.

RESULTS
Out of the 100 patients studied 66 patients were males and 34 were females ( Table 2). According to Table 3, out of 100 HIV positive patients, 66% (n=66) were between the age group of 30 to 39 years. 26% (n=26) were between the age group of 40 to 50 years, while only 8% (n=8) were between 20 to 29 years. The analysis of socioeconomic status of the patients is given in Table 4. 60 of them (60%) belong to low socioeconomic group. 30 of them (30%) were of middle socioeconomic group. Only 10 (10%) of them belong to high socioeconomic group. According to  Table 7.      Cervical lymphadenopathy and sensorineural hearing loss 10 (10)

DISCUSSION
This study evaluated ENT manifestations in 100 HIV infected patients and the frequency of ENT manifestations is discussed as below. Here, as per Table  1, 66 patients were males and 34 were females. As per Table 2, 66% of patients were of the age group 30 to 39 years, 26% of patients were of the age group 40 to 50 and 8% of patients were of the age group 20 to 29 years. Hence the commonest age group, affected in this study was 30 to 39 years. This is the age group that is most economically productive in the society. They have more exposure. Also, even if they were exposed in younger age the manifestations become apparent after some years only. This could possibly be the reason why this age group is the most common affected group.
As per Table 4 the people in low socioeconomic status group were the most commonly affected. 60% of the patients belong to low socioeconomic group. 30% were of middle socioeconomic status and only 10% belong to high socioeconomic status. This is so because only low socioeconomic status people are more ignorant, illiterate and do not know or follow safe sexual practices. Also, sexually transmitted diseases (STDs) are more common in low socioeconomic group due to poor hygiene, crowding and ignorance regarding early consultation and also several myths are commoner in low socioeconomic group. Also, native and traditional treatments are followed among low socioeconomic group people commonly. STDs naturally increase the risk of transmission of HIV.
According to Table 5, throat manifestations, which comprise of oral candidiasis, oral herpes simplex, tuberculous laryngitis, Kaposi's sarcoma and oral hairy leukoplakia were the commonest (74%). Nose manifestations which comprise of chronic sinusitis and nasal polyps were of 14%. Ear manifestations which comprise of chronic otitis media and sensorineural hearing loss were of 24%. Neck manifestation which comprises of only cervical lympadenopathy was of 30%.

Figure 1: Oral candidiasis.
According to Table 6, the most common ENT manifestation among 100 HIV infected patients happened to be oral candidiasis which occurred in 40 (40%) patients. Candidiasis (Figure 1) 11 It is estimated that tuberculosis is 100 to 500 times more common in HIVpositive patients. This is not surprising because the main defense against mycobacteria is cell mediated immunity. The most common symptoms were hoarseness, odynophagia and shortness of breath. The majority of the patients had white exophytic lesions which may involve any area of the larynx and looked like carcinoma or chronic laryngitis. Systemic symptoms such as fever, night sweats, and weight loss are very common in AIDS patients and coupled with other illnesses masked the possibility of laryngeal disease. This may delay the diagnosis of laryngeal tuberculosis. The diagnosis is made by tissue examination and culture. Polymerase chain reaction identifying tuberculous DNA shows potential in making this diagnosis more rapidly. Cultures should be obtained to determine drug susceptibility because of the high incidence of multi-drug resistant tuberculosis. 90% of cases of laryngeal tuberculosis are associated with active pulmonary tuberculosis making this a contagious illness. Therefore, patient isolation is needed as long as the patient has potentially infectious sputum. Adequate room ventilation/filtration and masks for all health care providers are necessary. The individual must have a chest X-ray and a PPD test (although many AIDS patients are allergic) to check for active tuberculosis. The most common presenting symptom of laryngeal tuberculosis is hoarseness, with a high percentage of patients also reporting dysphagia, odynophagia, cough, and weight loss. 20 to 40% of patients show no evidence of pulmonary involvement, but purified protein derivative is usually positive. Almost any area of the larynx can be involved as well as supraglottic structures such as the aryepiglottic folds and epiglottis.
Lesions range from areas of nonspecific inflammation to a nodular, exophytic lesion or mucosal ulcerations. Histopathological examination of biopsied tissue revealed tubercles consisting of a homologous caseous centre (staining red with eosin), a periphery of pale epithelial cells containing one or more giant cells, and an outer zone of lymphocytes. The palate serves as the site for 95 percent of these oral lesions, while any other mucosal surface of the mouth can also be a site. In the early stages, the lesions are macular, dark or erythematous, maturing into more raised and lobulated mucosa. The lesions can ulcerate but rarely bleed or become tender. Kaposi's sarcoma is usually slow to develop but, in some reported cases, the lesions rapidly disseminate to involve the thoracic and abdominal viscera. Symptoms include increasing pain, odynophagia, dysphagia and difficulty in mastication. The epidemic form of Kaposi's sarcoma is associated with AIDS. It presents with skin lesions anywhere and disseminate to mucous membranes, GI tract, lymph nodes and viscera. In the early stages, irregular dilated epidermal vascular spaces, extravasated red cells and hemosiderin are characteristic in histological examination. This histologic appearance is very similar to that of granulation tissue or stasis dermatitis. Later in the disease process, more characteristic lesions show spindle cells around slit spaces with extravasation of erythrocytes. In contrast, irregular vascular spaces lined by nests of uniform cells describes the histologic appearance of glomus tumor, while multiple dilated endothelial lined vessels that lack red blood cells.

CONCLUSION
To conclude, our study findings have showed that the most common ENT manifestation in Tamil Nadu patients having HIV/AIDS were oral candidiasis followed by cervical lymphadenopathy, oral herpes simplex and sensorineural hearing loss. Although ENT symptoms are not diagnostic of a disease, it might be suggestive of HIV infection or related to its progression and treatment efficacy. A better knowledge about the regional prevalence of ENT manifestation in HIV/AIDS patients help ENT surgeons, for better understanding and a multidisciplinary approach in treatment to these patients, as creation of awareness is the key to prevention.