HIV and ENT: what to look for in the ear, nose, mouth and neck
- Topic
Mouth thrush, white tongue patches, purple lesions or swollen glands can be the first sign of HIV; offer the test and look for treatable infections.
What it is
Most people with HIV have a head and neck finding at some point, and the mouth is where it shows first. Some findings appear at any CD4 count (persistent generalised lymphadenopathy, the sore throat and ulcers of acute HIV), others mark falling immunity (oral candidiasis, hairy leukoplakia, Kaposi sarcoma, lymphoma) and others are the infections that rise below a CD4 count of about 200 cells per microlitre. For the general doctor, the job has three parts: recognise the pattern, offer an HIV test, and not miss the dangerous causes behind a common symptom, such as tuberculosis or lymphoma in a neck node, invasive fungus in the sinuses, or cryptococcal or syphilitic disease behind hearing loss. Antiretroviral treatment reverses many of these findings.
Structure
- Mouth: candidiasis (pseudomembranous, erythematous, angular cheilitis), hairy leukoplakia, Kaposi sarcoma, necrotising gingivitis and periodontitis, large aphthous ulcers, herpes simplex and CMV ulcers, HPV warts, dry mouth, lymphoma.
- Pharynx and oesophagus: candida oesophagitis (odynophagia), adenotonsillar lymphoid hyperplasia, ulcers.
- Neck: persistent generalised lymphadenopathy, tuberculous lymphadenitis, lymphoma, Kaposi sarcoma, metastatic HPV-related cancer.
- Salivary glands: benign lymphoepithelial cysts of the parotid (diffuse infiltrative lymphocytosis), dry mouth.
- Nose and sinuses: recurrent or chronic rhinosinusitis, unusual organisms (Pseudomonas, fungi) and invasive fungal sinusitis when CD4 is very low.
- Ear: otitis media with effusion in adults (often from adenoid hyperplasia, but a nasopharyngeal tumour must be excluded), otitis externa, sensorineural hearing loss (HIV itself, cryptococcal meningitis, syphilis, ototoxic drugs), facial palsy (zoster, seroconversion).
ENT signs of HIV: what they mean and what to do
| Site | Finding | Cause | Next step |
|---|---|---|---|
| Mouth | White plaques that wipe off; red base | Candida | Topical antifungal or fluconazole; HIV test if unexplained |
| Tongue (sides) | White corrugated patches that do not wipe off | Hairy leukoplakia (EBV) | No treatment needed; start or optimise antiretroviral therapy |
| Palate and gums | Purple macules or nodules | Kaposi sarcoma (HHV-8) | Biopsy; HIV team and oncology |
| Gums | Painful necrosis of papillae, bleeding, foul breath | Necrotising periodontal disease | Dental care, debridement, antibiotics |
| Neck | New, asymmetric or growing node | TB, lymphoma, Kaposi, cancer | Fine-needle aspiration with acid-fast stain and culture |
| Parotid | Bilateral soft swelling with cysts | Benign lymphoepithelial cysts | Ultrasound; observation; biopsy if it changes |
| Ear | Sudden or rapid hearing loss | HIV, syphilis, cryptococcus, drugs | Audiometry, syphilis serology, same-day ENT if sudden |
In clinical practice
- Odynophagia with oral thrush suggests candida oesophagitis, an AIDS-defining illness.
- Hairy leukoplakia needs no specific treatment; it regresses with antiretroviral therapy, but it tells you immunity is failing.
- Any chronic oral ulcer in a person with HIV is biopsied: CMV, herpes, histoplasmosis, lymphoma and squamous cell carcinoma look alike.
- An adult with new one-sided otitis media with effusion needs a nasopharynx exam to rule out lymphoma or carcinoma.
- Sudden or rapid hearing loss in HIV: look for syphilis and cryptococcal meningitis and review ototoxic drugs.
- After starting antiretroviral therapy, nodes may enlarge again from immune reconstitution (IRIS), often unmasking tuberculosis.
Next step / Initial management
- Unexplained oral candidiasis, hairy leukoplakia, Kaposi-like lesions, generalised nodes, recurrent zoster or a mononucleosis-like illness: offer an HIV test with consent and counselling (rapid test), and test for syphilis.
- New HIV diagnosis: CD4 count and viral load, screening for TB, and referral to the HIV care programme to start antiretroviral therapy without delay; priority referral, within days.
- Oral candidiasis: topical antifungal (nystatin, clotrimazole) for mild cases; fluconazole for moderate or severe disease or odynophagia.
- New or asymmetric neck node, chronic ulcer or palatal lesion: priority referral (within two weeks) to ENT or head and neck surgery for fine-needle aspiration or biopsy with cultures.
- Same-day referral for sudden hearing loss, facial necrosis or black nasal crusts with fever (invasive fungal sinusitis), stridor or a deep neck infection.
- Use standard precautions for every patient; after a needlestick, follow the post-exposure prophylaxis protocol at once.
Test yourself
Think of the answer, then tap the question to see it.
A 32-year-old man has white, corrugated patches on both sides of the tongue that cannot be scraped off. What is the likely lesion and its cause?
Oral hairy leukoplakia, caused by Epstein-Barr virus; it is a marker of HIV progression. Offer an HIV test and start antiretroviral therapy.
A person with HIV has white plaques in the mouth that wipe off and now pain on swallowing. What does the pain suggest?
Candida oesophagitis, an AIDS-defining illness; treat with systemic fluconazole and check CD4 and viral load.
A patient with HIV has a new, firm, enlarging node in one side of the neck with night sweats. What is the next step?
Fine-needle aspiration with acid-fast stain, mycobacterial culture and cytology, looking for tuberculosis, lymphoma or Kaposi sarcoma.
A woman with HIV has painless, bilateral parotid swelling; ultrasound shows multiple cysts. What is the likely diagnosis?
Benign lymphoepithelial cysts of the parotid; they are observed and often shrink with antiretroviral therapy; biopsy if they change.
Elsewhere in DurgiPedia
- HIV and the mouth
- Oral candidiasis (thrush)
- Necrotising gingivitis and periodontitis
- HIV and the eye: CMV retinitis and more
- How HIV destroys CD4 T cells
Connections
Microorganisms9
Educational content; it does not replace a medical assessment and is not a clinical instruction. For a real case, follow current guidelines and specialist advice.
Sources: HIV and AIDS (StatPearls Publishing (NCBI Bookshelf), 2026); HIV-1–Associated Opportunistic Infections (StatPearls Publishing (NCBI Bookshelf), 2026); Oral Candidiasis (StatPearls Publishing (NCBI Bookshelf), 2023); Hairy Leukoplakia (StatPearls Publishing (NCBI Bookshelf), 2023); Kaposi Sarcoma (StatPearls Publishing (NCBI Bookshelf), 2026); HIV/AIDS & Oral Health (National Institute of Dental and Craniofacial Research (NIDCR), NIH, 2024).
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Representative model, for educational purposes only.