Oral cavity and oropharyngeal tumors in human immunodeficiency virus-positive patients: acute response to radiation therapy.

BACKGROUND: The survival of patients with human immunodeficiency virus (HIV) has improved considerably with modern medical management. However, there remains surprisingly little information on treating head and neck neoplasms in HIV-positive patients. OBJECTIVE: To report our recent experience treating oral cavity and oropharyngeal tumors in HIV-positive patients. DESIGN AND PATIENTS: Retrospective analysis of a cohort of 8 HIV-positive patients with Kaposi sarcoma (KS), lymphoma, or squamous carcinoma of the oral cavity or oropharynx who were consecutively treated during a single year with radiation therapy at a tertiary care referral center. Length of follow-up was at least 2 years (mean, 2.5 years). RESULTS: All patients had partial and complete responses to treatment lasting until the last follow-up. However, we found that treatment was considerably better tolerated by patients with non-KS tumors, with fewer acute reactions and significantly less weight loss, despite larger treatment volumes and higher radiation doses, compared with patients with KS. Patients with non-KS tumors received a mean radiation dose of 62.6 Gy to 2636 cm3, yet lost only a mean of 0.1 kg in weight, whereas patients with KS were treated with a mean radiation dose of 19 Gy to a mean volume of 568 cm3, but lost a mean of 5.8 kg during treatment (P = .005) and on average sustained an additional grade of severity on a standard scale of mucosal reaction (P = .01). CONCLUSIONS: Oral cavity and oropharyngeal tumors in HIV-positive patients respond to radiation therapy, but there is a marked difference in the degree of acute reactions to treatment between patients with and without KS. Infection with HIV is not a contraindication when aggressive radiation therapy is needed in select patients.     

Bilateral tonsillar and esophageal Kaposi sarcoma in an HIV-negative patient

Tonsillar involvement in Kaposi sarcoma is extremely rare, as only a few such cases have been reported; all but 1 of these previously reported cases occurred in patients with human immunodeficiency virus (HIV) infection. We describe what to the best of our knowledge is the first reported case of concurrent bilateral tonsillar and esophageal Kaposi sarcoma in an HIV-negative patient. A 68-year-old man presented with sore throat and dysphagia. Clinical examination revealed the presence of bilateral and asymmetrical tonsillar masses, as well as generalized lymphadenopathy in the cervical chain. The masses were resected, and findings on histopathologic analysis were consistent with Kaposi sarcoma. In addition, human herpesvirus 8 was demonstrated on a tonsil specimen by polymerase chain reaction, and microinvasive squamous cell carcinoma was also detected. Later, another Kaposi sarcoma lesion was detected in the lower third of the esophagus. We recommend that clinicians not discount the possibility of oral classic Kaposi sarcoma in the workup of an immunocompetent patient with oral vascular lesions.     

Can acquired immunodeficiency syndrome and Creutzfeldt-Jakob disease be transmitted via otologic homografts?

Materials commonly employed in the preparation of otologic homografts such as ethanol and formaldehyde are effective in vitro in inactivating human immunodeficiency virus (HIV). However, to our knowledge, the complete permeation of homograft materials with preservative has not been demonstrated. Ethanol and formaldehyde have not been shown to be effective in inactivating the Creutzfeldt-Jakob agent. The literature on sterilization procedures for these agents is reviewed. Standard procedures for preparation of otologic homografts are examined. It is recommended that donor HIV serologic status be determined when otologic homografts must be used. Further research is required to determine the efficacy of otologic homograft sterilization techniques against HIV and Creutzfeldt-Jakob disease.     

The association between sinusitis and survival among individuals infected with the human immunodeficiency virus.

The purpose of this study was to determine the association between sinusitis and survival among human immunodeficiency virus (HIV)-infected persons. All patients enrolled in the adult spectrum of disease data base from November 1, 1990 to November 1, 1999 were included. Patients were followed until death, loss to follow-up, or the end of the study on January 10, 2000. A Cox proportional hazard regression analysis was conducted to evaluate the association between sinusitis, various other cofactors, and survival. Of the 7513 HIV-infected patients followed, 57% were <35 years old, 59.5% were black, 78.5% were male, and 20.8% had an opportunistic infection (OI) at entry. The incidence of one or more diagnoses of sinusitis in the cohort was 14.5%. The mean entry CD4 count for the entire cohort was 347.8 (SD, 298.9) and the mean follow-up time was 33.2 months (SD, 25.7). The mean CD4 count at the time of sinusitis diagnosis was 391 (SD, 316). In the multivariate analysis, older age and lower CD4 cell count were associated with death. Sinusitis, gender, and race were not associated with survival. Sinusitis is frequent in individuals infected with HIV. After adjusting for level of immunodeficiency, age, gender, and race, sinusitis is not associated with an increased hazard of death. This may have implications for treatment, because a diagnosis of sinusitis does not portend a poor prognosis in individuals infected with HIV.     

Otologic pathophysiology in patients with human immunodeficiency virus

During the initial phase of clinical diagnosis and treatment of the manifestations of acquired immunodeficiency syndrome, involvement of the ear appeared minor. In the past several years, however, otologic disorders increasingly have been reported in individuals with human immunodeficiency virus (HIV), as well as in retrospective studies of such patients. The otologic data appear quite variable. Functionally, conductive hearing loss, unilateral and bilateral sudden or progressive sensorineural hearing losses, vertigo, and tinnitus have been reported. In addition, tissue responses in each division of the ear have been observed. Based on collective serologic and immunologic diagnostic assays, clinical histories, and temporal bone histopathology, otologic symptoms may not be the direct effect of HIV alone, but rather a combination of the effects of HIV infection coupled with that of opportunistic microorganisms and/or possible ototoxic effects of certain therapeutic agents. It is within this context that otologic findings in this population of subjects will be discussed.     

Tuberculosis in the upper aerodigestive tract and human immunodeficiency virus coinfections

OBJECTIVE: To describe the clinical manifestations of tuberculosis in the upper aerodigestive tract. DESIGN: Retrospective chart analysis. SETTING: Srinagarind Hospital, Department of Otolaryngology, Faculty of Medicine, Khon Kaen University, Khon Kaen, Thailand. METHODS: A review of medical records of patients diagnosed with mycobacterial infection of the upper aerodigestive tract between January 1991 and December 2000. MAIN OUTCOME MEASURES: Presenting symptoms, clinical findings, pathologic findings, pulmonary involvement, and outcome of treatment. RESULTS: Forty-five patients presented with upper aerodigestive tract tuberculosis. The nasopharynx was involved in 23 patients, the larynx in 16, the tonsils in 6, and the soft palate in 1. One patient had tuberculous infections in both the nasopharynx and tonsils. The mean duration of symptoms before diagnosis was 2.1 months. The pathologic findings included caseous granuloma and/or positive acid-fast bacilli (AFB) in 39 cases and chronic granulomatous inflammation with negative AFB in 6 cases. Pulmonary tuberculosis was found in 19 of the 36 patients who underwent radiography. A positive serologic test for human immunodeficiency virus (HIV) infection was found in 4 of 26 patients. These 26 patients, who received a full course of treatment, responded well. CONCLUSION: The most common site of tuberculosis in the head and neck involved the cervical lymph nodes and nasopharynx. Upper aerodigestive tract tuberculosis is difficult to differentiate from carcinoma; thus, tissue biopsy is necessary for a definite diagnosis. Chest radiography and screening for HIV infection are recommended in all patients with upper aerodigestive tract tuberculosis.     

The comparison of the pathological data of oropharyngeal masses between HIV and non-HIV patients

Conclusion: Although this study did not show higher risk of oropharyngeal malignancy in HIV patients overall, they still had much higher prevalence of NHL as well as HL than HIV negative patients. Presence of cervical lymphadenopathy is unreliable in differentiating malignant oropharyngeal tumours from benign lymphoid hyperplasia in HIV patients.

Objectives: The aim of this study was to compare the histology of oropharyngeal masses between HIV positive and negative patients.

Methods: A retrospective review of 119 patients who underwent oropharyngeal biopsies in a tertiary institution between 2007–2014 and whose HIV status was known (HIV positives =47; negatives =72).

Results: Malignancies occurred in 63.8% of HIV patients and 65% of the negative group (p?=?0.87). While non-Hodgkin’s lymphoma (NHL), squamous cell carcinoma (SCC), and Hodgkin’s lymphoma (HL) constituted 40%, 27%, and 17% of malignancies in HIV patients, respectively; in the HIV-negative group, it was 53%, 13%, and 2% for SCC, NHL, and HL, respectively (p?=?0.039, 0.017, and 0.035, respectively). Reactive lymphoid proliferation accounted for 82.4% of the benign masses in the HIV positive group. Malignant tumours were recorded more in younger patient in the HIV positive than the negative group (p?=?0.001).     

Early ENT manifestations of HIV infection/AIDS. An analysis of 76 cases observed in Africa

OBJECTIVE: The aim of this work is to describe the ENT clinical manifestations by which HIV positive patients inaugurate their AIDS-illness and to classify these manifestations in respect to the biological state of the infection. MATERIAL AND METHOD: It was a multicenter, prospective study carried out in the ENT services of Yaounde (Cameroon), between the period of September 2000 and June 2002. Included in this study were HIV patients who started their AIDS with an ENT illness. The stage of evolution of the HIV infection was evaluated using the CD4 and CD8 T lymphocyte counts. This was carried out using the Flux cytometric technique of Fascount/Becton. RESULTS: We thereafter recruited 76 patients. The incidence rate of ENT early manifestations in HIV positive patients was 11.5%. Pharyngeal and oral candidosis represented the most observed manifestation (30.60%), followed by peripheral facial paralysis (11.13%) and rhino-sinusitis (10.58%). Parotid gland hypertrophy represented 8.23% of the affections. Persistant cervical lymphadenopathy was observed in 7.05% of cases. Kaposi sarcoma and cervical lymph node tuberculosis represented each 3.53% of cases of the sample. The correlation of lymphocytic count and initial ENT manifestations showed that these manifestations were observed in all the biological states of the HIV/AIDS infection. CONCLUSION: The above mentioned ENT manifestations in the patient should motivate the request of the HIV screening tests.     

Parotid localized Castleman’s disease and HHV-8 infection: a case report

Castleman’s disease (CD) is an unusual massive proliferation of lymphoid tissue distinct in two clinical forms, localized and multicentric. The multicentric form has been related to human herpesvirus 8 (HHV-8), especially in HIV-infected patients, whereas the localized form of CD is still unrelated to viral pathogens. We report a case of a HIV-negative 16-year-old male referred to our hospital with a 12-month history of a painless swelling in his right parotid region. A parotidectomy was performed, and histological analysis evidenced a localized CD. The search for HHV-8 revealed an active virus infection. The patient was commenced on corticosteroid therapy and a follow-up was performed every 6 months. The patient was commenced on corticosteroid therapy and there has been no recurrence after 24 months. The authors report a case of localized parotid CD in a patient with evidence of an active HHV-8 infection. The results of this study does for the first time suggest an association between HHV-8 and localized CD in HIV-negative subjects.     

Kaposi's sarcoma of an intraparotid lymph node leading to a diagnosis of HIV

OBJECTIVE: Kaposi's sarcoma is a common malignancy in patients infected with HIV but is rarely seen in the major salivary glands. If a patient is known to be HIV-positive, however, Kaposi's sarcoma must be considered in the differential diagnosis of salivary gland masses in addition to the benign and malignant neoplasms that occur in immunocompetent patients. We present a unique case in which an otherwise healthy patient was diagnosed with HIV after resection of his enlarged parotid gland revealed Kaposi's sarcoma. STUDY DESIGN: Case report. METHODS: A 58-year-old man presented with slowly enlarging bilateral parotid masses of approximately 3 years' duration. The patient's presentation, workup, and final diagnosis of Kaposi's sarcoma are discussed. RESULTS: A magnetic resonance imaging scan of the neck showed two right parotid lesions and one left parotid mass. The patient underwent a right superficial parotidectomy for a suspected diagnosis of Warthin's tumor, given the bilaterality of the lesions. Histologic evaluation of the surgical specimen revealed spindle-shaped cells with extravasated erythrocytes typical of Kaposi's sarcoma. After discussion of the results with the patient, HIV risk factors were elucidated, and subsequent testing revealed the patient to be HIV-positive. CONCLUSIONS: Although Kaposi's sarcoma is common in AIDS patients, there are few case reports of this malignancy arising in the salivary glands. Previously reported cases include salivary gland Kaposi's sarcoma in known HIV-positive patients and a handful of reports in patients without confirmed immunocompromise. The patient presented here is unique because the diagnosis of parotid gland Kaposi's sarcoma led to a new diagnosis of HIV. This interesting case reiterates the need for complete history taking and the inclusion of Kaposi's sarcoma in the differential diagnosis of salivary gland masses in the appropriate patient population.     

Kaposi's sarcoma and community-acquired immune deficiency syndrome

Kaposi's sarcoma (KS), or idiopathic multiple hemorrhagic sarcoma, has heretofore been considered an indolent disease of the elderly, which also occurs in immunosuppressed hosts. Within the last two years, an epidemic of a community-acquired immune deficiency syndrome (AIDS) and disseminated KS has been reported in various population groups across the United States. The head and neck manifestations of KS in AIDS and our experience at UCLA are reviewed. Of 45 patients with AIDS, 18 (40%) had initial disease in the head and neck region. Most commonly, dermal lesions (44%), oropharyngeal lesions (39%), and cervical lymphadenopathy (33%) were noted. One patient had coexistent lymphoma. Six patients (33%) died of opportunistic infections. Head and neck lesions often herald more extensive disease. Early recognition of AIDS is important for complete patient evaluation as well as for personal safety.     

Oropharyngeal plasmablastic lymphoma in a man with human immunodeficiency virus infection: A case report

Oropharyngeal lymphomas are rare, typically high-grade neoplasms. We describe a case of plasmablastic lymphoma that originated in the oropharynx of a 40-year-old man who was positive for human immunodeficiency virus (HIV). The diagnosis was based on fine-needle aspiration cytology of the mass followed by histopathologic examination supplemented with immunophenotyping. The mass was excised, but the patient refused antiretroviral therapy, and he died within 6 months of the diagnosis. In HIV-positive patients, non-Hodgkin lymphomas frequently involve sites, including the oropharynx, that are unusual in patients without HIV.     

Classic (Mediterranean) Kaposi’s sarcoma of the true vocal cord: a case report and review of the literature

Kaposi’s sarcoma (KS) is a rare subcutaneous lesion linked mainly with patients suffering from acquired immunodeficiency syndrome. The aim of the present study is to present the first documented case of classic Kaposi’s sarcoma (CKS) located in the right true vocal cord. A 62 year old male presented with cough and hoarseness for 2 months. Clinical examination revealed a nodule on the right vocal cord. The patient underwent surgery and the lesion was removed and biopsied. The histopathology report showed that the lesion was KS but with no complete removal of the lesion, since the surgical margins of the nodule were not healthy. The patient, although fully informed, refused any further treatment. Further laboratory tests were performed, revealing an HIV-negative immunodeficiency profile. Although (Mediterranean) CKS is not an aggressive malignancy, surgery with complete removal of the affected area is indicated when it is applicable. Moreover, conservative treatment and follow up of the patient is essential in order to prevent relapse or other primary lesions.     

Upper airway obstruction due to tonsillar lymphadenopathy in human immunodeficiency virus infection

Head and neck manifestations of human immunodeficiency virus (HIV) infection are common and include diffuse cervical lymphadenopathy, cutaneous and mucosal Kaposi's sarcoma, mucosal herpes simplex infection, upper aerodigestivetractcandidiasis, and parotidlymphadenopathy and cysts. Recurrent otitis media and chronic sinusitis have been noted in the pediatric HIV population. We describe a patient with HIV-associated tonsillar and adenoid lymphadenopathy and upper airway obstruction. Pathologic analysis of the tonsillar tissue revealed severe lymphofollicular hyperplasia similar to that of other lymphoid tissue in HIV infection. The importance of symptomatic treatment of the airway obstruction is stressed.     

Transoral robotic surgery using an image guidance system

Objectives: To describe a novel technique using the image guidance system for transoral robotic surgery of the pharyngeal and parapharyngeal spaces. Study Design: Case series presentation. Methods: Three cases of oropharyngeal and pharyngeal space lesions are reviewed for presentation, workup, and original management. Results: Final pathology of a vascular malformation, an acinic cell adenocarcinoma, and a squamous cell carcinoma were located and minimally invasively removed by a transoral robotic approach with the aid of image guidance. No complications or recurrences were observed on an average of 7 month follow‐up. Conclusions: Transoral robotic surgery using an image guidance system seems safe and effective in assisting dissection.     

Tularemia is becoming increasingly important as a differential diagnosis in suspicious neck masses: experience in Turkey

Neck mass can be an initial finding of many diseases at any age. The differential diagnosis is broad and includes inflammatory, congenital and neoplastic lesions. We retrospectively analyzed charts of the 145 patients with neck mass and without known primary malignancy whose diagnoses were confirmed with histopathologic and serologic examination between July 2003 and July 2008. Twenty-six patients (17.9%) were diagnosed with tularemia. Before 2004, serologic testing for tularemia was not a part of our workup for patients with an inflammatory neck mass. Otolaryngologists should be familiar with head and neck manifestations of tularemia and consider the disease in the differential diagnosis of neck masses. The tularemia outbreak in central Black Sea region, Turkey in 2004 changed our approach to a patient presenting with neck mass.     

Parotid mass as an early sign of Kaposi's sarcoma associated with human herpesvirus 8 infection

Kaposi's sarcoma of an intraparotid lymph node is extremely rare in non-immunocompromised human immuno-1 deficiency virus (HIV)-negative patients. We report a case of a left parotid mass as an early sign of Kaposi's sarcoma-associated human herpesvirus 8 (HHV-8) infection in a 57-year-old patient. After subtotal parotidectomy and histopathological diagnosis of lymph node localization of Kaposi's sarcoma, an accurate dermatological investigation revealed a solitary small lesion in the left foot. Chemotherapy with five cycles of vincristine gave a temporary response of the cutaneous lesion. Seven months later, a few small, firm, purplish-red lesions appeared in different areas of the body, but no adjuvant treatment was accepted by the patient since the lesions occasionally disappeared or remained stable in size. At four years follow-up, there has been no recurrence in the parotid region, and the patient is alive with cutaneous disease but in good general health. The problems related to the diagnosis, the management strategy of such a rare condition and the prognosis are also discussed.     

Detection of HHV-8 and HPV in laryngeal carcinoma

OBJECTIVE: In this study we aimed to investigate the presence of human herpesvirus 8 (HHV-8) and human papillomavirus (HPV) in laryngeal carcinoma. MATERIALS AND METHODS: Fifty patients operated on because of laryngeal carcinoma were included in the study. Forty-seven had squamous cell carcinoma (SCC) whereas three had verrucous carcinoma. Fresh tumoral tissues, or tumoral tissues obtained from archival paraffin-embedded blocks, were examined. HHV-8 DNA and HPV DNA were detected using polymerase chain reaction (PCR) and viral genotypes of HPV were determined via the hybrid capture method. The presence of HHV-8 DNA and HPV DNA were also investigated in normal appearing laryngeal tissue collected from 50 cadavers at autopsy. RESULTS: HPV DNA was detected in seven patients (7/50; 14%) (5 out of 47 patients with SCC (5/47; 10.6%) and two out of three patients with verrucous carcinoma). HHV-8 DNA was detected in five patients and they all had SCC (5/47; 10.6%). One case had both HHV-8 and HPV DNA. None of the control samples from cadavers harbored HHV-8 DNA, or HPV DNA. There was a statistically significant correlation between HHV-8 DNA and HPV DNA positivity and laryngeal SCC (Fisher exact test; p=0.023 for each). No statistically significant correlations were found between the presence of HHV-8 and/or HPV and age, gender, tumor stage, differentiation, the site of the tumor, smoking and alcohol use. CONCLUSIONS: The findings of the present study suggest that beside HPV, HHV-8 might have a role in laryngeal carcinogenesis. Further investigations are necessary to clarify the exact role of these viruses in laryngeal carcinoma.     

HIV infection initially presenting as sinonasal Burkitt's lymphoma

Burkitt's lymphoma is a common comorbidity of infection with the human immunodeficiency virus, but rarely the initial clinical manifestation of undiagnosed AIDS, especially for the otolaryngologist. We report the case of a patient with recalcitrant rhinosinusitis subsequently diagnosed with sinonasal Burkitt's lymphoma and HIV.     

Prevalence of sinonasal symptoms in patients with HIV infection.

Infection with the human immunodeficiency virus (HIV) is increasing in prevalence, and disease patterns are changing as patient survival lengthens. The purpose of this cross-sectional epidemiological study was to assess the prevalence and severity of self-reported symptoms of otolaryngologic disease in a group of patients attending a general HIV outpatient clinic (n = 203), and to compare the prevalence of self-reported symptoms with a sample of patients without HIV infection (n = 100). Of the HIV-infected patients, 65% of patients had AIDS, 35% were HIV-positive, and the median CD4 count was 135. Although only 11% of patients had seen an otolaryngologist in the prior 6 months, the majority of patients (66%) reported the presence of sinonasal disease during that time. Allergic rhinitis (80%) and sinusitis (54%) were the most commonly reported sinonasal symptoms, and 44% regularly used nasal or sinus medications. Sinonasal disease severity was significantly higher than the self-reported severity of mouth/throat disease (p = 0.01), ear disease (p = 0.03), and neck/salivary disease (p = 0.01). Although patients' self-reported overall health status was associated (p = 0.02) with CD4 count, the severity of sinonasal symptoms was not associated (p = 0.93) with CD4 count. Similarly, sinonasal symptom severity did not differ between HIV-positive and AIDS patients (p = 0.45). In other words, sinonasal disease severity did not improve as general health status improved.