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Clinical Manual of Otolaryngology

CHAPTER 11AIDS/HIV, Hepatitis and Otolaryngology

Otolaryngologists are involved with patients with communicable diseases both in the clinic

and in the operating room. The otolaryngologist is not only involved in diagnosing and

caring for these patients, but is also involved and concerned to reduce the risk of infection

to themselves, their OR assistants and their clinic staff. Two key references are (1)

Exposure to Blood: what health care workers need to know and (2) Guidelines for

prophylaxis of occupational exposure to HIV.

As physicians, we are involved with infectious diseases, many of which are transferable.

The most commonly transmitted diseases are viral respiratory tract and intestinal tract

disease. These are carried by fomites, sputum or other body fluids and these are spread by

direct contact, not by aerosolized spray. The physician has obvious risk, for if they touch a

patient, and then place their hands in their eye or mouth, they may transmit disease.

Frequent hand washing reduces this risk. Keep in mind, however, that patients hands are

also contaminated and they touch virtually everything they come in contact with, from the

front door through the entire clinic visit. Patients may therefore wipe their nose with their

hand or fail to wash after the toilet and contaminate every doorknob in the clinic. Anyone

who touches these doorknobs and then rubs their eye or places their hand in their mouth,

directly or via a snack in the back room, is at risk for infection.

It is alleged that we often contract respiratory tract infections on airplanes. I do not believe

this comes from a poor air system, but rather if the patient in the 1st or 2nd row has a cold

and smears their hands with infected secretion and then decides to travel to the back to

use the rest room, get a magazine or just take a walk, they typically touch each and every

seat as they travel down the aisle. Every body else who travels the aisle, also touches

these seats for balance. Snacks are served, flights are long and people invariably

contaminate themselves by itching their eyes, placing food in their mouth and picking their

teeth. This is all complicated by the stewardesses who serves the food and beverages, and

touching everybody and everything on their serving trip down the aisle.

Most of us recover from a cold without significant sequelae. This is not true for tuberculosis,

HIV illness or hepatitis. Tuberculosis is not covered here, but suffice it to say, it is a major

health risk. Otolaryngologists are involved with patients with TB for they present with cough

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and neck mass.

Hepatitis is the disease which the physician should fear the most. The hepatites are

transmitted differently. Hepatitis A is transmitted through ingestion and Hepatitis B and C

are more commonly transmitted by blood, but with direct contact, other transmission

infection can result. Whether this is through the alimentary track or whether it is through a

small, forgotten cut in the skin, is irrelevant. The bottom line is that these diseases are

readily transmittable, both in the clinic and in the operating room. The risk of transmission

of Hepatitis B and C after needle stick is Hepatitis B 6-30% and Hepatitis C 3.5% (0-7%).

Hepatitis infection requires as few as 100 viral particles, and with salivary and blood

products carrying up to 12 trillion viral particles per cc, very small volumes are required for

successful transmission.

In contrast, HIV illness requires a million viral particles and this commonly requires up to a

cc of blood for successful transmission.

Hepatitis does not particularly have head and neck manifestations and so it is not a disease

that otolaryngologists are called upon to diagnose and treat. However, patients with

hepatitis certainly have other head and neck illnesses and as the otolaryngologist treats

these, are at risk for infection.

HIV illness does have head and neck manifestation and as such, is an important illness.

While the primary care physicians caring for HIV patients are slowly but surely increasing

their abilities to diagnose and treat head and neck illness in the HIV patient, the

otolaryngologist is still called upon to participate in both diagnosis and treatment.

It is difficult to keep track of the magnitude of this illness. The CDC maintains the most

current data. You should refer to the CDC website. Having spent sometime on this website

you will have to browse and determine which sources of information are the most useful.

The numbers which are most impressive to myself are the number of patient currently

infected in the United States, the staggering costs of medical care, the cost of research for

this illness and the magnitude of the illness in 3rd world countries, particularly Africa. In

some countries up to 50% of the sexually active adults are infected with HIV illness.

A summary of current statistics garnered from multiple sources shows that worldwide there

are 36 million people with HIV illness, 35 million adults, 1.5 million children. 70% live in

Africa and 16% live in Asia.

80% of adult HIV infections result from heterosexual relations. 90% of pediatric infections

result from mother to fetus transmission.

In the U.S. the CDC estimates 800,000 to 900,000 people with HIV illness, one third are

http://www.cdc.gov/http://www.cdc.gov/

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unaware of their infection. 40,000 new cases occurred in 1998, 70% men, 30% women,

and 50% were younger than age 25.

60% of males are homosexual, 25% of HIV adults are infected via injection drugs and 15%

are infected via heterosexual sex.

New pediatric HIV infections are decreasing.

As of December 1999, 430,441 deaths from AIDS in the U.S. were reported to the CDC.

This is now the 5th leading cause of adult mortality second only to injuries, cancer, heart

disease and suicide.

Millions of Americans have hepatitis C, most unaware of their infection. 8000 to 10,000

people die annually from hepatitis, primarily B and C.

The HIV retrovirus infects T lymphocytes. These are called CD4 lymphocytes. A normal,

healthy person has approximately 1000 CD4 lymphocytes per cubic milliliter of blood.When the CD4 count drops below about 200 cells/mL, the body's immunity is significantly

compromised, cellular immunity is affected predominately and, hence, organisms such as

protozoans (Pneumocystis), fungi (Candida), and viruses (cytomegalovirus, herpes, and

Epstein-Barr) that are normally cytotoxically killed by CD4 1ymphocytes, can and do

produce disease.

Tumors that are also under the surveillance of the CD4 lymphocytes may begin to appear.

Humoral antibody is also adversely affected, but not to the same degree as the cytotoxic

immune system.

As the immune system is impaired, infections and tumors manifest. The opportunistic

pathogens and the tumors are most notable for two reasons. First, these require cellular

immunity that is now compromised. Second, current medicines against these opportunistic

diseases have not been well developed, because prior to AIDS these were infrequently

troublesome diseases.

The more common bacterial infections are still more frequent. They are of less concern for

two reasons. First, humoral immunologic protection is not as severely affected and, second,current antibiotic availability provides excellent coverage to control and eradicate the

bacterial disease.

Mycobacteria, particularly M. tuberculosis is a relatively common infection. It can present as

a cervical adenopathy that may or may not have a pulmonary component. Extrapulmonary

tuberculosis is particularly increased. The adenopathy is multiple. Normally, it is

successfully eradicated with aggressive medical therapy, but if the nodes are large and

develop necrotic foci, excision of the involved nodes is required. Atypical mycobacterial

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infection, especially M.avium complex, are more common problems than M. tuberculosisin

AIDS.

Fungi present frequently as a pathogen. Candida is the most common and oral candidiasis

is prevalent. Different presentations are seen. The patient will complain of a sensitive,

painful mouth. On examination, the mucosa can be red and sensitive or there may be a

build-up of white exudate. The candida can spread to the pharynx and esophagus and

present as odynophagia. Treatment is topical clotrimazole. A 10-mg troche is prescribed

five times a day, and success is dependent on the patient sucking the troche and keeping

the clotrimazole in contact with the fungi as long as possible. The dissolved clotrimazole is

swallowed, killing the candida in the pharynx and esophagus. Ketoconazole or fluconazole

are alternatives for cases refractory to topical treatment. Histoplasmosis may present with

ulcerative granulomatous lesions in the pharynx. Cases of disseminated histoplasmosis

and coccidiomycosis are increasingly recognized.

Protozoans are uncommon pathogens in healthy humans. Pneumocystis carinii is an

opportunistic protozoan and is common in AIDS. The vast majority of P carinii infections are

pulmonary, but the protozoan has been reported in the external auditory canal, middle ear,

thyroid, and in widely disseminated forms.

Viral infection is also common, and most of the viruses have head and neck manifestations.

The most commonly recognized viruses include cytomegalovirus, Herpes simplex, Herpes

zoster, Epstein-Barr, and human papilloma virus. These can be quite troublesome but are

treated the same as in the general population. Ganciclovir, Foscarnet & Cidofovir are

important new antivirals licensed for treatment of cytomegalovirus infection.

Lymphoproliferative head and neck disorders are also common and can be the initial AIDS

presentation. Patients come to the head and neck surgeon for biopsy with a differential

diagnosis including lymphoma, tuberculosis, and metastatic malignancy. Although a good

history should identify important risk factors, the patient may not always provide the

necessary information. HIV serology should be included in the initial work-up. Operating

room and laboratory personnel must be warned that HIV is a consideration. Even in the HIV

illness patients, different lymphoproliferative disorders are seen. These include reactive

lymph adenopathy, lymphoma, and metastatic malignancy.

Kaposi's sarcoma is also common in HIV illness. Although it normally presents initially with

mucocutaneous lesions, it can manifest in the cervical lymph nodes and it must be

differentiated from epidermoid carcinoma. In a patient with known HIV illness, cervical

lymph node biopsy is frequently requested to differentiate between the myriad of the

aforementioned diseases. Special precautions are necessary for these surgeries and will

be discussed later in this chapter.

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There has been a tendency to subcategorize HIV illness in the head and neck. For the

most part, the diseases such as otitis media, tonsillitis, and sinusitis present the same and

are treated the same as in patients who are immunologically normal. Opportunistic

infections are similar to those seen in other immunocompromised patients. Perhaps these

infections are more difficult to treat and, as with oral candidiasis, may require a longer

medical regimen.

For the most part, the otolaryngologist's primary role is to diagnose. The infections and

tumors are often difficult for the primary care physician to diagnose, and biopsies of

mucosal and lymphoid tissues can be helpful in keeping individual patients well. Because

the otolaryngologist will see HIV illness patients -- some with a known diagnosis, some

without knowledge of the transmission risks is important. Precautions to protect the entire

health team are important.

Since the early 1980s, health care providers have feared (at times irrationally) contracting

AIDS in part because of the social stigma and in part because of the prolonged, miserable

death. As of June 1997, 114 health care workers were considered possible occupational

transmissions. 52 cases are documented; some were by needle stick with contaminated

blood, fewer by spillage of blood into an open wound. Three cases involved spilling

contaminated blood onto mucous membranes.

Current data indicate the risk of contracting AIDS from a percutaneous inoculation of

infected blood to be 0.36%, or a little less than 1 in 300. The risk from mucous membrane

contamination is so low that reliable statistics do not exist. The risk in the dental profession

is estimated at 0.08% (1 in 1300) and occurs from spillage of blood-contaminated saliva

into an open wound. Although other body fluids-tears, saliva, peritoneal fluid, contain HIV,

disease transmission has not been documented. The bottom line is that there may be a

risk, but it is small.

Hepatitis, on the other hand, is highly contagious. The CDC estimates that of 12,000 health

care providers infected annually with hepatitis, 500 to 600 require hospitalization and up to

1200 will become carriers; up to 250 will die annually as a direct result of hepatitis infection.

It therefore behooves all health care providers to take appropriate precautions. The

following are the guidelines recommended by the Operating Room Committee at the VA

San Diego Healthcare System.

Prevention of Transmission of AIDS and Hepatitis for the OR Personnel

The OR Committee recommends that the Medical Center assume an active role in the

prevention of transmission of AIDS and hepatitis for the OR personnel.

1. The OR Committee strongly supports HIV testing for all patients cared for at the

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Medical Center.

2. The OR Committee strongly supports the availability of combination antiretroviral

therapy in the OR suite for immediate administration to consenting OR personnel

accidentally incurring percutaneous or mucous membrane exposure to blood or

body fluids.

3. All OR personnel should be tested and immunized for HBV.

4. The OR Committee strongly supports HIV transmission precautions for all ORpersonnel.

a. The following patient categories are recognized:

High risk = known HIV or HBV positive or at high risk for HIV or HBV

infection;

Low risk = known HIV and HBV negative or at low risk for HIV and HBV

infection.

b. The patient category will be determined by the most senior surgeon in the

OR.

c. The following operational policies are recommended:

AttireHigh-Risked

Patients

Low-Risked

Patients

Eye protection Required Required

Double gloves Required Optional

Impermeable gown Required Optional

Boots Optional Optional

Air filter system Optional Optional

Techniques

Intra-Op self gowning Required Required

Post-Op hand

washingRequired Required

Sharps isolation Required Required

Student/intern

exclusionRequired Required

1.

d. The following clarifications are noteworthy:

i. Eye protection or a face shield is required for the entire operating team

at all times. The only exceptions are individuals performing surgery

through a microscope or endoscope where such gear compromises

visual acuity .Where high-pressure irrigation is used the operating

team will be required to wear full face shields during the irrigation.

ii. Heavy orthopedic gloves may substitute for double gloves. Double

gloves or heavy gloves are recommended for all operating team

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members at all times. Exceptions are those procedures requiring the

delicate touch offered by single gloves.

iii. Impermeable gowns are recommended for all cases where excessive

blood loss, high volume irrigation, or extensive splattering is

anticipated.

iv. Impermeable boots are recommended for cases involving blood or fluid

spillage beyond the operative field.v. Air-filter systems are expensive and should not be used routinely.

However, high risk cases involving extensive splashing, plumes, or

aerosolization make air-filter systems a serious consideration.

vi. Following the initial incision, surgeons scrubbing into a case must

gown and glove themselves if the scrub nurse has contacted tissue,

blood, or body fluids directly or by handling instruments.

vii. All OR personnel are required to wash their hands immediately after

degloving.

viii. Special techniques for passing sharp instruments, pins, and wires willbe required in all high-risk cases.

ix. Inexperienced personnel such as interns and medical students are not

permitted to scrub on high risk cases. Although it is acceptable for

medical students to work with and examine AIDS patients, the

inexperienced should not:

(1) Draw blood on HIV and hepatitis-positive patients.

(2) Assist at surgery on HIV-positive patients.

(3) Perform surgery on HIV and hepatitis-positive patients.

Until venepuncture and surgical skills are developed to a high level of proficiency, the risk is

simply unnecessary .

Every health care provider should be vaccinated against hepatitis infection. Last, should an

inadvertent blood inoculation occur, particularly from a known HIV-infected patient,

everyone should have made the decision to take or not to take combination antiretroviral

therapy (ART) treatment. If one has opted to take ART, it should be readily available and

should be taken within minutes of the inoculation.