BLOCK 12

Viruses of the ENT

Introduction

• Acute infections

– Pharyngitis, Common cold, Sinusitis, Otitis media

• Recurrent infections

– Herpes zoster oticus

• Chronic infections

– HIV and ENT manifestations

• Neoplasms

– Benign

– Malignant : Nasopharyngeal carcinoma, Kaposi sarcoma

• Sensorineural hearing loss

Acute infections of the ENT

Viral pharyngitis/tonsillitis/laryngitis

• Rhinovirus

• Coronaviruses

• Adenovirus types

• Parainfluenza virus

• Influenza virus

• Coxsackie A and other enteroviruses

• Herpes Simplex virus (HSV)

• Epstein-Barr virus (EBV)

• Cytomegalovirus (CMV)

• HIV

Respiratory viruses

• 70% of acute sore throats are caused by viruses

Pharyngitis: Causes

Enteroviruses: Herpangina

• Causative agent: Coxsackie A viruses

• 3 to 10 years of age

• Present with

– Flu-like symptoms

– Painful vesicles and ulcerations of the posterior pharynx and

tonsils

• Vesicles rupture, leaving grayish-white-based ulcers

with erythematous borders

• Self-limiting: resolves in 3 to 7 days

• Treatment: symptomatic e.g. analgesics

Enteroviruses: Hand, Foot and Mouth Disease

• Cause: Coxsackie A 16 & Enterovirus 71

• Most often affects children < 5 years old

• Presents with

– Fever

– Lesions are tender, papules or vesicles on the

dorsum of the hands, feet and buttocks

• Self-limited, resolving within 2 to 3 days

• Treatment consists of analgesics

HSV: Acute herpetic gingivostomatitis

• Adults have more severe symptoms, with fever, cervical lymphadenopathy and general malaise

• Vesicles may be limited to the posterior pharynx and tonsils

Infectious mononucleosis-like syndromes

• EBV (70%)

• CMV

• HHV-6

• Adenovirus

• HIV – acute seroconversion

• Toxoplasmosis

Classic

Triad

Sore throat

Fever Lymphadenopathy

EBV=Infectious mononucleosis

• Most cases: 15 - 24 years of age

• Prodrome: Chills, sweats, feverishness and malaise

• May also have

– Enlarged tonsils

– Erythematous pharynx, often covered with a thick continuous exudate

– Palatal petechiae

Sore throat

Fever Lymphadenopathy

Classic

Triad

Acute retroviral syndrome

• Primary infection with HIV can manifest as a

syndrome of fever, nonexudative pharyngitis,

arthralgia, myalgia, and lymphadenopathy

Common cold

• Spread by direct contact e.g. hands and droplets

• Incubation: 24-72h

• Symptoms: sneezing, nasal congestion and rhinorrhoea,

pharyngitis , cough, low grade fever, headache and malaise

• Complications: otitis media, sinusitis, lower respiratory tract

infection

• Treatment: supportive

Virus % of colds

Rhinovirus 30-50%

Coronavirus 10-15%

Influenza 5-15%

RSV 5%

Parainfluenza 5%

Adenovirus < 5%

Picornaviridae family, >100 serotypes of Rhino virus

Most commonly : HCoV-229E and HCoV-OC43

Acute rhinosinusitis (ARS)

• Inflammation of the nasal cavity and paranasal

sinuses lasting < 4 weeks

• Subdivided into acute viral rhinosinusitis (AVRS)

and acute bacterial rhinosinusitis (ABRS)

• Causitive agents

– Viruses: Rhinovirus, influenza etc.

– Secondary bacterial infection

Acute Otitis Media (AOM)

• Viral URTI is the most common predisposing

factor for the development of AOM

– Predisposes to obstruction of the eustachian tube

leading to negative pressure and accumulation of

middle ear secretions

– Impairment in host defences such as normal

mucociliary action of the respiratory mucosa

Acute Otitis Media (AOM)

• Bacterial causes

– Streptococcus pneumoniae

– Haemophilus influenzae

– Moraxella catarrhalis

• Viral causes: Respiratory viruses

– Respiratory syncytial virus

– Rhinoviruses

– Influenza viruses

– Adenoviruses

Recurrent viral infections of the ENT

Recurrent infections of the ENT

Ramsay Hunt syndrome Herpes zoster oticus

• VZV establishes a latent infection in sensory ganglia

after primary varicella infection

• During reactivation the virus travels down the axon and

re-infects the dermatome supplied by the sensory

ganglia to produce painful vesicles on the skin

Ramsay Hunt syndrome : Herpes zoster oticus

• Reactivation of VZV within the geniculate

ganglion with subsequent involvement of the

eighth cranial nerve

• Triad of ipsilateral facial paralysis, ear pain, and

vesicles in the auditory canal and auricle

Chronic infections: HIV and the ENT

HIV oral lesions

HIV Oral lesions

Typical lesions• Candidiasis • Oral hairy leukoplakia: EBV• Herpes labialis: HSV• Zoster: VZV

Neoplasms• Kaposi’s sarcoma (HHV-8)• Non-Hodgkin lymphoma

Periodontal diseaseSalivary gland disease• Xerostomia: ↑ caries

Lesions of uncertain origin• Recurrent aphthous

stomatitis

• Oral lesions are among the first signs of HIV infection

HIV: Pharynx, Larynx and Esophagus

• Candida

– severe odynophagia

– when the larynx is affected,

hoarseness is a prominent

feature

• HSV

• CMV

Viruses: Neoplasms of the ENT

Benign Neoplasms

HPV: Laryngeal papillomatosis

• Benign papillary tumour derived from

squamous epithelial cells, generally observed

in children

• HPV6 &11 are involved in the majority

• Symptoms

– change of voice and inspiratory stridor; aphonia

and respiratory distress in advanced disease

Malignant Neoplasms: EBV

Epithelial tumours

• Nasopharyngeal carcinoma

– High incidence: Southern Chinese population

– All cases associated with EBV

• Lymphoepithelial carcinoma (salivary gland)

– Asian and Greenland Eskimo’s

– All cases associated with EBV

• Sinonasal undifferentiated carcinoma

– Strong EBV association in Asians (65%)

Lymphoma

• Nasal/nasopharyngeal T-cell lymphoma

– Strong EBV association= 90%

Malignant Neoplasms

HHV-8: Kaposi sarcoma

• Multifocal vascular tumour caused by HHV-8

• AIDS-defining lesion

• Usually on the soft palate and gingiva

Malignant Neoplasms

HPV: SCCHN

• HPV type 16 and 18 is a newly identified

causal factor for squamous cell carcinoma of

the head and neck (SCCHN)

– About 25% of all SCCHN contain HPV DNA

• The association between HPV and SCCHN is

– strongest for cancers of the tonsil

– intermediate for the rest of the oropharynx

– weakest for the oral cavity and larynx

Infections associated with

sensorineural hearing loss

Infections associated with

Sensorineural hearing loss

• Congenital

– CMV

– Rubella

• Childhood

– Mumps

• Other

– Lassa