THIEME
Original Article 105
Otolaryngologic Lesions among Human 
Immunodeficiency Virus-infected Children
Oluwabusayo D. Babatunde1 Adebolajo A. Adeyemo1 Regina E. Oladokun2
1Institute of Child Health, College of Medicine, University of Ibadan, Address for correspondence Adebolajo A. Adeyemo, MBBS, MSc, 
Ibadan, Nigeria FWACS, Institute of Child Health, College of Medicine, University of 
2Department of Pediatrics, College of Medicine, University of Ibadan, Ibadan, Nigeria (e-mail: adebolajo@gmail.com).
Ibadan, Ibadan, Nigeria
Ann Otol Neurotol ISO 2018;1:105–110
Abstract Background Otolaryngologic (ORL) lesions are common in children. ORL lesions 
occur even more commonly and more severely in HIV-infected children. The few avail-
able literature has reported a high prevalence in human immunodeficiency virus (HIV)–
infected children; however, there are inadequate data on the impact of HIV infection 
on hearing and the pattern of manifestations of ORL lesions among African children.
Objectives This study was conducted to describe the prevalence and manifestations 
of ORL lesions among HIV-infected children and controls in Nigeria.
Materials and Methods A prospective comparative cross-sectional study design was 
adopted. Clinical evaluation was done, and hearing assessment was done using oto-
acoustic emission for all participants and pure tone audiometry for participants aged 
≥ 5 years. Hearing thresholds were defined according to the World Health Organization 
classification.
Results One hundred children were studied: 50 HIV-infected and 50 HIV-negative 
children. The prevalence of ORL lesions among HIV-infected children was 66%, whereas 
it was 46% (p = 0.044) among HIV-negative children. ORL lesions were more  prevalent 
Keywords among children between the 18-month and 5-year age group (p = 0.003) irrespective 
► human immunodefi- of HIV status. The lesions that were associated with HIV infection were cervical ade-
ciency virus nopathy (44%, p = 0.010) and hearing loss (36%, p = 0.023).
► otolaryngology Conclusion The frequency of ORL lesions is high in HIV-infected children, but 
► pediatric improved outcomes following use of medications may be responsible for the slight 
disparity in prevalence when compared with HIV-negative children.
Introduction of individuals with HIV infection.7–10 Although ORL lesions are 
common occurrences in children; however, in HIV-infected 
The human immunodeficiency virus (HIV) infection remains a children, they are more severe, last longer, and are recurrent. 
major public health concern worldwide, but sub-Saharan Africa These lesions can occur as part of the symptoms of the HIV 
accounts for an estimated 69% of all HIV infections, making it the  disease or as complications of disease or treatment. As a result 
most severely affected region.1 Currently, Nigeria has the larg- of the challenges of access to diagnostic services in resource-
est burden of pediatric HIV infection, and v ertical transmission poor countries, ORL lesions have been considered as possible 
remains the predominant means of infection among Nigerian s urrogates of diagnosis of HIV infection.7,11,12
children.2–4 HIV infection has become a chronic disease due to In Nigeria, there are few studies on the burden of ORL 
improved survival as a result of global commitment to  control lesions among the pediatric HIV-infected population. The 
of the disease. Thus, survivors of the disease may d evelop objective of this study was to describe the prevalence and 
impairment in different body systems and suffer disabilities.5,6 pattern of ORL lesions among HIV-infected children in com-
Otolaryngologic (ORL) lesions occur in approximately 40 to 90% parison with HIV-negative children.
DOI https://doi.org/ Copyright ©2018 Indian Society of 
10.1055/s-0038-1675661 Otology
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106 ORL Lesions among HIV-Infected Children Babatunde et al.
Materials and Methods occurrence of impairment of both air and bone conduction 
and air bone gap > 10 dB.
The study was conducted in a tertiary health facility that Acute otitis media (AOM) was defined as ear pain, inflamed 
receives donor support for pediatric HIV care. A prospec- tympanum, ear discharge < 2 weeks, whereas chronic suppu-
tive comparative cross-sectional study design was adopt- rative otitis media (CSOM) was defined as ear discharge of > 
ed. HIV-infected children and HIV-negative children aged 6 2-week duration or recurrent ear discharge. Cervical adenop-
weeks to 14 years were recruited from the Pediatric Infec- athy is defined as any cervical lymph node > 1.5 cm.
tious Diseases clinic, the General Out-Patient clinic, and the 
pediatric wards. Ethical approval for this study was obtained 
from the University of Ibadan and University College Hospital, Results
Ibadan Ethics Committee (UI/UCHEC). Informed consent was Total 50 HIV-infected and 50 HIV-negative children were 
obtained before recruitment of participants into the study. studied. In all, there were 55 boys and 45 girls g iving 
Demographic and clinical information was obtained using a  male-to-female ratio of 1.2:1. The age range of the 
a semistructured questionnaire. All participants underwent  participants was 4 months to 15 years, and mean age was 7.4 
clinical examination of the ears, nose, oral cavity, and neck years ± 4.6 years. Among the HIV-infected children, 28 (56%) 
including otoscopy. Ear swab was taken from children with were orphaned, whereas none of the HIV-negative children 
ear discharge using conventional swab sticks and a Remel were orphaned (►Table 1). An equal number of 43 HIV-neg-
A.C.T II swab stick (transport system for aerobic, anaerobic, ative and 43 HIV-infected children received routine immuni-
and facultative microorganisms). zation. Incomplete or no immunization was recorded among 
Hearing assessment was done using otoacoustic emis- four HIV-infected children, whereas the immunization status 
sion for all participants and pure tone audiometry (PTA) for of three HIV-infected children and seven HIV-negative chil-
participants older than 5 years. Audiometry was done at fre- dren was unknown. Overall, 82% of all the children were well 
quencies of 250, 500, 1,000, 2,000, 3,000, 4,000, 6,000 Hz, nourished, only 17% were underweight, and only 1 child was 
and 8,000 Hz. Hearing thresholds were defined according to overweight. HIV-infected children accounted for 64.7% of the 
the classification by the World Health Organization (WHO). underweight children (►Fig. 1).
Slight/mild hearing loss was defined as 26 to 40 dB, moder- The mode of transmission of HIV among the infected 
ate hearing loss as 41 to 60 dB, severe hearing loss as 61 to  children was mother to child (vertical) in 94%. Of the remain-
80 dB, and profound hearing loss as threshold above 81 dB.13 ing three with horizontal transmission, one was infected via 
Conduction hearing loss was described as air conduction PTA  sexual abuse, one was infected after using the toothbrush 
> 25 dB with normal bone conduction and an air-bone gap of her HIV-infected sibling, whereas the third was undeter-
of ≥ 10 dB. Sensorineural hearing loss was identified as air mined. The mean age at HIV diagnosis was 4 years 9 months 
conduction PTA > 25 dB, bone conduction PTA > 25 dB, and (± 3 years 10 months). Advanced disease (WHO clinical stag-
an air-bone gap < 10 dB. Mixed hearing loss was defined as es 3 and 4) was observed in 43/50 (86%) of the HIV-infected 
Table 1 Association between participants’ characteristics and presence of ORL lesions
ORL lesions Chi–square (p–Value)
Yes (%) No (%) Total
HIV status
 Infected 33 (66.0) 17 (46.0) 50 (100) 4.0 (0.044)*
 Negative 23 (46.0) 27 (54.0) 50 (100)
Age group
 6 wk–18 mo 4 (33.3) 8 (66.7) 12 (100) 14.11 (0.01)*
 >18 mo–5 y 21 (80.8) 5 (19.2) 26 (100)
 >5–10 y 21 (61.8) 13 (38.2) 34 (100)
 >10–15 y 10 (35.7) 18 (64.3) 28 (100)
Nutritional status
 Undernourished 13 (76.47) 4 (23.53) 17 (100) 3.6 (0.06)
 Normal 42 (51.22) 40 (48.78) 82 (100)
Orphan status
 Not orphaned 43 (55.1) 35 (44.9) 78 (100) 1.38 (0.71)
 Maternal orphan 7 (58.3) 5 (41.7) 12 (100)
 Paternal orphan 1 (33.3) 2 (66.7) 3 (100)
 Double orphan 5 (71.4) 2 (28.6) 7 (100)
Abbreviations: HIV, human immunodeficiency virus; ORL, otolaryngologic. 
*p-Value < 0.05.
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ORL Lesions among HIV-Infected Children Babatunde et al. 107
children and 18 (36%) had CD4 count < 350 cells/µL. Only 12 was higher among HIV-infected children, undernourished 
(24%) children had viral load < 1,000 copies/mL (►Table2). children, and double orphans (►Table 1).
Antiretroviral therapy (ART) was recorded among 43/50 Among HIV-infected children, the frequency of ORL 
(86%) HIV-infected children. lesions increased as indices of HIV disease severity worsened, 
whereas children on ART had lower prevalence of ORL lesions 
Prevalence and Manifestations of than those who were ART-naïve (►Table 2).
Otolaryngologic Lesions ►Table 3 shows the distribution of ORL lesions among all the study participants according to their HIV s tatus. Cervi-
The overall prevalence of ORL lesions among all children in cal adenopathy (p = 0.010) and hearing loss (p = 0.02) were 
this study was 56%. The prevalence of ORL lesions among the only lesions that were significantly related to HIV. The 
HIV-infected children was 66% and it was 46% (p = 0.004) predominant organisms cultured from the ear swabs were 
among HIV-negative children. The frequency of ORL lesions gram-negative organisms. Only one child (HIV-negative) 
Fig. 1 Nutritional status categories by human immunodeficiency virus (HIV) status.
Table 2 Association between ORL lesions, WHO clinical staging, CD4 count, viral load, and ART treatment
ENT lesions p–Value
Yes (%) No (%)
WHO clinical stage
 Stage 1 0 (0.0) 1 (5.9) 7.2 (0.09)
 Stage 2 5 (15.1) 1 (5.9)
 Stage 3 19 (57.6) 14 (82.3)
 Stage 4 9 (27.3) 1 (5.9)
CD4 count
 < 350 cells/µL 10 (30.3) 8 (47.1) 2.2 (0.3)
 350–749 cells/µL 14 (42.4) 7 (41.2)
 ≥ 750 cells/µL 9 (27.3) 2 (11.7)
Viral load
 < 1,000 9 (27.27) 3 (17.6) 1.6 (0.65)
 1,000–10,000 6 (18.18) 3 (17.6)
 10,000–100,000 13 (39.39) 6 (35.4)
 > 100,000 5 (15.15) 5 (29.4)
ART treatment
 Yes 27 (48.2) 16 (36.4) 1.4 (0.25)
 No 6 (51.8) 1 (63.6)
Abbreviations: ART, antiretroviral therapy; ENT, ear–nose–throat; ORL, otolaryngologic; WHO, World Health Organization.
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108 ORL Lesions among HIV-Infected Children Babatunde et al.
grew Staphylococcus aureus, a gram-positive organism HIV-negative children. Among the children with hearing loss, 
(►Table 4). other ear lesions were present in 9 (34.6%) children: AOM 
►Table 5 shows that bilateral and unilateral hearing loss and CSOM were seen in two and three HIV-infected chil-
was present in most HIV-infected children compared with dren, respectively, whereas wax impaction occurred in two 
Table 3 ORL lesions among study participants
ORL lesion HIV–infected HIV–negative p–Value
n (%) n (%)
Wax impaction 6 (12.0) 10 (20) 0.27
CSOM 4 (8.0) 0 (0.0) 0.12
AOM 2 (4.0) 2 (4.0) 1.00
Adenoidal hypertrophy 0 (0.0) 3 (6.0) 0.24
Acute/chronic sinusitis 10 (20.0) 10 (20.0) 0.96
Tonsillar enlargement 10 (20.0) 7 (14.0) 0.42
Recurrent aphthous ulcer 0 (0.0) 1 (2.0) 1.00
Candidiasis 2 (4.0) 0 (0.0) 0.50
Herpes simplex 5 (10.0) 0 (0.0) 0.06
Gingivitis 1 (2.0) 0 (0.0) 1.00
Oral hairy leucoplakia 1 (2.0) 0 (0.0) 1.00
Cervical adenopathy 22 (44.0) 10 (20.0) 0.01*
Parotid enlargement 5 (10.0) 0 (0.0) 0.06
Hearing loss 18 (36.0) 8 (16.0) 0.02*
Abbreviations: AOM, acute otitis media; CSOM, chronic suppurative otitis media; HIV, human immunodeficiency virus; ORL, otolaryngologic.
*p < 0.05.
Table 4 Bacterial isolates from culture of ear discharge
HIV status Age (y) Bacterial isolates
HIV–infected
CSOM #1 2 Pseudomonas aeruginosa, Klebsiella pneumoniae
#2 4 P. aeruginosa, Proteus mirabilis
#3 4 Escherichia coli
#4 14 P. aeruginosa
AOM #5 8 Coagulase–negative Staphylococcus
#6 11 P. aeruginosa
HIV–negative
AOM #7 2 P. aeruginosa
#8 4 Staphylococcus aureus
Abbreviations: AOM, acute otitis media; CSOM, chronic suppurative otitis media; HIV, human immunodeficiency virus.
Table 5 Hearing thresholds of HIV–infected and HIV–negative children
Hearing assessment Total n = 100 HIV–infected n = 50 HIV–negative n = 50 p–Value OR 95% CI
OAE
  Pass 87 (87%) 45 (90%) 42 (84%) 0.37 0.58 0.18–1.19
  Fail 13 (13%) 5 (10%) 8 (16%) 0.37 1.71 0.52–5.66
PTA Hearing state Total n = 62 HIV–infected HIV–negative p–Value OR 95% CI
n = 34 n = 28
Normal 44 (71%) 18 (53%) 26 (92.9%) 0.001 11.5 2.36–53.55
Mild loss 7 (11.3%) 5 (14.7%) 2 (7.1%) 0.44 0.45 0.08–2.50
Moderate loss 11 (17.7%) 11 (32.3%) 0 (0%) 0.01 2.2 1.64–3.00
Abbreviations: CI, confidence interval; HIV, human immunodeficiency virus; OAE, otoacoustic emission; OR, odds ratio; PTA, pure tone audiometry.
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ORL Lesions among HIV-Infected Children Babatunde et al. 109
HIV-infected children and two (7.7%) HIV-negative children, form of hearing loss among HIV-infected children.15,19 In both 
respectively. countries, middle ear infections and perforation of the tym-
Using PTA, hearing loss was detected 18 HIV-infected chil- panic membrane were more prevalent among HIV-infected 
dren. Six (33.3%) children had conductive hearing loss (CHL), children with subsequent CHL than sensorineural and mixed 
four (22.2%) had sensorineural hearing loss, and two (11.1%) hearing loss. In this Nigerian study, CHL was seen more 
had mixed hearing loss. The remaining two HIV-infected among HIV-infected children due to the higher prevalence of 
children became restless and did not complete the PTA test; otitis media among them unlike HIV-negative children who 
hence, the type of deafness could not be categorized. Among had more cases of SNHL.
the HIV-negative children, 28 children had PTA and hearing The high prevalence of hearing loss suggests that HIV 
loss was detected in 2 (7.1%) children; both of whom had infection is a significant contributor to hearing loss in chil-
mixed hearing loss. dren and may require more attention in public health efforts 
to control deafness. Hitherto, deafness has not been given 
much consideration as a complication or morbidity resulting 
Discussion from the HIV infection and/or from treatment of HIV infec-
This study found that ORL lesions are common in both tion. As observed in this study, HIV-negative children who 
HIV-infected and HIV-negative children. The prevalence of had hearing impairment were mostly younger than 5 years, 
ORL lesions in HIV- infected children was 66% and it was whereas HIV-infected children with hearing loss who were 
46% in HIV-negative children. The proportion of ORL lesions mostly older than 5 years. It is possible that the hearing loss 
increased as HIV disease severity worsened and reduced with among uninfected children may be due to other viral infec-
use of ART. The prevalence of ORL lesions found in this study tions such as cytomegalovirus (CMV), measles, or from peri-
is high although lower than the prevalence reported among natal events.20,21 Therefore, accepting that HIV is now import-
Angolan children.9 In Angola, the prevalence of ORL lesions ant in the epidemiology of hearing loss18 and controlling HIV 
was 92% in HIV-infected children and 72% in HIV-negative infection may lead to reduction in the prevalence of hearing 
children whereas in Brazil 90% of the HIV- infected children loss in children.
were documented to have at least one ENT lesion.11 Hadfield The bacterial isolates among HIV-infected children 
et al7 in the United Kingdom also reported a high prevalence with otitis media were predominantly gram-negative 
of ENT (ear-nose-throat) lesions (90%) among HIV- infected organisms such as Klebsiella spp., Pseudomonas spp., and 
children. All these studies were conducted at least 8 years  Proteus spp. This is comparable to other reports.12,22 There 
prior to this study. The difference between the prevalence is a study, which reported predominance of Streptococcus 
rate in this study and other reports may be due to the decline p neumoniae23 conducted before pneumococcal vaccine and 
in new pediatric HIV infections globally and improved access was included in the routine immunization program, which 
to art. may explain the predominance of S. pneumoniae, although 
In general, HIV-infected children had more ORL lesions some other recent reports have shown predominance of 
than HIV-negative children. Cervical adenopathy and hearing S. pneumoniae in isolates from middle ear discharge.24 
loss were the only ORL lesions that showed significant asso- Another factor that may modify the spectrum of predom-
ciation with pediatric HIV infection in this study. Although inant bacteria is the emergence of drug-resistance organ-
cervical adenopathy was common among HIV-infected chil- isms that are now being seen among community-acquired 
dren, the prevalence among HIV-negative children was also infections.
high. There is a myriad of etiologies of cervical adenopathy in In this study, there was scarce reporting of lesions that 
children regardless of HIV status. Many of these etiologies are had been previously described to occur commonly in HIV 
benign infections such as viral upper respiratory tract infec- infection such as oral candidiasis, herpes simplex, hairy 
tions. Less commonly are chronic conditions such as tubercu- leukoplakia, and Kaposi’s sarcoma. This probably could be 
losis, autoimmune diseases, and malignancies. explained by the fact that a large percentage of the HIV-in-
Hearing loss was another ORL lesion that was common fected children were on ART, which halts progression of 
among HIV-infected children. The prevalence of hearing loss the disease to more severe stages in which the aforemen-
among children with HIV in this study was 36% that is com- tioned lesions occur.
parable to 33% by Christopher et al14 in Uganda and 33.8% 
by Chao et al15 in Peru. When compared with HIV-negative Conclusion
children, a prevalence of 16% in this study is comparable The ORL lesions occur more commonly among HIV-infected 
to 15% recorded in Angola.9 All children with CSOM in this children than HIV-negative children. Use of ART improves the 
study were HIV infected and had higher prevalence of hear- clinical course and outcome of HIV-infected children result-
ing loss than children with wax impaction, who comprised ing in fewer ORL lesions. Hearing loss is associated with HIV 
more HIV-negative children. Middle ear infections and often infection, and evaluation for hearing loss should be routine 
associated tympanic membrane perforations are the primary for all HIV-infected children.
mechanisms of hearing loss described in HIV-infected chil-
dren.9,12,16–18 These mechanisms were demonstrated in data Conflict of Interest
from Peru and Malawi where CHL was the predominant None.
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110 ORL Lesions among HIV-Infected Children Babatunde et al.
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