European Journal of Cardiovascular Medicine

It is widely known that Human immunodeficiency virus (HIV) is a retrovirus that infects cells of the immune system impairing their function and results in deterioration of the immune system. The virus infects and damages helper T-cells, weakens both cell-mediated and humoral immunity, and increases susceptibility to encapsulated organisms such as Streptococcus pneumoniae and other bacteria. Destruction of both cell-mediated and humoral immunity predisposes an individual to develop acquired immunodeficiency syndrome (AIDS) with ear nose and throat (ENT) manifestation. Commonly reported ENT manifestations in HIV-positive patients include; oral candidiasis, lymph node enlargement, rhinosinusitis, allergic rhinitis, lymph node enlargement in the neck, adenoid enlargement, and chronic suppurative otitis media.1–8

Several studies have observed that 70% to 90% of HIV-infected patients will present with ear, nose and throat symptoms, so our research aimed to identify the prevalence of ENT manifestations among clients attending HIV-clinics at a tertiary hospital in India. Knowing the prevalence will create a high index of suspicion to physicians and health-care providers in encouraging HIV testing to patients presenting to hospital with ENT symptoms. Also, by knowing how commonly used HIV clinical markers associated with ENT manifestations, it will be possible to devise ENT screening schedules for clients of HIV-clinics.

This was a descriptive hospital-based cross-sectional study conducted from July 2022 to January 2023. All HIV positive patients both adult and children who attended the HIV clinic were recruited and invited to participate in the study.

Inclusion Criteria

We included all patients who were HIV test positive attending at any of the clinics and ENT clinic during the study period.

Exclusion Criteria

Patients or care takers who were not willing to participate in the study were excluded.

Data Collection Tools and Methods

Potential study participants in HIV clinics were approached by a researcher and consented to participate in the study. A pretested questionnaire was used to capture the patient’s demographic and illness history. A headlight and otoscope were then employed by the researcher to examine the ears, nose and throat of the patient in an attempt to identify any ENT condition, fiberoptic nasolaryngoscope was used at the ENT clinic to examine patients whom we suspected to have nasopharyngeal tumor or history of nasal bleeding. The findings of the examination were recorded along with the demographic and clinical history.

Statistical Analysis

The data obtained from the study were analyzed using Statistical Package for Social Sciences (SSPS) version 10 computer software. Data are expressed as frequencies, percentages, means, and standard deviations (SD). For all statistical analyses, a two-tailed p value of less than 0.05 was considered significant.

Four hundred HIV seropositive patients that attended at our tertiary hospital between July 2022 and January 2023 were studied to determine the magnitude and distribution of ENT manifestations by age, sex and CD4 count. All patients were already enrolled on highly active antiretroviral therapy (HAART) by the time of this study. Their age ranged from 4 to 78 years (median age of 40 years). Majority of participants were females 270 (67.5%). The

demographic characteristics of participants are shown in (Table 1).

Table 1: Demographic details of the study participants.

Figure 1: Distribution of ENT manifestations in HIV patients

Rhinosinusitis was the most common clinical manifestation, present in 26 (24%) out of 136 patients who presented with ENT manifestations. The distribution of other clinical ENT manifestations is summarized in (Figure 1).

Table 2: ENT Manifestations According to Age Groups (N=400)

During the study period, 136 (34%) patients out of 200 presented with ENT manifestations. Most cases were in the age group of 40–49 but in terms of proportions within the age groups, the highest proportions were in the age groups 0–9 years (50%), and 14 in 50–59 years (45.2%). Table 2 shows the ENT manifestations that we saw in the study participants.

Table 3: ENT Manifestations by Sex (N=400)

Chi square, 0.12; P-value, 0.73

The prevalence of ENT manifestations among females was higher (23.5%) compared to males (10.5%). This difference was however not statistically significant (Table 3)

Table 4: ENT Manifestations by CD4 Count (N=400)

Chi square, 20.75; P-value, <0.01.

ENT manifestations among patients with CD4 count less than 200 cells/µL were seen in 56.3% of patients, while amongst those with a CD4 count between 200 and 499 cells/µL, they were in 52.5% of patients, and in those with CD4 count greater or equal to 500 cells/µL, 34% (Table 4).

The prevalence of ENT manifestations amongst the 200 HIV-positive participants we recruited in our study was 34%.

A 2006 study in India with a sample size of 968 HIV seropositive patients reported a prevalence of 79% for ENT manifestations.4 At the time of the India study, not all patients were on HAART, making it likely that they had lower CD4 counts compared to our patients, and thus they had a higher prevalence. Our finding of patients with low CD4 having more ENT manifestations supports this hypothesis.

In this study, 6(50%) patients in the age group 0–9 years showed a higher prevalence of ENT manifestations and 12(23.1%) patients of age group 20–29 years were the least prevalent with ENT manifestations. In comparison, a study done at Muhimbili National hospital observed the most prevalent age group was 20–29 years in 12 (50%) patients while the least prevalent group was 50–59 years with 7(24.1%) patients.9 We speculate this difference to be the result of numbers.

Our study did not find any statistical association between sex and the ENT manifestations, despite the proportion of females with ENT complaints being higher. This is contrary to a study done at Muhimbili National Hospital where the prevalence of ENT manifestations was higher among males 35.7% than female 33.3%; this was however not statistically significant.9 In Iran, ENT manifestations have also been found to be higher in men compared to women but this was also not statistically significant.10 Empowerment of women in our study area and the better health seeking behavior of men compared to women might have contributed to the higher proportion of women in our study.

We found that ENT manifestations decreased as CD4 counts increased. Swai in Muhimbili Tanzania found a similar trend. It is plausible that as a person’s CD4 count drops and the person becomes more prone to opportunistic infections, the likely hood of developing ENT manifestations as part of the opportunistic infections increases.9 Some ENT conditions are recognized as opportunistic infections in HIV and have been used in the WHO clinical staging of HIV.11

Although this study succeeded in highlighting some common ENT manifestations, it was limited in the number of patients that were reached due to time limitations. Also, being conducted in a tertiary hospital, it is possible that milder ENT manifestations may exist in lower health facilitates and are not picked up by clinicians.

Of the 200 HIV-positive patients we examined, 34% had ENT manifestations. These were however not their presenting complaints and were uncovered as a result of our screening. We found that as CD4 count drop, there more patients had ENT manifestations. We therefore recommend that all clients seeking care at HIV-clinics, particularly those with CD4 counts below 500 cells/µL be screened for ENT conditions.

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