Seropositivi1\!, adenoid hvperfrophv and secretory otitis media in adults-A recognized clinical entity Luanshya, Zambia
SHAILESH DHIRUBHAI DESAI, Master of Surgery (Otorhinolaryngology),
Otolaryngologlc manifestations of AIDS have been described In the past. In this study, I had examined 14 adults with nasal obstruction and mouth breathing. Nine patients also reported deafness-unilateral In three of them and bilateral In six. All of them revealed a mass In the nasopharynx, either on the posterior rhinoscopy or the x-ray neck-lateral view. To exclude nasopharyngeal malignancy, all of the patients underwent examination of the nasopharynx while under general anaesthesia and biopsy. The histopathologic diagnosis In every patient was nonspecific, reactive lymphoid hyperplasia, which has been described In the background of HIV Infections. Four were already confirmed HIV-posltlve and 10 were found positive on the HIV antibody test. A strong association was established between seropositivity, adenoid hypertrophy, and secretory otitis media In adults. (OTOLARYNGOL HEAD NECK SURG 1992:107:755.) METHODS AND MATERIAL
A 3-year review was undertaken of 14 adults who manifested nasal blockage and mouth breathing. Nine of these patients also reported deafness: The study was done in the ENT clinics at various Zambia Consolidated Copper Mines (ZCCM) hospitals in the Copperbelt of Zambia. All underwent routine ENT examination. The patients with nasal polyposis, deviated nasal septum, hypertrophied inferior turbinates, and nasopharyngeal malignancy were excluded from the study. All had examination of the nasopharynx while they were under general anaesthesia and biopsy. Myringotomies were performed in patients with secretory otitis media. The histopathologic diagnosis was nonspecific and HIV-related. The HIV antibody test was requested for each of the 14 patients to establish the association between seropositivity, .adenoid hypertrophy, and secretory otitis media. RESULTS
The age range of the patients was from 18 to 51 years. There were eight men and six women (Table 1).
The main presenting symptoms in this study were
From the Zambia Consolidated Copper Mines Limited, Luanshya Mine Hospital. Received for publication June 5, 1992; accepted Sept. 28, 1992. Reprint requests: Shailesh Dhirubhai Desai, Master of Surgery, Zambia Consolidated Copper Mines Limited, Luanshya Mine Hospital, P.O. Box 90098, Luanshya, Zambia. 23/1/42946
o
nasal obstruction, mouth breathing, and deafness (Table 2). The posterior rhinoscopy revealed a pinkish, adenoid-like mass in 10 cases. In four patients, posterior rhinoscopy was not possible, even after the local anaesthetic spray. All had x-ray neck, lateral view, which showed a nasopharyngeal mass (Fig. 1). Nine patients with deafness had clinical evidence of secretory otitis media on ear examination. The tuning fork tests and audiometry confirmed the conductive deafness. Tympanometry was not carried out because of breakdown of the equipment. The rest of the ENT examination was nonsignificant. The distribution of clinical findings is shown in Table 3. The examination of nasopharynx while patients were under general anaesthesia confirmed the adenoid-like mass in all of the patients. The biopsy was taken to rule out nasopharyngeal malignancy. On myringotomies, seven patients had fluid in the middle ear, two were dry. Grommets were inserted in only four cases because of nonavailability and high price of grommets. The histopathologic diagnosis of nonspecific follicular and parafollicular lymphoid hyperplasia was established in all the patients. Because of high index of suspicion, I decided to establish the HIV status of the patients. Four were already confirmed seropositive as a result of other HIV-related ailments. Ten patients tested positive on the HIV antibody test. DISCUSSION
Otorhinologic manifestations of AIDS have been described in the past. Abrams' described sinus congestion, pharyngitis, herpes labialis, thrush,
755
756
Otolaryngology Head and Neck Surgery
DESAI
Table 1. Age and sex distribution of the patients Age In years 0-9
10-19
20·29
30-39
2 1
3
Male Female
4
40-49
50-59
2
Table 2. Distribution of symptoms In 14 patients Symptoms
Nasal obstruction and mouth breathing Deafness
No. 01 patients (%1
14 (100%) 9 (64.2%)
Table 3. Distribution of the clinical findings In 14 patients Clinical IIndlng
Mass in the nasopharynx on posterior rhinoscopy Presence of mass on x-ray neck lateral view Evidence of secretory otitis media
No. 01 patients (%1
10* (71.4%) 14 (100%) 9 (64.2%)
"Posterior rhinoscopy was not possible in the other four patients.
Fig. i. X-ray of the neck: lateral view shows a nasopharyngeal mass.
and hairy leukoplakia, in relation to AIDS. Poole et al.' reported a case of a 25-year-old male homosexual with AIDS who had eNS toxoplasmosis, mucosal candidiasis, recurrent otitis media, and purulent sinusitis. Cytomegalovirus ulceration of the oropharynx in both iatrogenic and HIV-induced immunosuppression has been documented.' Desai et al.' also reported a case of laryngeal granuloma-an unusual presentation of AIDS. Kaposi's
sarcoma of the palate and severe hypertrophy of the tonsils have been observed in relation to HIV infections. The findings reported here establish a strong association between seropositivity, adenoid hypertrophy, and secretory otitis media in adults. To my knowledge, there have been no previous reports on the above triad of clinical features. The adenoids grow rapidly until a child reaches about the age of 6 years of age, after which time it usually shows retrogressive changes.' Adenoid hypertrophy in adults was the unusual feature of this study. Any mass in the nasopharynx tends to produce obstruction to the nasal airway, and there may also be obstruction of the eustachian tube, with conductive deafness and secretory otitis media." Malignant neoplasms of the nasopharynx account for occasional cases of secretory otitis media in adults.' To exclude nasopharyngeal malignancy, the patients underwent examination of the nasopharynx under general anaesthesia and biopsy. The biopsy result in all of them showed nonspecific follicular and parafollicular lymphoid hyperplasia, whicfi has been described in relation to HIV infections."
Volume 107 Number 6 Port 1 December 1992
Seropositivity, adenoid hypertrophy, and secretory otitis media In adults
All had been found to be seropositive and the strong association was confirmed between seropositivity, adenoid hypertrophy, and secretory otitis media in adults. I would like to thank Mr. G. K. Chibuye, the General Manager of ZCCM Luanshya Division; Dr. H. Sensenta, the Chief Medical Officer for facilitation of the study; Dr. R. G. Goel, for confirming the histopathologic diagnosis, Dr. C. K. Patel, for the radiologic report; and Mrs. Patricia Matafwali, for preparation of the manuscript. REFERENCES
1. Abrams DI. Lymphadenopathy related to the acquired immune deficiency syndrome in the homosexual men. Med Clin North Am 1986;70:693-706. 2. Poole MD, Postma D, Cohen MS. Pyogenic otorhinologic infections in acquired immune deficiency syndrome. Arch Otolaryngol 1984;110:130-1. .
757
3. French PD, Birchall MA, Harris JRW. Cytomegalovirus ulceration of the oropharynx. J Laryngol Otol 1991;105:739-42. 4. Desai SD, Rajratnam K. Laryngeal granuloma-an unusual presentation of AIDS. J Laryngol Otol 1988;102:372-3. 5. McNab Jones RF. Anatomy of the mouth, pharynx, and oesophagus. In: Ballantyne J, Groves J, eds. Scott-Brown's diseases of the ear, nose, and throat. Vol. 1. 4th ed. London: Butterworths & Co, Ltd., 1979:263-311. 6. Ranger D. Tumours of the pharynx. In: Ballantyne J, Groves J, eds. Scott-Brown's diseases of the ear, nose, and throat, Vol. 4. 4th ed. London: Butterworths & Co, Ltd., 1979:171-206. 7. Gibb AG. Nonsuppurative otitis media. In: Ballantyne J, Groves J, eds. Scott-Brown's diseases of the ear, nose, and throat, Vol. 2. 4th ed. London: Butterworths & Co, Ltd., 1979;193-235. 8. Groopman JE. The acquired immunodeficiency syndrome. In: Wyngaarden JB, Smith LH, eds. Cecil textbook of medicine. 18th ed. Philadelphia: WB Saunders Company, 1988;1799-808.
SHAILESH DHIRUBHAI DESAI, Master of Surgery (Otorhinolaryngology),
Otolaryngologlc manifestations of AIDS have been described In the past. In this study, I had examined 14 adults with nasal obstruction and mouth breathing. Nine patients also reported deafness-unilateral In three of them and bilateral In six. All of them revealed a mass In the nasopharynx, either on the posterior rhinoscopy or the x-ray neck-lateral view. To exclude nasopharyngeal malignancy, all of the patients underwent examination of the nasopharynx while under general anaesthesia and biopsy. The histopathologic diagnosis In every patient was nonspecific, reactive lymphoid hyperplasia, which has been described In the background of HIV Infections. Four were already confirmed HIV-posltlve and 10 were found positive on the HIV antibody test. A strong association was established between seropositivity, adenoid hypertrophy, and secretory otitis media In adults. (OTOLARYNGOL HEAD NECK SURG 1992:107:755.) METHODS AND MATERIAL
A 3-year review was undertaken of 14 adults who manifested nasal blockage and mouth breathing. Nine of these patients also reported deafness: The study was done in the ENT clinics at various Zambia Consolidated Copper Mines (ZCCM) hospitals in the Copperbelt of Zambia. All underwent routine ENT examination. The patients with nasal polyposis, deviated nasal septum, hypertrophied inferior turbinates, and nasopharyngeal malignancy were excluded from the study. All had examination of the nasopharynx while they were under general anaesthesia and biopsy. Myringotomies were performed in patients with secretory otitis media. The histopathologic diagnosis was nonspecific and HIV-related. The HIV antibody test was requested for each of the 14 patients to establish the association between seropositivity, .adenoid hypertrophy, and secretory otitis media. RESULTS
The age range of the patients was from 18 to 51 years. There were eight men and six women (Table 1).
The main presenting symptoms in this study were
From the Zambia Consolidated Copper Mines Limited, Luanshya Mine Hospital. Received for publication June 5, 1992; accepted Sept. 28, 1992. Reprint requests: Shailesh Dhirubhai Desai, Master of Surgery, Zambia Consolidated Copper Mines Limited, Luanshya Mine Hospital, P.O. Box 90098, Luanshya, Zambia. 23/1/42946
o
nasal obstruction, mouth breathing, and deafness (Table 2). The posterior rhinoscopy revealed a pinkish, adenoid-like mass in 10 cases. In four patients, posterior rhinoscopy was not possible, even after the local anaesthetic spray. All had x-ray neck, lateral view, which showed a nasopharyngeal mass (Fig. 1). Nine patients with deafness had clinical evidence of secretory otitis media on ear examination. The tuning fork tests and audiometry confirmed the conductive deafness. Tympanometry was not carried out because of breakdown of the equipment. The rest of the ENT examination was nonsignificant. The distribution of clinical findings is shown in Table 3. The examination of nasopharynx while patients were under general anaesthesia confirmed the adenoid-like mass in all of the patients. The biopsy was taken to rule out nasopharyngeal malignancy. On myringotomies, seven patients had fluid in the middle ear, two were dry. Grommets were inserted in only four cases because of nonavailability and high price of grommets. The histopathologic diagnosis of nonspecific follicular and parafollicular lymphoid hyperplasia was established in all the patients. Because of high index of suspicion, I decided to establish the HIV status of the patients. Four were already confirmed seropositive as a result of other HIV-related ailments. Ten patients tested positive on the HIV antibody test. DISCUSSION
Otorhinologic manifestations of AIDS have been described in the past. Abrams' described sinus congestion, pharyngitis, herpes labialis, thrush,
755
756
Otolaryngology Head and Neck Surgery
DESAI
Table 1. Age and sex distribution of the patients Age In years 0-9
10-19
20·29
30-39
2 1
3
Male Female
4
40-49
50-59
2
Table 2. Distribution of symptoms In 14 patients Symptoms
Nasal obstruction and mouth breathing Deafness
No. 01 patients (%1
14 (100%) 9 (64.2%)
Table 3. Distribution of the clinical findings In 14 patients Clinical IIndlng
Mass in the nasopharynx on posterior rhinoscopy Presence of mass on x-ray neck lateral view Evidence of secretory otitis media
No. 01 patients (%1
10* (71.4%) 14 (100%) 9 (64.2%)
"Posterior rhinoscopy was not possible in the other four patients.
Fig. i. X-ray of the neck: lateral view shows a nasopharyngeal mass.
and hairy leukoplakia, in relation to AIDS. Poole et al.' reported a case of a 25-year-old male homosexual with AIDS who had eNS toxoplasmosis, mucosal candidiasis, recurrent otitis media, and purulent sinusitis. Cytomegalovirus ulceration of the oropharynx in both iatrogenic and HIV-induced immunosuppression has been documented.' Desai et al.' also reported a case of laryngeal granuloma-an unusual presentation of AIDS. Kaposi's
sarcoma of the palate and severe hypertrophy of the tonsils have been observed in relation to HIV infections. The findings reported here establish a strong association between seropositivity, adenoid hypertrophy, and secretory otitis media in adults. To my knowledge, there have been no previous reports on the above triad of clinical features. The adenoids grow rapidly until a child reaches about the age of 6 years of age, after which time it usually shows retrogressive changes.' Adenoid hypertrophy in adults was the unusual feature of this study. Any mass in the nasopharynx tends to produce obstruction to the nasal airway, and there may also be obstruction of the eustachian tube, with conductive deafness and secretory otitis media." Malignant neoplasms of the nasopharynx account for occasional cases of secretory otitis media in adults.' To exclude nasopharyngeal malignancy, the patients underwent examination of the nasopharynx under general anaesthesia and biopsy. The biopsy result in all of them showed nonspecific follicular and parafollicular lymphoid hyperplasia, whicfi has been described in relation to HIV infections."
Volume 107 Number 6 Port 1 December 1992
Seropositivity, adenoid hypertrophy, and secretory otitis media In adults
All had been found to be seropositive and the strong association was confirmed between seropositivity, adenoid hypertrophy, and secretory otitis media in adults. I would like to thank Mr. G. K. Chibuye, the General Manager of ZCCM Luanshya Division; Dr. H. Sensenta, the Chief Medical Officer for facilitation of the study; Dr. R. G. Goel, for confirming the histopathologic diagnosis, Dr. C. K. Patel, for the radiologic report; and Mrs. Patricia Matafwali, for preparation of the manuscript. REFERENCES
1. Abrams DI. Lymphadenopathy related to the acquired immune deficiency syndrome in the homosexual men. Med Clin North Am 1986;70:693-706. 2. Poole MD, Postma D, Cohen MS. Pyogenic otorhinologic infections in acquired immune deficiency syndrome. Arch Otolaryngol 1984;110:130-1. .
757
3. French PD, Birchall MA, Harris JRW. Cytomegalovirus ulceration of the oropharynx. J Laryngol Otol 1991;105:739-42. 4. Desai SD, Rajratnam K. Laryngeal granuloma-an unusual presentation of AIDS. J Laryngol Otol 1988;102:372-3. 5. McNab Jones RF. Anatomy of the mouth, pharynx, and oesophagus. In: Ballantyne J, Groves J, eds. Scott-Brown's diseases of the ear, nose, and throat. Vol. 1. 4th ed. London: Butterworths & Co, Ltd., 1979:263-311. 6. Ranger D. Tumours of the pharynx. In: Ballantyne J, Groves J, eds. Scott-Brown's diseases of the ear, nose, and throat, Vol. 4. 4th ed. London: Butterworths & Co, Ltd., 1979:171-206. 7. Gibb AG. Nonsuppurative otitis media. In: Ballantyne J, Groves J, eds. Scott-Brown's diseases of the ear, nose, and throat, Vol. 2. 4th ed. London: Butterworths & Co, Ltd., 1979;193-235. 8. Groopman JE. The acquired immunodeficiency syndrome. In: Wyngaarden JB, Smith LH, eds. Cecil textbook of medicine. 18th ed. Philadelphia: WB Saunders Company, 1988;1799-808.
