Clinical Guide > Common Complaints > Ear, Nose, Sinus, Mouth

# Ear, Nose, Sinus, Mouth

January 2011

### Chapter Contents

      - Background 
      - **Ears**
      - S: SubjectiveO: ObjectiveA/P: Assessment and Plan**Nose and Sinuses**
S: SubjectiveO: ObjectiveA: AssessmentP: Plan**Mouth and Throat**
S: SubjectiveO: ObjectiveA/P: Assessment and PlanReferencesPotential ARV Interactions
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 (e.g., 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 also may be caused by 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 information regarding the following 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 is an important measure of immunosuppression and is important in determining whether the patient is at risk of opportunistic infections as causes of ear complaints.

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

If hearing loss is reported or suspected, evaluate hearing and refer the patient for an audiogram. Perform a neurologic examination and draw rapid plasma regain (RPR) or Venereal Disease Research Laboratory (VDRL) test.
A/P: Assessment and PlanOtitis Externa/Interna
Proceed 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 (e.g., furosemide, aminoglycosides).
**Nose and Sinuses**
Nasal and paranasal sinus conditions occur frequently in HIV-infected patients. Sinusitis, nasal obstruction, allergic rhinitis, and nasal lesions are common. Epistaxis can occur in patients with platelet disorders (e.g., 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 information regarding the following 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 is an important measure of immunosuppression and is a key element in determining whether the patient is at risk of 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 attributable 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.
- Acute infection of one 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.
- Tumors may be caused by KS, squamous papilloma, or lymphoma; biopsy is necessary for determining the cause.
- Painful, ulcerated vesicles in the nasal mucosa may be caused by HSV or other infections.
P: PlanAcute Sinusitis
Combination therapy with antibiotics, decongestants, mucolytics, saline nasal spray, and topical nasal steroids may be effective. See chapter *Sinusitis* for details. Note: For patients taking ritonavir or ritonavir-boosted protease inhibitors, fluticasone (Flonase) nasal spray should not be used, and budesonide (Rhinocort Aqua) should be avoided if possible; see "Potential ARV Interactions," below.
Chronic Sinusitis
Treat with a systemic decongestant (guaifenesin), saline nasal spray BID, and topical nasal saline spray. Patients with exacerbations of sinusitis should be treated as for acute sinusitis. For more detailed information, see chapter *Sinusitis*. With patients taking ritonavir-boosted PIs, avoid fluticasone and budesonide nasal sprays; see "Potential ARV Interactions," below.
Allergic Rhinitis
Patients should avoid exposure to known or suspected allergens. Nasal steroids may be very effective, but avoid fluticasone and budesonide nasal sprays with patients taking ritonavir (see "Potential ARV Interactions," below). Second-generation nonsedating antihistamines such as cetirizine, fexofenadine, and loratadine are not as effective as nasal steroids, but may give additional symptom relief. Note that ritonavir may increase the serum levels and half-life of cetirizine. Daily nasal lavage with normal saline often is beneficial.
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.
Epistaxis
Epistaxis caused by coagulopathy or tumor is managed the same as for immunocompetent patients with these conditions. Cauterization of an identified bleeding point or packing may be necessary. ITP should be managed in collaboration with a hematologist; antiretroviral therapy (ART) typically is used for chronic management, and corticosteroids or other therapies may be used for acute management.
Potential ARV Interactions
**Caution:** Protease inhibitors (PIs), particularly ritonavir-boosted PIs, may increase serum glucocorticoid levels if used concurrently with nasal steroids. Fluticasone (Flonase) nasal spray should not be used with ritonavir-boosted PIs unless expected benefits out weigh possible risks, and should be avoided, if possible, in patients taking unboosted PIs. Budesonide (Rhinocort Aqua) nasal spray should be avoided with ritonavir-boosted PIs. Interactions between PIs and other nasal steroids have not been well studied.

Ritonavir may increase serum levels of cetirizine and may prolong its half-life; start with low dosage and monitor for adverse effects.
**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, ulcers, nonhealing lesions at the corners of the mouth, sore gums, loose teeth, dysphagia, or odynophagia.

Obtain information regarding the following during the history:
- Medications (prescription and over-the-counter) and herbal supplements (note that some medications may cause aphthous ulcers)
- Usual oral hygiene (toothbrushing, tongue brushing or scraping, flossing, use of mouthwash)
- Date of last dental examination
- Use of tobacco (cigarettes, chewing tobacco)
- Involuntary weight loss
O: Objective
Recent CD4 count reflects degree of immunosuppression and is helpful in determining whether the patient is at risk of 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). Look for ribbed, whitish lesions on the lateral aspects of the tongue that cannot be scraped off (oral hairy leukoplakia). Check for ulcerations, inflamed gums, and loose teeth (see section *Oral Health*). Look for discoloration or nodular lesions on the hard palate (Kaposi sarcoma). Check the pharynx for adenotonsillar hypertrophy. Rule out HIV-unrelated causes of pharyngitis, including streptococci or respiratory viruses.
A/P: 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 <200 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 surface of the 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 it is characterized by fissuring at the corners of the mouth. For information on 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 generally is not needed. Lesions often resolve with effective ART. For more details, see chapter *Oral Hairy Leukoplakia*.
Kaposi Sarcoma
KS 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 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 if they are severe or numerous, refer to an oncology specialist for chemotherapy. For more details, see chapter *Kaposi Sarcoma*.
Gingivitis
See chapter *Necrotizing Ulcerative Periodontitis and Gingivitis* for 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 valacyclovir, famciclovir, 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*.
*Neisseria gonorrhoeae* Pharyngitis
*Neisseria gonorrhoeae* may be transmitted by orogenital exposure; the patient may have mild symptoms (e.g., sore throat) or be asymptomatic. Physical examination may reveal an erythematous pharynx or exudates. Anterior cervical lymphadenopathy also may be present. Most cases of *N. gonorrhoeae* pharyngeal infection will resolve spontaneously without treatment and usually do not cause adverse sequelae. However, treatment should be initiated to reduce the spread of the infection (see chapter *Gonorrhea and Chlamydia*). Regular screening is recommended for patients at risk of *N. gonorrhoeae* infection.
Medication-Related Mouth or Throat Lesions- Candidiasis: antibiotics
- Xerostomia: antihistamines, anticholinergics, tricyclics, antipsychotic
- Gingival hyperplasia: phenytoin, calcium channel blockers
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 (e.g., nutritional supplements).
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