Upper Airway Obstruction due to Tonsillar Lymphadenopathy in Human Immunodeficiency Virus Infection Dennis H. Kraus, MD; Susan J. Rehm, MD; James P. Orlowski, MD;
\s=b\ Head man
and neck manifestations of hu-
immunodeficiency virus (HIV) infec-
tion are common and include diffuse cervical lymphadenopathy, cutaneous and mucosal Kaposi's sarcoma, mucosal herpes simplex infection, upper aerodi\x=req-\
gestivetractcandidiasis, andparotidlymphadenopathy and cysts. Recurrent otitis
Raymond
R.
Tubbs, DO; Howard L. Levine, MD
with human immunodefi¬ Patients ciency virus (HIV) infection de¬ head and neck
man¬ velop an array of ifestations during the natural history of this disease. Generalized lymphade¬ nopathy with cervical involvement is a common finding. However, involve¬
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. (Arch Otolaryngol Head Neck Surg.
ment of the lymphoid tissue in Waldeyer's ring has rarely been docu¬
1990;116:738-740)
A 17-year-old boy had received multiple blood transfusions between 1983 and 1985 during scoliosis surgery. When one of the blood donors was subsequently diagnosed with acquired immunodeficiency syndrome, the patient was tested and found to have HIV antibodies by both enzyme-linked immunosorbent assay and Western blot anal¬
Accepted for publication February 5, 1990. From the Departments of Otolaryngology and
Communicative Disorders (Drs Kraus and
Levine), Infectious Diseases (Dr Rehm), Anesthesia (Dr Orlowski), Pediatrics (Dr Orlowski), and Pathology (Dr Tubbs), Cleveland (Ohio) Clinic Foundation. Reprint requests to
Department
of
Otolaryn-
gology and Communicative Disorders, Cleveland Clinic Foundation, 9500 Euclid Ave, Cleveland, OH 44195 (Dr Levine).
mented. This report details the case of an adolescent patient with HIV-asso¬ ciated tonsillar and adenoid lymphad¬ enopathy and symptomatic upper air¬ way obstruction. Pathogenesis, differ¬ ential diagnosis, and management are reviewed. REPORT OF A CASE
ysis. On baseline examination in April 1987, he denied symptoms related to HIV infection. He had long-standing dyspnea on exertion related to severe thoracic deformities.
There was diffuse lymphadenopathy and bilateral tonsillar enlargement. His HIV infection was classified as Centers for Dis¬ ease Control1 clinical group IV. His CD4 (T helper, T4) lymphocyte count was 185/mL
(normal, 436 to 1394/mL).
Over the next 9 months the patient's res¬ piratory symptoms progressed. He had dys¬ pnea and cyanosis on mild exertion and used continuous oxygen supplementation every night. His tonsillar hypertrophy pro¬ gressed, with the tonsils approximating in the midline, and his voice was hyponasal. Pulmonary function tests revealed a mixed
obstructive and restrictive pattern. At the time of otolaryngology consulta¬ tion, the patient was in mild respiratory distress and required continuous oxygen therapy by nasal cannula. Physical exami¬ nation revealed severe kyphoscoliosis, mas¬ sive tonsillar and adenoid enlargement, and diffuse lymphadenopathy. There were no signs of active tonsil or adenoid infection. In July 1988, the patient underwent tonsil¬ lectomy and adenoidectomy. Postopera¬ tively, a posterior nasal pack was necessary because of diffuse adenoid bed bleeding. The patient received prophylactic intravenous injections of vancomycin hydrochloride while the posterior nasal pack was in place. The patient remained intubated in the in¬ tensive care unit because of his respiratory condition until the pack was removed in the
Downloaded From: http://archotol.jamanetwork.com/ by a University of British Columbia Library User on 06/20/2015
operating room on the fourth postoperative day. Histologie evaluation of the tonsillar and adenoid tissue revealed severe follicular hyperplasia. Cultures for aerobic and anaerobic bacteria, fungi, and acid-fast bacteria were negative. Postoperatively, the patient has resumed his normal activities; he no longer requires oxygen therapy, and dyspnea and cyanosis occur only with extreme exertion. Twelve months postoperatively, the results of pulse oximetry were significantly improved, and pulmonary function tests revealed only a restrictive defect related to severe chest wall deformity. The CD4 lymphocyte count was 300/mL.
COMMENT As of July 1989, there were fewer than 400 reported cases of acquired immunodeficiency syndrome in adoles¬ cents (ages 13 to 19 years) in the United States; the number of HIV-infected adolescents who have not yet devel¬ oped the acquired immunodeficiency syndrome is unknown. Our patient contracted the HIV infection from blood transfusions between 1983 and 1985. It appears that the majority of HIV infections in the adolescent age group are transfusion related, often affecting hemophiliacs. However, it is possible that sexual transmission and intravenous drug-related infections may be important in the near future. Laboratory assessment of patients with HIV infection reveals positive antibody tests by enzyme-linked immunosorbent assay and Western blot analysis, blood cultures positive for HIV, inversion of T-helper-suppressor cell ratio, and impaired cellular and humoral immune function.2 The virus is often latent for many years before symptoms develop, but 3-year survival is rare in symptomatic individuals. Death usually results from opportu¬ nistic infections, of which Pneumocystis carinii pneumonia is the most common.3 The frequent occurrence of recur¬ rent otitis media and chronic sinusitis in HIV-infected children is secondary to B-cell dysfunction, with the patient being susceptible to upper airway in¬ fection from Streptococcus pneumoni¬ ae, Haemophilus influenzae, and other upper respiratory tract organisms. In¬ fection with these bacterial agents is less common in adult HIV infection,
because of the production of protective antibodies prior to the development of immunodeficiency." To our knowledge, the role of enlarged tonsils and ade¬ noids in the development of otitis me¬ dia and chronic sinusitis in the pediat¬ rie population has not been docu¬ mented.
Our patient presented with progres¬ sive dyspnea associated with tonsillar enlargement and upper airway ob¬ struction. There was no evidence of lower airway involvement in the form of carinii pneumonia. Tonsillar en¬ largement with upper airway obstruc¬ tion has been associated with pulmo¬ nary hypertension, cor pulmonale, and right ventricular failure in normal children.5 Similarly, our patient's hy¬ poxia and the obstructive component of pulmonary disease and dyspnea at rest resolved with tonsillectomy and adenoidectomy. The risk of postobstructive pulmonary edema must be considered in these patients; the use of
postoperative positive end-expiratory
prevent this sequela.6 Bleeding occurred in our patient even though the results of preoperative co¬ agulation studies were normal. The use of antibiotic prophylaxis is sup¬ ported by (1) the heavy growth of mul¬ tiple microorganisms in normal pa¬ tients who have posterior nasal packs and who are not receiving antibiotic therapy, and (2) the risk of toxic shock syndrome from nasal packs.7 pressure will
Head and neck manifestations of HIV infection are common; 41% of pa¬ tients in one series initially presented with involvement in this region.3 The differential diagnosis of tonsillar and adenoid enlargement in patients with HIV should include recurrent bacte¬ rial infection, chronic candidiasis and other opportunistic infections, Kaposi's sarcoma, lymphoma, and benign lymphoid hyperplasia. Acute or recur¬ rent bacterial infection is accompa¬ nied by fever, pharyngitis, dysphagia with poor oral intake, and tonsillar in¬ flammation with exúdate. Neonatal HIV infection is associated with im¬ paired humoral immunity and poor response to bacterial infections." Oral cavity or esophageal candidiasis is present in 31% of HIV infections at initial presentation.3 The remainder of patients will develop mucosal Candida
infection during antimicrobial ther¬ apy for other opportunistic infections. Isolated involvement of Waldeyer's ring is unusual, and lymphoid enlarge¬ ment due to Candida infection is atyp¬ ical. Consideration of a number of op¬ portunistic infections requires appro¬ priate cultures and stains for aerobic and anaerobic bacteria, mycobacteria, viruses, protozoa, fungi, and acid-fast bacteria. Kaposi's sarcoma in the oral cavity is present on initial evaluation in a significant number of adults with HIV infection.3 The intraoral sites have a characteristic bluish angiomatous quality. The palate is the most com¬ mon site, although tonsillar involve¬ ment is not uncommon. Histologie analysis reveals the predominant cell to be spindle-shaped; it also reveals the formation of narrow vascular chan¬ nels. Three distinct patterns have been described: (1) predominant spindle cells, (2) spindle cell and vascular en¬ dothelial cell mixture, and (3) anaplastic cells with necrosis. Benign enlargement of the adenoids, tonsils, or lymph nodes was detected in 15 of 43 HIV-seropositive patients by computed tomography and/or mag¬ netic resonance imaging.8 Pathologic evaluation revealed benign follicular hyperplasia in eight patients, site un¬
specified. Benign lymphadenopathy uniformly homogeneous in com¬ puted tomographic density and mag¬ netic resonance signal intensity. Ra¬ diographic assessment may provide information in distinguishing benign enlargement of Waldeyer's ring from malignant lymphadenopathy. Changes in lymph node morpholog¬ ical features described in parotid and cervical specimens in patients with was
HIV infection may be similar to Waldeyer's ring lymphoid tissue in¬ volvement. Several histopathologic patterns have been described, includ¬ ing florid follicular hyperplasia, paracortical hyperplasia, angioimmunoblastic lymphadenopathy, and lym¬
phocyte depletion.9 Ryan et al10 distinguish between hy¬ perplastic and atrophie histologie pat¬ terns in HIV-associated salivary gland lymphadenopathies. The hyperplastic pattern consists of lymphoid follicles with enlarged germinal centers, which
Downloaded From: http://archotol.jamanetwork.com/ by a University of British Columbia Library User on 06/20/2015
are
irregularly shaped, voluminous,
and coalescent. A diffuse, mixed in¬ flammatory infiltrate invades the ger¬ minal center. This represents the acute pattern of lymphadenitis of HIV in¬ fection. The chronic pattern is charac¬ terized by small, atrophie lymphoid
follicles, inconspicuous germinal cen¬ ters, and marked vascular prolifera¬ tion. In
study, pathologic speci¬ mens from periparotid lymph nodes revealed benign lymphoid hyperplasia and a uniform follicular hyperplasia." Follicular hyperplasia may suggest a
recent
the acute phase of the process. This may reflect some preservation of im¬ mune status, consistent with the clin¬ ical stage of the patient. An association between a rapidly enlarging cervical mass and Burkitt's lymphoma was noted in 13 patients with HIV infection.3 A subsequent re¬ port documented a diffuse, large cleaved-cell (non-Hodgkin's) lym¬ phoma involving lymph nodes and bone marrow associated with HIV infection.10 Impaired immune function may
CONCLUSIONS
Our patient presented with upper airway obstruction due to HIV-associated tonsillar and adenoid lymphade¬ nopathy. He tolerated this condition poorly because of simultaneous scoliosis-induced restrictive pulmonary dis¬ ease, but he experienced symptomatic relief following tonsillectomy and ad¬
enoidectomy.
We would like to thank Janna Kennedy for her assistance in manuscript preparation.
predispose to malignant lympho¬
mas.
References 1. Centers for Disease Control. Classification system for human T-lymphotropic virus type III/
lymphadenopathy-associated virus infections. MMWR. 1986;35:334-339. 2. Williams ME. Head and neck findings in pediatric acquired immunodeficiency syndrome.
Laryngoscope 1987;97:713-716. 3. Marcusen DC, Sooy CD. Otolaryngologic and head and neck manifestations of acquired immunodeficiency syndrome (AIDS). Laryngoscope. 1985;95:401-405.
4. Church JA. Human
immunodeficiency virus
(HIV) infection at Children's Hospital of Los Angeles: recurrent otitis media or chronic sinusitis as the presenting process in pediatric AIDS. Im-
munol Allergy Pract. 1987;9:25-32. 5. Edison BA, Kerth JD. Tonsilloadenoid hypertrophy resulting in cor pulmonale. Arch Oto-
laryngol. 1973;98:205-207. 6. Feinberg AN, Shabino CL. Acute pulmonary edema complicating tonsillectomy and adenoidec-
tomy. Pediatrics. 1985;75:112-114. 7. Derkay CS, Hirsch BE, Johnson JT, Wagner
RL. Posterior nasal packing: are intravenous antibiotics really necessary? Arch Otolaryngol Head Neck Surg. 1989;115:439-441. 8. Olsen WL, Jeffrey RB, Sooy CD, Lynch MA, Dillon WP. Lesions of the head and neck in patients with AIDS: CT and MR findings. AJNR.
1988;9:693-698.
9. Ewing EP, Chandler FW, Spira TJ, Brynes RK, Chan WC. Primary lymph node pathology in
AIDS and AIDS-related lymphadenopathy. Arch Pathol Lab Med. 1985;109:977-981. 10. Ryan JR, Ioachim HL, Marmer J, Loubeau JM. Acquired immune deficiency syndrome\p=n-\related lymphadenopathies presenting in the salivary gland lymph nodes. Arch Otolaryngol.
1985;111:554-556.
11. Shugar JMA, Som PM, Jacobson AL, Ryan JR, Bernard PJ, Dickman SH. Multicentric pa-
rotid cysts and cervical adenopathy in AIDS patients: a newly recognized entity: CT and MR manifestations. Laryngoscope. 1988;98:772-775.
In Other AMA Journals ARCHIVES OF NEUROLOGY Late Recovery of Auditory Comprehension in Global Aphasia Margaret A. Naeser, PhD; Ann Gaddie, MS; Carole L. Palumbo; Denise Stiassny-Eder, MS (Arch Neurol. 1990;47:425-432) The Contribution of Multicenter Trials to Stroke Prevention and Treatment H. J. M. Barnett, MD (Arch Neurol. 1990;47:441-445)
Controlled Clinical Trials in Cerebrovascular Disease John Marshall, MD (Arch Neurol. 1990;47:444) Multicenter Trials in Stroke Vladimir Hachinski, MD, DSc (Arch Neurol. 1990;47:445)
Migraine-Related Stroke in the Context of the International Headache Society Classificaiton of Head Pain K. M. A. Welch, MD; Steven R. Levine, MD (Arch Neurol. 1990;47:458-462)
Downloaded From: http://archotol.jamanetwork.com/ by a University of British Columbia Library User on 06/20/2015
\s=b\ Head man
and neck manifestations of hu-
immunodeficiency virus (HIV) infec-
tion are common and include diffuse cervical lymphadenopathy, cutaneous and mucosal Kaposi's sarcoma, mucosal herpes simplex infection, upper aerodi\x=req-\
gestivetractcandidiasis, andparotidlymphadenopathy and cysts. Recurrent otitis
Raymond
R.
Tubbs, DO; Howard L. Levine, MD
with human immunodefi¬ Patients ciency virus (HIV) infection de¬ head and neck
man¬ velop an array of ifestations during the natural history of this disease. Generalized lymphade¬ nopathy with cervical involvement is a common finding. However, involve¬
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. (Arch Otolaryngol Head Neck Surg.
ment of the lymphoid tissue in Waldeyer's ring has rarely been docu¬
1990;116:738-740)
A 17-year-old boy had received multiple blood transfusions between 1983 and 1985 during scoliosis surgery. When one of the blood donors was subsequently diagnosed with acquired immunodeficiency syndrome, the patient was tested and found to have HIV antibodies by both enzyme-linked immunosorbent assay and Western blot anal¬
Accepted for publication February 5, 1990. From the Departments of Otolaryngology and
Communicative Disorders (Drs Kraus and
Levine), Infectious Diseases (Dr Rehm), Anesthesia (Dr Orlowski), Pediatrics (Dr Orlowski), and Pathology (Dr Tubbs), Cleveland (Ohio) Clinic Foundation. Reprint requests to
Department
of
Otolaryn-
gology and Communicative Disorders, Cleveland Clinic Foundation, 9500 Euclid Ave, Cleveland, OH 44195 (Dr Levine).
mented. This report details the case of an adolescent patient with HIV-asso¬ ciated tonsillar and adenoid lymphad¬ enopathy and symptomatic upper air¬ way obstruction. Pathogenesis, differ¬ ential diagnosis, and management are reviewed. REPORT OF A CASE
ysis. On baseline examination in April 1987, he denied symptoms related to HIV infection. He had long-standing dyspnea on exertion related to severe thoracic deformities.
There was diffuse lymphadenopathy and bilateral tonsillar enlargement. His HIV infection was classified as Centers for Dis¬ ease Control1 clinical group IV. His CD4 (T helper, T4) lymphocyte count was 185/mL
(normal, 436 to 1394/mL).
Over the next 9 months the patient's res¬ piratory symptoms progressed. He had dys¬ pnea and cyanosis on mild exertion and used continuous oxygen supplementation every night. His tonsillar hypertrophy pro¬ gressed, with the tonsils approximating in the midline, and his voice was hyponasal. Pulmonary function tests revealed a mixed
obstructive and restrictive pattern. At the time of otolaryngology consulta¬ tion, the patient was in mild respiratory distress and required continuous oxygen therapy by nasal cannula. Physical exami¬ nation revealed severe kyphoscoliosis, mas¬ sive tonsillar and adenoid enlargement, and diffuse lymphadenopathy. There were no signs of active tonsil or adenoid infection. In July 1988, the patient underwent tonsil¬ lectomy and adenoidectomy. Postopera¬ tively, a posterior nasal pack was necessary because of diffuse adenoid bed bleeding. The patient received prophylactic intravenous injections of vancomycin hydrochloride while the posterior nasal pack was in place. The patient remained intubated in the in¬ tensive care unit because of his respiratory condition until the pack was removed in the
Downloaded From: http://archotol.jamanetwork.com/ by a University of British Columbia Library User on 06/20/2015
operating room on the fourth postoperative day. Histologie evaluation of the tonsillar and adenoid tissue revealed severe follicular hyperplasia. Cultures for aerobic and anaerobic bacteria, fungi, and acid-fast bacteria were negative. Postoperatively, the patient has resumed his normal activities; he no longer requires oxygen therapy, and dyspnea and cyanosis occur only with extreme exertion. Twelve months postoperatively, the results of pulse oximetry were significantly improved, and pulmonary function tests revealed only a restrictive defect related to severe chest wall deformity. The CD4 lymphocyte count was 300/mL.
COMMENT As of July 1989, there were fewer than 400 reported cases of acquired immunodeficiency syndrome in adoles¬ cents (ages 13 to 19 years) in the United States; the number of HIV-infected adolescents who have not yet devel¬ oped the acquired immunodeficiency syndrome is unknown. Our patient contracted the HIV infection from blood transfusions between 1983 and 1985. It appears that the majority of HIV infections in the adolescent age group are transfusion related, often affecting hemophiliacs. However, it is possible that sexual transmission and intravenous drug-related infections may be important in the near future. Laboratory assessment of patients with HIV infection reveals positive antibody tests by enzyme-linked immunosorbent assay and Western blot analysis, blood cultures positive for HIV, inversion of T-helper-suppressor cell ratio, and impaired cellular and humoral immune function.2 The virus is often latent for many years before symptoms develop, but 3-year survival is rare in symptomatic individuals. Death usually results from opportu¬ nistic infections, of which Pneumocystis carinii pneumonia is the most common.3 The frequent occurrence of recur¬ rent otitis media and chronic sinusitis in HIV-infected children is secondary to B-cell dysfunction, with the patient being susceptible to upper airway in¬ fection from Streptococcus pneumoni¬ ae, Haemophilus influenzae, and other upper respiratory tract organisms. In¬ fection with these bacterial agents is less common in adult HIV infection,
because of the production of protective antibodies prior to the development of immunodeficiency." To our knowledge, the role of enlarged tonsils and ade¬ noids in the development of otitis me¬ dia and chronic sinusitis in the pediat¬ rie population has not been docu¬ mented.
Our patient presented with progres¬ sive dyspnea associated with tonsillar enlargement and upper airway ob¬ struction. There was no evidence of lower airway involvement in the form of carinii pneumonia. Tonsillar en¬ largement with upper airway obstruc¬ tion has been associated with pulmo¬ nary hypertension, cor pulmonale, and right ventricular failure in normal children.5 Similarly, our patient's hy¬ poxia and the obstructive component of pulmonary disease and dyspnea at rest resolved with tonsillectomy and adenoidectomy. The risk of postobstructive pulmonary edema must be considered in these patients; the use of
postoperative positive end-expiratory
prevent this sequela.6 Bleeding occurred in our patient even though the results of preoperative co¬ agulation studies were normal. The use of antibiotic prophylaxis is sup¬ ported by (1) the heavy growth of mul¬ tiple microorganisms in normal pa¬ tients who have posterior nasal packs and who are not receiving antibiotic therapy, and (2) the risk of toxic shock syndrome from nasal packs.7 pressure will
Head and neck manifestations of HIV infection are common; 41% of pa¬ tients in one series initially presented with involvement in this region.3 The differential diagnosis of tonsillar and adenoid enlargement in patients with HIV should include recurrent bacte¬ rial infection, chronic candidiasis and other opportunistic infections, Kaposi's sarcoma, lymphoma, and benign lymphoid hyperplasia. Acute or recur¬ rent bacterial infection is accompa¬ nied by fever, pharyngitis, dysphagia with poor oral intake, and tonsillar in¬ flammation with exúdate. Neonatal HIV infection is associated with im¬ paired humoral immunity and poor response to bacterial infections." Oral cavity or esophageal candidiasis is present in 31% of HIV infections at initial presentation.3 The remainder of patients will develop mucosal Candida
infection during antimicrobial ther¬ apy for other opportunistic infections. Isolated involvement of Waldeyer's ring is unusual, and lymphoid enlarge¬ ment due to Candida infection is atyp¬ ical. Consideration of a number of op¬ portunistic infections requires appro¬ priate cultures and stains for aerobic and anaerobic bacteria, mycobacteria, viruses, protozoa, fungi, and acid-fast bacteria. Kaposi's sarcoma in the oral cavity is present on initial evaluation in a significant number of adults with HIV infection.3 The intraoral sites have a characteristic bluish angiomatous quality. The palate is the most com¬ mon site, although tonsillar involve¬ ment is not uncommon. Histologie analysis reveals the predominant cell to be spindle-shaped; it also reveals the formation of narrow vascular chan¬ nels. Three distinct patterns have been described: (1) predominant spindle cells, (2) spindle cell and vascular en¬ dothelial cell mixture, and (3) anaplastic cells with necrosis. Benign enlargement of the adenoids, tonsils, or lymph nodes was detected in 15 of 43 HIV-seropositive patients by computed tomography and/or mag¬ netic resonance imaging.8 Pathologic evaluation revealed benign follicular hyperplasia in eight patients, site un¬
specified. Benign lymphadenopathy uniformly homogeneous in com¬ puted tomographic density and mag¬ netic resonance signal intensity. Ra¬ diographic assessment may provide information in distinguishing benign enlargement of Waldeyer's ring from malignant lymphadenopathy. Changes in lymph node morpholog¬ ical features described in parotid and cervical specimens in patients with was
HIV infection may be similar to Waldeyer's ring lymphoid tissue in¬ volvement. Several histopathologic patterns have been described, includ¬ ing florid follicular hyperplasia, paracortical hyperplasia, angioimmunoblastic lymphadenopathy, and lym¬
phocyte depletion.9 Ryan et al10 distinguish between hy¬ perplastic and atrophie histologie pat¬ terns in HIV-associated salivary gland lymphadenopathies. The hyperplastic pattern consists of lymphoid follicles with enlarged germinal centers, which
Downloaded From: http://archotol.jamanetwork.com/ by a University of British Columbia Library User on 06/20/2015
are
irregularly shaped, voluminous,
and coalescent. A diffuse, mixed in¬ flammatory infiltrate invades the ger¬ minal center. This represents the acute pattern of lymphadenitis of HIV in¬ fection. The chronic pattern is charac¬ terized by small, atrophie lymphoid
follicles, inconspicuous germinal cen¬ ters, and marked vascular prolifera¬ tion. In
study, pathologic speci¬ mens from periparotid lymph nodes revealed benign lymphoid hyperplasia and a uniform follicular hyperplasia." Follicular hyperplasia may suggest a
recent
the acute phase of the process. This may reflect some preservation of im¬ mune status, consistent with the clin¬ ical stage of the patient. An association between a rapidly enlarging cervical mass and Burkitt's lymphoma was noted in 13 patients with HIV infection.3 A subsequent re¬ port documented a diffuse, large cleaved-cell (non-Hodgkin's) lym¬ phoma involving lymph nodes and bone marrow associated with HIV infection.10 Impaired immune function may
CONCLUSIONS
Our patient presented with upper airway obstruction due to HIV-associated tonsillar and adenoid lymphade¬ nopathy. He tolerated this condition poorly because of simultaneous scoliosis-induced restrictive pulmonary dis¬ ease, but he experienced symptomatic relief following tonsillectomy and ad¬
enoidectomy.
We would like to thank Janna Kennedy for her assistance in manuscript preparation.
predispose to malignant lympho¬
mas.
References 1. Centers for Disease Control. Classification system for human T-lymphotropic virus type III/
lymphadenopathy-associated virus infections. MMWR. 1986;35:334-339. 2. Williams ME. Head and neck findings in pediatric acquired immunodeficiency syndrome.
Laryngoscope 1987;97:713-716. 3. Marcusen DC, Sooy CD. Otolaryngologic and head and neck manifestations of acquired immunodeficiency syndrome (AIDS). Laryngoscope. 1985;95:401-405.
4. Church JA. Human
immunodeficiency virus
(HIV) infection at Children's Hospital of Los Angeles: recurrent otitis media or chronic sinusitis as the presenting process in pediatric AIDS. Im-
munol Allergy Pract. 1987;9:25-32. 5. Edison BA, Kerth JD. Tonsilloadenoid hypertrophy resulting in cor pulmonale. Arch Oto-
laryngol. 1973;98:205-207. 6. Feinberg AN, Shabino CL. Acute pulmonary edema complicating tonsillectomy and adenoidec-
tomy. Pediatrics. 1985;75:112-114. 7. Derkay CS, Hirsch BE, Johnson JT, Wagner
RL. Posterior nasal packing: are intravenous antibiotics really necessary? Arch Otolaryngol Head Neck Surg. 1989;115:439-441. 8. Olsen WL, Jeffrey RB, Sooy CD, Lynch MA, Dillon WP. Lesions of the head and neck in patients with AIDS: CT and MR findings. AJNR.
1988;9:693-698.
9. Ewing EP, Chandler FW, Spira TJ, Brynes RK, Chan WC. Primary lymph node pathology in
AIDS and AIDS-related lymphadenopathy. Arch Pathol Lab Med. 1985;109:977-981. 10. Ryan JR, Ioachim HL, Marmer J, Loubeau JM. Acquired immune deficiency syndrome\p=n-\related lymphadenopathies presenting in the salivary gland lymph nodes. Arch Otolaryngol.
1985;111:554-556.
11. Shugar JMA, Som PM, Jacobson AL, Ryan JR, Bernard PJ, Dickman SH. Multicentric pa-
rotid cysts and cervical adenopathy in AIDS patients: a newly recognized entity: CT and MR manifestations. Laryngoscope. 1988;98:772-775.
In Other AMA Journals ARCHIVES OF NEUROLOGY Late Recovery of Auditory Comprehension in Global Aphasia Margaret A. Naeser, PhD; Ann Gaddie, MS; Carole L. Palumbo; Denise Stiassny-Eder, MS (Arch Neurol. 1990;47:425-432) The Contribution of Multicenter Trials to Stroke Prevention and Treatment H. J. M. Barnett, MD (Arch Neurol. 1990;47:441-445)
Controlled Clinical Trials in Cerebrovascular Disease John Marshall, MD (Arch Neurol. 1990;47:444) Multicenter Trials in Stroke Vladimir Hachinski, MD, DSc (Arch Neurol. 1990;47:445)
Migraine-Related Stroke in the Context of the International Headache Society Classificaiton of Head Pain K. M. A. Welch, MD; Steven R. Levine, MD (Arch Neurol. 1990;47:458-462)
Downloaded From: http://archotol.jamanetwork.com/ by a University of British Columbia Library User on 06/20/2015
