Head and Neck Manifestations of HIVAIDS

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Head and NeckManifestations ofHIV/AIDS

• Adam Ray, MD
• SIU Division of Otolaryngology-Head and Neck
  Surgery

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Objectives

• Basic Science
• Incidence
• Pathogenesis in the Head and Neck
• Evaluation and Treatment
• Case study review

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Case Report

• 29 year old male with known HIV and history of
  lymphadenopathy in the neck returns to clinic
  with complaints of an increasing neck mass on the
  right side. Previous FNA as shown benign
  follicular hyperplasia. Patients complaints
  include general malaise and examination reveals a
  large level II lymph node on the right that is
  much larger than the adenopathy palpated on the
  remainder of the neck exam. the patient is on
  anti-retroviral medication. Laboratory
  evaluation reveals increased sed rate and CD4
  counts of 400.

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Case Report

• What is the next step in this patients workup?
• What is the criteria for open bx vs observation
  only?

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Basic Science

• Structure of the HIV particle
• a. lipid bilayer capsule
• b. viral core
• c. RNA strands
• d. reverse transcriptase

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Basic Science

• HIV life cycle
• Binding with the host cell (CD4)
• Synthesis of DNA
• Incorporation into the host cell DNA-provirus
• Latent period
• Synthesis of new HIV particles

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Incidence

• 1) 42 million adults and 1 million children are
  infected with HIV worldwide.
  
• 2) 16,000 new infections per day.
• 3) 40 of infected adults are women.
• 4) vertical transmission mother-child.
• 5) children
• a. most common cause of immunodeficiency.
• b. one of the top 10 leading cause of death in
  U.S.
  
• 6) 50 of HIV infected people will develop AIDS
  within 10 years.
  
• 7) occupational risks and prevention
• a. risk of seroconversion after percutaneous
  exposure is 0.31.
  
• b. universal precautions.

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Incidence

• AIDS
• Opportunistic infections
• Absolute CD4 counts less than 200

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Pathogenesis

• Dermatologic
• Otologic
• Nose and Paranasal Sinuses
• Oral Cavity and Pharynx
• Larynx
• Neck

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Pathogenesis Dermatologic

• candidiasis
• molluscom contagiosum
• bacillary angiomatosis
• seborrheic dermatitis
• herpes zoster
• Idiopathic multiple sarcoma
• (Kaposis Sarcoma)

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Pathogenesis Dermatologic

• Kaposis Sarcoma
• pink to purplish in color, raised or nodular
• histopathology
• mucosal and skin lesion
• adenopathy

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Pathogenesis Otologic

• otitis externa
• otitis media
• serous otitis
• facial paresis/paralysis
• SNHL
• HIV labyrinthitis

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Pathogenesis Nose and Paranasal Sinuses

• herpetic lesions
• neoplasms
• allergies
• chronic sinusitis
• invasive fungal sinusitis

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Pathogenesis Oral Cavity and Pharynx

• oral candidiasis most common
• herpetic stomatitis
• apthous ulcers
• hairy leukoplakia
• Kaposis Sarcoma
• Non-Hodgkins Lymphoma
• peridontal disease

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Pathogenesis Larynx

• infections
• neoplasms
• recurrent respiratory papillomatosis

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Pathogenesis Neck

• salivary glands
• lymphocytic infiltrates
• Parotid masses

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Pathogenesis Neck

• Lymphadenopathy
• follicular hyperplasia
• Kaposis Sarcoma, NHL
• TB
• atypical mycobacteria
• histoplasmosis, toxoplasmosis
• Cat scratch disease

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Evaluation

• PMHx
• Social Hx
• Complete Head and Neck exam (nasal endoscopy/
  flexable laryngoscopy)
  
• FNA
• Imaging (CT or MRI )
• Pathology

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Evaluation

• Laboratory Dx
• Western blot
• Viral titer
• CD4 counts
• Monitor anti-viral Rx

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Treatments

• Medical
• Antiviral, anti-retroviral drugs
• Chemo/RT for Kaposis and NHL
• Antibiotics
• Post-exposure zidovudine prophylaxsis

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Treatments Surgical

• Dermatologic excison and curettage,
  cryotherapy
  
• Otologic myringotomy and tube, mastoidectomy
• Sinus surgical drainage
• Larynx mucosal bx, intervention for
  obstruction
  

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Treatments Surgical

• Neck FNA, excisional bx
• Criteria for open excisional bx
• Constitutional symptoms
• Localized adenopathy
• Disproportionately large node in a patient with
  persistent generalized LAD
  
• Cytopenia or elevated SED rate

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Case Study Revisited

• This patient meets the criteria for open bx
• general malaise
• New large lymph node in a patient with known
  generalized LAD
  
• increased SED rate
• Patient does not have AIDS as CD4 count is 400

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Summary

• All aspects of society are affected by the
  disease including children and heterosexual
  women.
  
• 50 of those infected with the virus will develop
  head and neck manefestations.
  
• Understanding symptoms and surgical treatments is
  crucial in the proper management of these
  patients.

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