almost 30 years after its first description , hiv still remains a global pandemic , particularly affecting the countries of sub - saharan africa , southeast asia , and latin america . hiv is an rna retrovirus which compromises the immune system , and renders the infected person susceptible to opportunistic infections and malignancy . the incidence of hiv infection in 2009 was 2.6 million , whilst the respective prevalence ranged between 31.435.3 million people . the prevalence of hiv had risen by 27% compared to the previous decade , although the annual rate of new cases had been steadily declining since the late 1990s . in addition , the estimated number of children living with hiv increased to approximately 2.5 million in 2009 . the increased incidence of hiv has resulted in a greater number of hiv - infected patients presenting to ent doctors . indeed , up to 80% of hiv - infected patients eventually develop ent manifestations . among the latter , oral disease seems to be the most common , occurring in approximately 4050% of hiv positive patients . predisposing factors for hiv - related ent conditions include cd4 + cell count of less than 200/l , plasma hiv - rna levels greater than 3000 copies / ml , xerostomia , poor oral hygiene , and smoking . although ent manifestations may not be diagnostic of hiv infection , they may be heavily suggestive of such an infection . in addition , the occurrence of certain oral manifestations in patients with known hiv disease who are not receiving treatment may be related to the progression of the disease . finally , the presence of ent disease in patients on antiretroviral therapy could be the result of an increase in the plasma hiv - rna and suggest treatment failure . in this context , the provision of appropriate care to hiv patients may require a multi - disciplinary approach . the aim of the present paper is to review the current knowledge on ent manifestations of hiv infection , and present the available diagnostic and treatment options . the implications of the early identification of hiv - associated ent disease from a public health perspective are also discussed , along with clinical markers of immune compromise . oral candidiasis , commonly known as thrush , is by far the most common oral manifestation of hiv infection . candidal infection can occur in the oropharynx , hypopharynx , and larynx , and usually results in severe odynophagia and swallowing difficulties . the prevalence of candidiasis varies from 3090% among hiv positive adult patients whereas the respective percentage in children ranges between 22.5 and 83.3% . oral candidiasis can present in three forms : pseudomembranous candidiasis , erythematous candidiasis , and angular cheilitis ( figures 13 ) . it has been associated with more frequent progression of hiv to aids , and also used as a clinical marker to define the severity of hiv infection . it appears as creamy , white , curd - like plaques on the buccal mucosa , tongue , and other oral mucosal surfaces . the most common organism involved is candida albicans ; however involvement of non - albicans species , such as candida glabrata and candida dubliniensis , has also been described . reproduced with permission from ias - usa . top hiv med 2005;13:143 - 8 . erythematous candidiasis , on the other hand , presents as a red , flat , subtle lesion on the dorsal surface of the tongue , or on the hard or soft palate . the lesion often involves two opposing surfaces , i.e. if a lesion is present on the tongue , the palate should be examined for a matching lesion , etc . patients usually complain of a burning sensation , especially while eating spicy or salty food . when the hypopharynx , larynx , or esophagus are affected , symptoms may progress to severe odynophagia and swallowing difficulties . this may be especially true in children , in which candidal esophagitis may require hospital admission , and intravenous administration of amphotericin b. diagnosis is based on the clinical appearance of the lesions taking into consideration the history of hiv infection . however , candidiasis can be confirmed in challenging cases from the identification of fungal hyphae or blastospores in potassium hydroxide ( koh ) preparation . treatment of mild to moderate cases of both erythematous and pseudomembranous candidiasis includes clotrimazole troches , nystatin oral suspension , and nystatin pastilles , whereas systemic administration of fluconazole , intraconazole and voriconazole is warranted in moderate to severe cases ( table 1 ) . voriconazole should be reserved for cases of fluconazole resistance , due to more serious iteractions with other drugs . antifungal therapy should last for two weeks to reduce the colony forming units to the lowest level possible and prevent recurrence . table 1treatment regimens for hiv - associated ear , nose and throat ( ent ) manifestations in adults and children.hiv manifestationtreatment in adultstreatment in childrenoral candidiasistopical agentstopical agents  clotrimazole troches 10 mg : dispense 70 ,  nystatin 200,000 - 800,000 u : used qds , or 5 times a day  dissolve 1 troche in mouth 5 times a day for 14 days  miconazole 200,000 - 800,000 u : qds to 5 times a day . nystatin oral suspension 500,000 u : swish 5 ml in mouth  oral nystatin 200,000 u : in tablets dissolve  as long as possible then swallow ( optional ) , qds for 14 days  1 in the mouth 5 times a day  nystatin pastilles 100,000 u : dispense 56 ,  systemic agents  dissolve 1 in mouth qds for 14 days  fluconazole or ketoconazole 6mg / kg ofsystemic agents  body weight for 5 - 7 days  fluconazole 100 mg : dispense 15 tablets , take 2 tablets on day 1 ,  clotrimazole 10 mg bd  followed by 1 tablet od for the remainder of the 14-day treatment period  itraconazole oral suspension 10 mg/10 ml : dispense 140 ml , swish and swallow  10 ml per day for 7 - 14 days . voriconazole 200 mg : dispense 14 tablets , take 1 tablet bd for 2 weeks  or at least 7 days following resolution of symptomsangular cheilitismiconazole cream apply qds for 14 daysmiconazole cream apply qds for 14 daysketoconazole cream apply qds for 14 daysketoconazole cream apply qds a day for 14 daysnecrotizing periodontitismetronidazole 500 mg : 1 tablet bd for 7 - 10 days.metronidazole 15 - 30 mg / kg / day orally in 3 dividedamoxicillin 500 mg : tds for 7 - 10 days.doses tds for 7 - 10 daysclindamycin 150 to 300 mg : qds for 7 - 10 days.amoxicillin 40 mg / kg / day in divided doses tdsfor 7 - 10 days.into 3 or 4 equal doses for 7 - 10 days.clindamycin 8 - 16 mg / kg / day ( 4 - 8 mg / lb / day ) dividedoral hsvacyclovir 800 mg , 5 times a day for 7 - 10 daysacyclovir 10 mg / kg qds or 5 times per day.famciclovir 500 mg tds for 7 dayshsv prophylaxis : acyclovir10 mg / kg bd , or tdssinusitiscd4>200 cells / mmamoxicillin 40 mg / kg / day tds in divided doses  amoxicillin 1.5 - 4 g / dayamoxicillin / clavulanate 125/31 tds between 1 - 6 years ,  amoxicillin / clavulanate : 1.75 - 4/250 g / day250/62 between 6 - 12 years  cefuroxime axetil 500 mg bdcefuroxime axetil 20 - 30 mg / kg daily given in 2 divided  trimethoprim / sulfamethoxazole:160 mg-800 mg orally bddoses in children > 4 weeks of age  telithromycintrimethoprim / sulfamethoxazole  erythromycin , clarithromycin , azithromycin6 - 10 mg / kg / day orally in children > 2 months of agecd4<200 cells / mm or failure of above therapyerythromycin , clarithromycin , azithromycin  fluoroquinolone + clindamycin or metronidazoleod , once daily , bd , twice daily ; tds , every 8 h ; qds , every 6 hbd , twice daily ; tds , every 8 h.*severe cases : acyclovir 10 mg / kg iv tds 
  od , once daily , bd , twice daily ; tds , every 8 h ; qds , every 6 hbd , twice daily ; tds , every 8 h. severe cases : acyclovir 10 mg / kg iv tds angular cheilitis presents as erythema , and/or fissuring in the corners of the mouth . it may co - exist with erythematous or pseudomembranous candidiasis , and persist for an extensive period of time if left untreated . treatment involves the use of a topical antifungal cream directly applied to the affected areas four times a day for two weeks . it most commonly presents as plaques similar to the ones found in non - hiv populations . linear gingival erythema ( figure 4 ) presents as a red band along the gingival margin , accompanied by occasional bleeding and discomfort . it most frequently appears at the anterior teeth , but can also extend to the posterior teeth . it can also present on attached and non - attached gingiva as petechia - like patches . treatment includes debridement by the dentist , mouth rinses with a 0.12% chlorhexidine gluconate suspension twice daily for two weeks , and home oral hygiene . in contrast , necrotizing gingivitis and necrotizing periodontitis ( figure 5 ) can result in the rapid destruction of soft tissue in the former and hard tissue in the latter condition . it is characterized by severe pain ( often described by patients as deep jaw pain ) , loosening of the teeth , bleeding , fetid odor , ulcerated gingival papillae , and rapid loss of bone and soft tissue . intervention is usually intensive curettage and debridement of all involved tissues , and use of topical antiseptic agents , such as 0.12% chlorhexidine gluconate or 10% povidoneiodine lavage . more severe cases should be supplemented by a short course of systemic antimicrobial therapy , usually metronidazole . oral infections with herpes simplex virus ( hsv ) ( figure 6 ) occur in up to 9% of adults and 1.324% of children with hiv . oral hsv presents as a small crop of vesicles which produce small , painful ulcerations extending onto the adjacent skin , and may coalesce to form giant herpetic lesions . although their clinical features are similar to non - hiv infected patients , the lesions are often bigger in hiv patients , recur more frequently , and tend to be more persistent . lesions most commonly appear on the lips , in the mouth , hard palate , and gums . although they are typically self - limiting , the use of antiviral agents , such as acyclovir , is sometimes required . hsv ulcers may become chronic in children with severe hiv , and convert into true membranes which may require hospital admission and intravenous administration of acyclovir ( table 1 ) . 
 figure 6oral herpes simplex virus . oral hairy leukoplakia ( figure 7 ) is a largely asymptomatic condition of the tongue caused by the epstein - barr virus . the prevalence of oral hairy leukoplakia varies from 0.4238% in hiv - infected adults to around 2% in children . the terminology of this condition arises from the appearance of elongated filiform papillae which can be accompanied by white plaquelike changes . in such cases , good results have been reported with topical application of trichloracetic or glycolic acid , podophyllum resin solution 25% and oral acyclovir . oral hairy leukoplakia . oral human papilloma - virus infection ( hpv ) ( figure 8) has increased in the era of highly active antiretroviral therapy ( haart therapeutic regimens ) . this suggests that a drug or combination of drugs used to treat hiv may be a risk factor for oral hpv infection . the most common hpv subtypes found in the oral cavity are subtypes 16 and 18 , which may be related to oral sexual behavior . the warts may be cauliflower - like , spiked , or raised with a flat surface . treatment involves surgery ( laser , or cryotherapy ) which may need to be repeated due to the frequent recurrence of the lesions . . top hiv med 2005;13:143 - 8 . 
  oral hpv lesion . reproduced with permission from ias - usa . kaposi 's sarcoma ( figure 9 ) is still the most common oral malignancy seen among patients with hiv . the prevalence of oral kaposi 's sarcoma of the mouth varies from 012% in africa and 038% in usa and europe . the oral cavity is commonly affected and is the first clinical site of kaposi 's sarcoma in 20% of cases , while it occurs concomitantly with skin and visceral involvement in up to 70% of patients . within the oral cavity , the hard palate is the most frequently involved , followed by the gingival and buccal mucosa , as well as the dorsum of the tongue . kaposi 's sarcoma - associated herpes virus was proven to be a co - factor in the presentation of kaposi 's sarcoma in patients with hiv . early lesions tend to be red , flat and asymptomatic , with the color becoming darker as the lesion ages . following the diagnosis of kaposi 's sarcoma , oral hygiene is necessary , and topical injections of chemotherapeutic agents , such as vinblastine sulfate , or even surgical removal or radiation therapy can be considered for treatment . systemic chemotherapy should be reserved for patients with both oral and extra - oral kaposi 's sarcoma . non - hodgkin 's lymphoma ( nhl ) is the second most common malignant condition associated with hiv infection . lymphomas present as a focal , ulcerated soft tissue mass on the palate or gingival tissues , which may be red and inflamed . many studies have shown that the chop regimen ( cyclophosphamide , doxorubicin , vincristine and prednisone ) can be considered the standard approach for patients with aggressive nhl in the context of hiv infection . surgical debulking may be required for pain relief and improvement of chewing , swallowing , and speech in large exophytic or pedunculated lesions , whereas radiotherapy may be considered for large lesions which can not be easily accessed . in addition to reactive lymphadenitis , cervical lymphadenopathy may result from tuberculosis , lymphoma , or kaposi 's sarcoma in hiv patients . the term hiv lymphadenopathy describes the presence of diffuse lymphadenopathy in two or more sites of the neck for longer than three months . this can occur in up to 70% of hiv patients within the first few months after seroconversion , even before any other symptoms of hiv infection appear . the lymph nodes are soft and symmetrical , ranging from 1 to 5 cm in diameter . fine needle aspiration is indicated in cases of asymmetry , rapidly enlarged lymph nodes , or any other suspicious features . biopsy under local or general anesthetic may be necessary in cases of high suspicion for lymphoma . it usually involves the parotid glands , tends to be bilateral , sometimes cystic , and can be accompanied by generalized lymphadenopathy . typically , the patient presents with a history of progressive parotid swelling with minimal tenderness over several months . salivary gland enlargement occurs in approximately 3 to 30% of adult patients infected with hiv , and in up to 30% of infected children . clinical examination should include assessment of the characteristics of the mass ( i.e. fixation ) and the function of the facial nerve . the three common causes of parotid enlargement in hiv - infected patients are reactive hyperplasia of an intraparotid lymph node , benign lymphoepithelial lesions with ductal metaplasia , and benign lymphoepithelial cysts . fine - needle aspiration is an effective method of distinguishing benign from malignant parotid lumps . aspiration of the cystic lesions can be of some temporary benefit , and injections of tetracycline and doxycycline have been shown to be successful , although with limitations due to the presence of multiple cysts . alternatively , external irradiation can be considered ( 24 gy in 1.5 gy daily fractions ) , with overall acceptable cosmetic and long - term functional results . it involves all three parts of the ear ( external , middle , inner ) , with a cumulative frequency of 2080% in both adults and pediatric patients . indeed , seborrheic dermatitis has been reported in up to 83% of patients , and usually involves the periauricular area . otitis externa , on the other hand , is usually caused by pseudomonas aeruginosa , whilst candida albicans is often the cause of otomycosis . otalgia is a very frequent symptom in hiv patients , which can be attributed to the disproportionately severe inflammatory changes in the mastoid air - cells even in otherwise asymptomatic carriers . otitis media with effusion secondary to nasopharyngeal lymphoid hyperplasia or other nasopharyngeal masses is also not uncommon in hiv - positive patients . acute otitis media may also occur , but is usually seen in patients with end - stage hiv disease . finally , an increased prevalence of pneumocystis carinii - infected aural polyps has been reported in hiv patients with chronic otitis media . treatment in cases of middle ear infection usually includes broad - spectrum antibiotics , whereas mastoid exploration may be necessary in cases unresponsive to conservative treatment ( figures 1012 ) . please note the difference in the signal on the right ( circle ) compared to the left side . please note the difference in the signal on the right ( circle ) compared to the left side . sensorineural hearing loss , either unilateral or bilateral , occurs in 2149% of hiv - infected patients . most patients show down - slopping hearing loss , usually moderate in the high frequencies , whereas speech discrimination is not significantly affected . this type of hearing loss can not be easily explained , as a histological study of the organ of corti in hiv patients did not reveal any abnormality , except from some cystic changes in the spiral ligament and stria vascularis . possible explanations include the involvement of either retrocohlear pathways , or the cochlear nerve itself . indeed , hiv was shown to induce neuropathological changes and damage to the central nervous system , particularly subcortical demyelination , in a large percentage of infected individuals , even in the absence of gross neurological manifestations . other causes of sensorineural hearing loss such as neoplasms , and ototoxic agents should also be excluded . if the hearing loss affects the patient 's everyday listening activities and quality of life , the provision of digital hearing aids should be considered . hiv patients also tend to experience significant disequilibrium , which is also often clinically attributed to central nervous system pathology . however , inner ear abnormalities have also been reported ( i.e. sub - epithelial elevation of the neurosensory epithelium of the saccule and utricle , inflammatory endolymphatic precipitations ) and may also be important in the pathogenesis of vertigo in these patients . finally , unilateral and bilateral facial nerve palsy is a condition that occurs with a 100-fold greater frequency in the hiv infected population ( 4.1% vs 0.04% ) ( table 2 ) . it may precede the appearance of hiv antibodies , and seems to occur more frequently in hiv carriers than patients with fullblown aids . peripheral facial nerve neuropathy is usually self - limiting , and may either be idiopathic , or due to herpes virus infection ( ramsey hunt syndrome ) . treatment includes acyclovir 800 mg five times daily for seven days , and administration of prednisolone 30 mg once daily for five days , with tapering of the starting dose in three - day intervals . facial nerve palsy can also be seen in end - stage patients either as an isolated entity , or as part of multiple cranial nerve involvement . however , it is usually secondary to opportunistic infections or intracranial tumors . table 2prevalence of hiv - associated ear , nose and throat ( ent ) manifestation in adults and children.common hiv - associated ent manifestationsprevalence in adultsprevalence in childrenoral manifestations  oral candidiasis30 - 90%22.5 - 83.3%  periodontal and gingival disease4%20%  herpes simplex virus infection9%1.3 - 24%  oral hairy leukoplakia0.42 - 38%2%neck manifestations  cervical lymphadenopathy70%70%  parotid gland enlargement3 - 30%30%nasal manifestations  allergic rhinitis70%n.r . sinusitis30 - 68%24%otological manifestations  otitis externa5%4%  otitis media13%46%  snhl21 - 49%n.r . nasal manifestations are not uncommon among hiv patients . indeed , rhinosinusitis seems to occur with a prevalence of 1170% in different studies . although cellular immunity is compromised in aids , studies have shown excessive production of ige , which can be suggestive of allergic rhinitis ( in the absence of active parasitic infections ) . reported a 2-fold increase in the incidence of allergic symptoms in hiv - infected men , which may reach 87% after the infection . treatment is challenging , due to the risk of iatrogenic cushing 's syndrome from the intranasally - administered steroids , in patients receiving ritonavir - containing antiretroviral regimens ( table 3 ) . budesonide is preferred over fluticasone , due to the significantly longer half - life of the latter , whereas montelukast can be successfully used . table 3interactions between commonly administered ear , nose and throat medications and antiretroviral drugs.ent medicationinteraction with antiretroviral drug / potential clinical effectsmanagementitraconazoleinhibition of cyp450 3a4 
 increased darunavir and itraconazole effects when itraconazole is combined with darunavir ( darunavir also inhibits cyp450 3a4)decreased itraconazole effects when combined with didanosine , ( decreased gastric acidity from the antacid buffer contained within didanosine tablets / suspension resulting in decreased itraconazole absorption)decreased itraconazole effects when combined with efavirenz ( efavirenz induces cyp450 3a4)increased indinavir effects when combined with indinavir ( due to cyp450 3a4 inhibition)increased lopinavir / ritonavir and itraconazole effects when combined with lopinavir / ritonavir ( lopinavir / ritonavir also inhibits cyp450 3a4)increased ritonavir effects when combined with ritonavir ( due to cyp450 3a4 inhibition)increased saquinavir and itraconazole effects when combined with saquinavir ( saquinavir also inhibits cyp450 3a4)if co - administration with darunavir is required , the dose of itraconazole should not exceed 200 mg dailyadminister itraconazole capsules at least 2 h after didanosine tablets / suspensiondo not co - administer with efavirenzdecrease indinavir to 600 mg tdsdo not exceed itraconazole 200 mg bdmanufacturer recommends against using high doses of itraconazole ( including drops ) with lopinavir / ritonavir ( 200 mg daily)dose adjustment when combined with ritanovir is not establishedconsider reducing itraconazole to 100 mg bd when combined with saquinavirvoriconazoleinhibition of cyp450 3a4decreased yoriconazole effects when combined with atazanavir/ darunavir ( due to possible induction of cyp450)possibly increased etravirine effects when combined with etravirine : ( due to cyp450 3a4 inhibition)decreased voriconazole levels when combined with lopinavir / ritonavir ( due to possible induction of cyp450 by ritonavir)decreased voriconazole effects when combined with ritonavir ( due to induction of cyp450 3a4)decreased voriconazole effects and increased efavirenz effects when combined with efavirenz ( efavirenz induces cyp450 3a4)do not co - administer with atazanavir/ darunavirno dose adjustment is necessary when combined with etravirinedo not co - administer with lopinavir / ritonaviravoid co - administration with ritonavirdo not co - administer with efavirenz at standard doses ; increase voriconazole to 400 mg bd , and decrease efavirenz to 300 mg qhsfluconazoleinhibition of cyp450 3a4increased etravirine , nevirapine , saquinavir , tipranavir , zidovudine effectsno dose adjustment necessaryketoconazoleinhibition of cyp450 3a4increased darunavir and ketoconazole effects when ketoconazole is combined with darunavir ( darunavir also inhibits cyp450 3a4)increased delavirdine effects when combined with delavirdine ( due to cyp450 3a4 inhibition)when combined with didanosine , possibly decreased didanosine effects ( decreased gastric acidity from the antacid buffer contained within didanosine tablets / suspension resulting in decreased ketoconazole absorption)decreased ketoconazole effects when combined with efavirenz ( efavirenz induces cyp450 3a4)increased indinavir effects when combined with indinavir ( due to cyp450 3a4 inhibition)when combined with lopinavir / ritonavir , increased ketoconazole effects , and decreased lopinavir / ritonavir effectsincreased maraviroc effects when combined with maraviroc ( due to cyp450 3a4 inhibition)increased nelfinavir effects when combined with nelfinavir ( due to cyp450 3a4 inhibition)decreased ketoconazole effects when combined with nevirapine ( nevirapine induces cyp450 3a4)decreased ketoconazole effects when combined with rilpivirineincreased ritonavir/ saquinavir effects when combined with ritonavir/ saquinavir ( due to cyp450 3a4 inhibition)dose adjustment when combined with darunavir is not establishedif co - administration is required , the dose of ketoconazole should not exceed 200 mg dailyno dose adjustment necessary when combined with delavirdineconsider didanosine ecadminister ketoconazole at least 2 h prior to didanosine tablets / suspensiondo not co - administer with efavirenzconsider decreasing indinavir to 600 mg tdsmanufacturer recommends against using high doses of ketoconazole ( including drops ) with lopinavir / ritonavir ( 200 mg daily)reduce maraviroc dose to 150 mg bd when used with ketoconazolno dose adjustment necessary when combined with nelfinavirdo not co - administer with nevirapineno dose adjustment necessary when combined with rilpivirine , but monitoring for potential failure of antifungal therapy is requireddose adjustment when combined with ritonavir/ saquinavir is not establishedcyp450 , cytochrome p450 enzyme complex - family 3-subfamily a - polypeptide 4 ; bd , twice daily ; tds , every 8 h ; qhs , at bedtime . cyp450 , cytochrome p450 enzyme complex - family 3-subfamily a - polypeptide 4 ; bd , twice daily ; tds , every 8 h ; qhs , at bedtime . in addition to compromised immunity , impaired mucocilliary clearance has also been reported , and can be held accountable for the high prevalence of rhinosinusitis in hiv patients . there is no difference in bacteriology compared with the general population , including streptococcus pneumoniae , haemophilus influenzae , moraxella catarrhalis , and streptococcus viridans in acute episodes , whereas staphylococcus aureus , staphylococcus epidermidis , and anaerobes are seen in chronic cases . however , atypical bacteria can also play an important role and need to be considered in the treatment of these patients , especially in cases of decreased cd4 count ( i.e. alternaria alternata , aspergillus , pseudallescheria boydii , cryptococcus , candida albicans , acanthamoeba castellani , microsporidian , and legionella pneumophila ) . standard outpatient medical therapy with oral antibiotics for three weeks and nasal decongestants are often sufficient . in chronic cases , oral antibiotics in cases of acute infection include amoxicillin ( standard or high doses ) , co - amoxiclav ( standard or high doses ) , or cefuroxime . trimethoprim / sulfamethoxazole or macrolides can be used in -lactam - allergic patients , but failure rates are higher . if the response to antibiotic therapy is partial , or when the cd4 count is less than 200 cells per mm , and in cases of chronic infection , the coverage should be broadened to include pseudomonas , staphylococci , and anaerobic species . appropriate oral treatment in these cases includes the combination of fluoroquinolone and clindamycin or metronidazole . the combination of two antimicrobial agents with activity against pseudomonas aeruginosa was shown to improve mortality in patients with hiv with pseudomonas infection , compared with monotherapy . patients with persisting symptoms require nasal endoscopy with culture of the obtained swabs , and a ct scan of the sinuses , with the view of performing endoscopic drainage ; intravenous antibiotics can also be used . patients with no improvement after maximal medical treatment can be considered candidates for functional endoscopic sinus surgery , especially when anatomic variations of the nasal and paranasal cavities which predispose to sinus disease are present . furthermore , surgical management is required in cases of invasive fungal sinusitis , with debridement of infected bone and tissue , correction of the conditions that predispose to infection , and antifungal medication . the use of liposomal amphotericin b which shows increased cure rates and decreased drug toxicity , compared with conventional amphotericin b therapy , should be preferred . washings with solutions containing amphotericine - b and water for injection may also prove useful . hiv is a global pandemic that affects millions of adults and children in the developed and developing countries . the prevalence of hiv has risen by 27% compared to the previous decade , although the annual rate of new cases had been steadily declining since the late 1990s . up to 80% of hiv - infected patients eventually develop ent manifestations . among ent manifestations , oral disease seems to be the most common , occurring in approximately 4050% of hiv positive patients . clotrimazole troches , nystatin oral suspension , and nystatin pastilles can be used in the treatment of mild to moderate cases , whereas systemic administration of fluconazole , intraconazole and voriconazole is warranted in moderate to severe cases . oral hpv infection has also increased in the era of haart therapeutic regimens , suggesting that a drug or combination of drugs used to treat hiv may be a risk factor for the former . kaposi 's sarcoma is still the most common oral malignancy seen among patients with hiv . this requires oral hygiene and topical injections of chemotherapeutic agents ; surgical removal or radiation therapy can also be considered for treatment . hiv lymphadenopathy may be the result of reactive lymphadenitis , tuberculosis , lymphoma , or kaposi 's sarcoma , and is the most common manifestation of hiv infection in the neck . salivary gland disease is also not uncommon , but its treatment still remains controversial in the presence of hiv disease . superficial parotidectomy has been proposed , and external irradiation seems to provide overall acceptable cosmetic and long - term functional results . acute otitis media is usually seen in patients with end - stage hiv disease and usually requires broad - spectrum antibiotics . hiv patients also tend to experience a 100-fold greater frequency of unilateral and bilateral facial nerve palsy , which usually requires treatment with acyclovir and prednisolone ( in a tapered dosologic regimen ) . although there is no difference in the bacteriology of rhinosinusitis compared with the general population , atypical bacteria can also play an important role and need to be considered in patient treatment , especially in cases of decreased cd4 count . oral antibiotics in cases of acute infection include amoxicillin , coamoxiclav , or cefuroxime , whereas trimethoprim / sulfamethoxazole or macrolides can be used in cases of allergy . in cases of chronic infection or low cd4 count patients with no improvement after maximal medical treatment , and cases of invasive fungal sinusitis are considered candidates for functional endoscopic sinus surgery . although ent symptoms are not diagnostic of the disease , they might be suggestive of hiv infection , or related to its progression and the respective treatment failure . in the era of haart ent manifestations of hiv it is important that ent doctors are aware of the ent conditions associated with hiv disease , and the respective diagnosis and treatment . a multi - disciplinary approach may be required to provide the appropriate level of care to hiv patients .
almost 30 years after its first description , hiv still remains a global pandemic . 
 the present paper aims to review the current knowledge on the ear , nose and throat ( ent ) manifestations of hiv infection , and present the available diagnostic and treatment options . 
 a literature review was conducted in medline and other available database sources . 
 information from related books was also included in the data analysis . 
 it is well acknowledged that up to 80% of hiv - infected patients eventually develop ent manifestations ; among which , oral disease appears to be the most common . 
 oro - pharyngeal manifestations include candidiasis , periodontal and gingival disease , hsv and hpv infection , oral hairy leucoplakia , kaposi 's sarcoma , and non - hodgkin 's lymphoma . 
 ent manifestations in the neck can present as cervical lymphadenopathy or parotid gland enlargement . 
 respective nasal manifestations include sinusitis ( often due to atypical bacteria ) , and allergic rhinitis . 
 finally , otological manifestations include otitis ( externa , or media ) , inner ear involvement ( sensorineural hearing loss , disequilibrium ) , and facial nerve palsy ( up to 100 times more frequently compared to the general population ) . 
 although ent symptoms are not diagnostic of the disease , they might be suggestive of hiv infection , or related to its progression and the respective treatment failure . 
 ent doctors should be aware of the ent manifestations associated with hiv disease , and the respective diagnosis and treatment . 
 a multi - disciplinary approach may be required to provide the appropriate level of care to hiv patients .