Otologic and audiologic evaluation of human immunodeficiency virus-infected patients

Original Contributions

Otologic and Audiologic Evaluation of Human Immunodeficiency Virus-Infected Patients Sujana S. Chandrasekhar, MD, Patricia E. Connelly, PhD, Sapna S. Brahrnbhatt, BS, Chetan S. Shah, MD, Patricia C. Kloser, MD, and So]y Baredes, MD Purpose; To quantify the incidence of ear disease in patients infected with human immunodeficiency virus (HIV). Materials and Methods: Th~s is a descnptive case series of HIV-positive patients, with data collected using an otologic questionnaire, otologlc examination, aud~olog~c evaluation, and chart review. The study was performed at an urban University Hospital's outpatient Infectious D~sease and Otolaryngology chn~cs. A consecutive sample of 50 HIV-mfected patients volunteered for this study. Ten subjects refused. Almost all patients received public assistance for medical care. Descnpt~ve results were tabulated. Audiometnc data were analyzed for ear, Centers for Disease Control (CDC) group, otologic complaint, and age effects. Data were compared with established norms. Results: Twenty-three men and 27 women with a mean age of 40 years and mean duration of HIV disease of 3.5 years were studied. Eighteen percent of patients were in category CDC-A, 38% in CDC-B, and 44% Jn CDC-C. Otologic complaints were more prevalent than expected: 34% of patients reported aural fullness, 32% dizziness, 29% hearing loss, 26% tmnitus, 23% otalg~a, and 5% otorrhea. Results of the neuro-otologlc examination were abnormal in 33%. Tympanometric examination was abnormal in 21%. A signdicant degree of Ngh-frequency sensorineural hearing loss was observed. CDC-B and CDC-C patients had worse heanng than CDC-A patients at 3 frequencies. Patients who complained of hearing loss had significantly worse otoacoustic emission results and hearing results than patients who d~d not, at all frequencLes except 1,000 Hz. Patients m their 30s had better hearing in the speech frequencies than did all other patients. Conclusions: Ear disease affects up to 33% of HIV-infected patients. Otltis media is a frequent finding. Sensorineural hearing loss is more severe m patients with more severe HIV infection. Patients with ear complaints have demonstrable otopathology Continuation of this preliminary descriptive work is necessary. (Am J Otolaryngo12000;21:1-9. Copyright © 2000 by W.B. Saunders Company)

From the Divisions of Otolaryngology--Head and Neck Surgery and Infectious Diseases, University of Medicine and Dentistry of New Jersey, New Jersey Medical School, Newark, NJ. Presented at the Eastern Section Meeting of the American Laryngologlcal, Rhinological, and Otolog]cal Society (The Tnologlc Society), Pittsburgh, PA, January 1995. Address repnnt requests to Suiana S Chandrasekhar, MD, Assistant Professor, Division of Otolaryngology-Head and Neck Surgery, UMDNJ--New Jersey Medical School, Director of Otology/Neurotology, UMDNJ-University Hospital, 185 South Orange Ave, Room MSB H-592, Newark, NJ 07103-2714 Copyright © 2000 by W B Saunders Company 0196-0709/00/2101-0001 $10 00/0

Many patients infected with human immunodeficiency virus (HIV), the causative organism in acquired immune deficiency syndrome (AIDS), eventually present with disease-related manifestations involving the ear, head, or neck. 1 Patients infected with HIV often present with derangements involving the ear, which negatively impact quality of life. The actual incidence of ear disease and hearing loss in this patient population is not known. This is of particular concern, because the disability of partial or complete hearing loss is magnified in a person with many other medical problems.

Amencan Journal of Otolaryngology, Vo121, No 1 (January-February), 2000. pp 1-9

1

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TABLEI.

CHANDRASEKHAR ET AL

Chnlcal Categortes of HIV Infection

Category CDC-A Asymptomatlc HIV mfectlon Persistent generahzed lymphadenopathy (PGL) Acute (primary) HIV infection with accompanying dlness or htstory of acute mfect]on Category CDC-B Bacdlary ang~omatos[s Candldtasts, oropharyngeal (thrush) Candldlasts, vulvovagmal; persistent, frequent, or poorly responstve to therapy Cervtcal dysplasla (moderate or severe)/cervtcal carctnoma-ln-sttu Constttuttonal symptoms, such as fever (38 5°C) or dtarrhea lasting longer than 1 month Ha~ry leukoplakla, oral Herpes zoster (shmgles mvolwng at least 2 distinct eptsodes or more than one dermatome) Idiopathic thrombocytopentc purpura LJstenosls Pelwc inflammatory disease, parttcularly ff comphcated by tubo-ovartan abscess Peripheral neuropathy Category CDC-C Cand~d~asts of bronch~, trachea, or lungs Candldlasis, esophageal Coccldtomycosls. dlssemtnated, or extrapulmonary Cryptococcus, extrapulmonary Cryptospondiosts >1 month CMV dtsease (other than hver/spleen/nodes) CMV rettnitls HIV encephalopathy Herpes simplex, chronic ulcers (>1 month) Herpes simplex, bronchltts/pneumonitis/esophagttLs H~stoplasmosis, dtsseminated, or extrapulmonary Isosponas]s >1 month Kaposl's sarcoma Lymphoma Mycobactenum awum complex Mycobactenum tuberculosis Pneumocystlscannhpneumonia Progressive mult~focal encephalopathy Salmonella sepsis Toxoplasmosls (cerebral) Recurrent pneumonia >2 Invasive cervical carctnoma Wastmg syndrome--loss >20% of body weight Abbrevtattons HIV, human ~mmunodeftctency vtrus; CMV, cytomegalovlrus

The literature regarding otologic manifestations in HIV and AIDS is scanty but reveals certain trends. Frequent otologic diagnoses encountered in HIV-infected patients include otitis externa, acute otitis media, and otitis media with effusion. 2 Opportunistic infections, such as otic infection caused by Pneumocystis carinii, have been documented in HIVinfected patients. 3,4 Syphilis affects HIVinfected patients at an accelerated rate, and

otosyphilis can occur at any stage of HIV infection. 5 Sensorineural hearing loss, both sudden in onset and gradual, is a reported finding in HIV-infected patients. 6,7 Possible causes responsible for hearing loss among HIV-infected patients include use of ototoxic medications, middle ear disease, presence of neurological infections, and direct effects of HIV on the inner ear. The Centers for Disease Control and Prevention (CDC) has reported that the number of children, adolescents, and adults diagnosed with AIDS before 1981 through December 1996 totals 581,429. 8 Recent literature reports that the time from acquiring HIV infection to the development of AIDS can approach 20 years. 9 With uncertain periods of HIV infection evolving into AIDS, 1° changes in the AIDS incidence trends, 11 and the emergence of n e w treatment regimens for HIV-infected patients, physicians are paying more attention to the non-life-threatening medical problems associated with a significant degree of morbidity and decrease in the quality of life of HIV-infected patients. The CDC classifies HIV-infected patients into 3 general categories (A, B, and C) based on symptomatology (Table 1). 12 These categories are further divided based on CD4-positive T helper lymphocyte counts (Table 2). The earliest stage of HIV infection is, therefore, given a CDC classification of A1, whereas the most severe HIV infection is classified as C3. Studies 13,14performed on the temporal bones of HIV-infected patients show pathological changes involving the middle ear, mastoid, and inner ear. Middle ear changes include low-grade and severe otitis media, cholesteatoma, and the presence of inclusions characteristic of cytomegalovirus (CMV) infection in middle ear epithelium. Inner ear pathology consists of cryptococcal infection, CMV infection, and Kaposi's sarcoma in the 8th nerve. The mastoid and petrous air cell systems show severe inflammatory changes even in asympTABLE2. CD4+ T-Cell Categories

CDC-A

CDC-B

CDC-C

(1) >500/L (2) 200-499/L (3) <200/L

A1 A2 A3

B1 B2 B3

C1 C2 C3

EVALUATION OF HIV-INFECTED PATIENTS

tomatic HIV-infected patients. On ultrastructural e x a m i n a t i o n , intracellular viral-like particles ( p r e s u m a b l y HIV) h a v e b e e n s h o w n on the tectorial m e m b r a n e s a n d c o n n e c t i v e tissue cells of the i n n e r ear. 14 A l t h o u g h t e m p o r a l b o n e studies c o n f i r m the clinical suspicions of extensive otologic disease in HIV-infected individuals, the exact m a g n i t u d e of the p r o b l e m r e m a i n s u n k n o w n . T h e c u r r e n t s t u d y aims to quantify the incid e n c e of otologic a n d audiologic d e r a n g e m e n t in patients infected w i t h HIV. Based on our findings, w e can make clinical r e c o m m e n d a tions for the early diagnosis and t r e a t m e n t of ear disease in this patient p o p u l a t i o n .

MATERIALS AND METHODS Adult HIV-positive patients treated in the Infectious Disease Clinic at University of Medicine and Dentistry of New Jersey (UMDNJ)--University Hospital in Newark, New Jersey, were asked to participate in this study. Patients were recruited for this study solely based on their positive HIV status and were not selected on the basis of otologic history or complaints. They were at least 18 years of age, of both sexes, and of all ethnic groups. Informed consent was obtained, per UMDNJ guidelines, and the study was conducted under the approval of the University's Institutional Review Board. An otologic questionnaire was administered to each patient. The questionnaire asked about the following complaints for each ear: otalgia, otorrhea, tinnitus, aural fullness, hearing loss, noise exposure, mastoiditis, otologic surgery, otitis media, herpes zoster oticus, trauma, and hearing aid use. Also elicited was information regarding facial nerve palsy, temporomandibular joint syndrome, and dizziness. A screening set of general otolaryngologic questions was asked and evoked information regarding sinusitis, allergies, nasal obstruction, oral cavity/ oropharyngeal disease, larynx/pharynx disease, and neck mass. A complete head and neck examination was

performed on each patient. The results of the examination were recorded on a data collection sheet. Laryngoscopy was only performed when indicated by patient complaint. Pure tone audiometry, speech discrimination scores (SDS), immittance, and otoacoustic emissions (OAE) evaluation of each patient were performed. Any otolaryngologic problems diagnosed during these evaluations were addressed at the time of evaluation. The medical charts of all patients who participated in the study were reviewed by a research nurse clinician from the Infectious Diseases clinic, and a medical data collection form for each patient was completed. This form recorded the following information: gender and race of the patient, HIV risk group(s), date of first positive HW test, white

3

blood cell profiles, and CDC-defined B-conditions or C-conditions. Hospitalizations and the number of physicians involved in the treatment of the patient since initially being diagnosed with HIV were identified. A list of medical conditions, current and past medications, and social history was obtained for each patient Data were collected using the patients' chart numbers and sorted using separately assigned study numbers. The Student's t-test (2-tailed) and 1- and 2-way analysis of variance tests were used in analysis. Statistical significance was set at P -- .05.

RESULTS Fifty patients (100 ears) were i n c l u d e d in this study. T h e r e were 23 m e n and 27 w o m e n w h o s e ages r a n g e d from 22 years to 58 years (mean age, 40 years). The average duration of diagnosis of HIV infection was 3.5 years, w i t h a range of 1.5 m o n t h s to 12 years. T h i r t y - n i n e patients were African American, 10 were Hispanic, a n d one was white. Risk factors for HIV t r a n s m i s s i o n w e r e as follows: Forty-seven percent w e r e e x p o s e d t h r o u g h i n t r a v e n o u s drug abuse, 12% t h r o u g h h o m o s e x u a l contact, and 67% t h r o u g h h e t e r o s e x u a l contact (male-tofemale t r a n s m i s s i o n in 69% and female-tomale in 21%). M u l t i p l e HIV risk factors were p r e s e n t in 25% of patients.

Questionnaire Results T h e results of the otologic q u e s t i o n n a i r e are as follows: Aural fullness was p r e s e n t in 34% of ears, tinnitus in 26%, otalgia in 23%, and otorrhea in 5%. Otitis m e d i a was a p r e s e n t or past c o m p l a i n t in 23% of ears. Hearing loss was present in 29% of the ears and was s u d d e n in onset in 3%, gradual in onset in 21%, a n d i n t e r m i t t e n t in 6%. Duration of hearing loss was available for 26 of the 29 ears w i t h c o m p l a i n t s of hearing loss and was an average of 2.5 years ranging from several weeks to 5 years. Hearing aid use was r e p o r t e d in one ear. S e v e n patients r e p o r t e d significant noise exposure. No patients gave a history of facial palsy or mastoiditis. Two patients gave a history of having h a d ear surgery in the past. Of these patients, one p r e v i o u s l y h a d m y r i n g o t o m y a n d tube insertion, and one p r e v i o u s l y h a d t y m p a n o p l a s t y . S e v e n t e e n patients rep o r t e d t r a u m a to the p i n n a or side of head; 2 patients r e p o r t e d h e r p e s zoster oticus.

4

Sixteen patients (32%) reported dizziness. Of these patients, 2 (4%) had spinning vertigo, 13 (26%) felt light-headed, and in 4 (8%), the symptoms were positional or fatigable. Some patients complained of m a n y types of dizziness. Twelve percent of patients reported sinusitis, 16% reported nonpharmacologic allergies, 20% complained of nasal obstruction, 28% complained of oral cavity or oropharyngeal disease, 8% noted laryngeal symptoms, and 16% complained of persistent neck mass. Examination Results

Neuro-otologic and otolaryngologic examination was normal in 20% of the patients. Neuro-otologic examination alone was abnormal in 33 % of ears. Two ears had dry tympanic membrane perforations, 2 had wet tympanic membrane perforations, 3 ears had otitis externa, 7 had acute otitis media, and 15 ears had cerumen impaction that was cleared. No patient had serous otitis media. One patient had decreased sensation in the distribution of the second branch of the trigeminal nerve on one side of the face. Cranial nerve examination was normal in all other patients. Abnormal findings on general otolaryngologic examinations were noted in 80% of the patients. Findings included thrush (oral candidiasis) in 6 patients (12%), oral cavity ulcers in 3 patients (6%), cervical lymphadenopathy in 14 patients (28%), and Kaposi's sarcoma of the hard palate and oral cavity leukoplakia seen in i patient. Medical Chart Review Results

CD4 (T-helper lymphocyte) counts (normal, >4O0/mm 3) were available for all 50 patients and ranged from 0 to 971 (mean CD4 count, 208). CD4 counts for male patients (n -- 23) ranged from 5 to 730 (mean = 196); for female patients (n = 27), the range was 26 to 971 (mean, 219). This difference was not statistically significant. Based on the CDC classification system for HIV infection, 12 9 patients (18%) were in category CDC-A, 19 (38%) were in category CDC-B, and 22 (44%) were in category CDC-C. Further divided into subcategories, 3 patients (6%) were classified as CDC-A1, 5 (10%) were CDC-A2, one (2%) was

CHANDRASEKHAR ET AL

CDC-A3, 12 (24%) were CDC-B2, 7 (14%) were CDC-B3, 3 (6%) were CDC-C2, and 19 (38%) were CDC-C3 (Table 2). The average age for patients in CDC-A was 35.7 years, was 41.7 years in CDC-B, and in CDC-C was 39.2 years. The age difference was not statistically significant. Category C conditions encountered were Pneumocystis carinii pneumonia in 15 patients (30%), coccidomycosis in one patient (2%), cryptococcus in one patient (2%), CMV disease in one patient (2%), herpes simplex virus (HSV) ulcers in one patient (2%), HSV bronchitis/pneumonitis/esophagitis in one patient (2%), mycobacterium avium complex in 2 patients (4%), and wasting syndrome in 2 patients (4%). Seven patients had documented syphilis, and all of these were rapid plasma reagin positive. Other medical problems encountered in these patients included hypertension (14%) and diabetes mellitus (2%). The use of past and current medications was documented. Twenty patients had been treated with oral or parenteral antibiotics. The one patient who had received intravenous medication had been treated with gentamicin. Other medications used were azidothymidine (AZT) (63%), acyclovir (35%), trimethoprim-sulfamethoxazole (29%), aerosolized pentamidine (20%), dideoxyinosine (DDI) (18%), and dideoxycytidine (DDC) (16%). Five patients are currently enrolled in a double-blind clinical trial that includes AZT alone, AZT with DDI, AZT with DDC, or DDI alone, so that the true number of patients currently taking AZT, DDI, and DDC is not known. Audiometric Results

Tympanometry. Overall, type A (normal) tympanograms were elicited in 67% of ears. Tympanometry was not able to be performed in 12% of ears. Of the remaining 21% abnormal tympanograms, 52% (11 ears) had type B (flat) tracings, 24% (5 ears) had type As (stiff) curves, 10% (2 ears) had Ad (high-amplitude) curves, and 14% (3 ears) had type C (negative pressure) tracings. Ear and Frequency Effects. On all audiometric data (pure tone, SDS, and OAE) collapsed across CDC group, otologic complaint, and age, there was no statistically significant

EVALUATION OF HIV-INFECTED PATIENTS

5

effect on the ear. Right and left ear data were combined for all subsequent analyses. There was a statistically significant effect for frequency (F[5,94] = 13.5, P < .05), as the mean hearing thresholds for 4,000 Hz (19.1 dB HL) and 8,000 Hz (21.2 dB HL) were significantly elevated relative to the others but not from each other. The mean hearing thresholds at 250 Hz (12.3 dB HL), 1,000 Hz (11.5 dB HL), and 2,000 Hz (12.5 dB HL) were not significantly different from one another. CDC Group Effects. There were significant differences ( P < .05) among mean hearing thresholds for the 3 CDC groups at 500 Hz, 2,000 Hz, and 8,000 Hz. Mean hearing levels for the CDC-A patients were significantly lower than for the CDC-B and CDC-C patients. Mean hearing levels for the CDC-B and CDC-C patients did not differ significantly. These data are summarized in Figure 1. Mean hearing thresholds were not statistically different for the 3 CDC groups at 250 Hz, 1,000 Hz, and 4,000 Hz. There were no statistically significant differences in SDS by CDC group. No statistically significant differences were found among the mean echo OAE data for each CDC group nor among mean OAE reproducibility data for each group. There was no correlation between medication used and hearing loss.

Otologic complaint effects. Four otolaryngologic complaints that relate specifically to the ear were evaluated: tinnitus, aural full-

ness, hearing loss, and dizziness. Reports of a positive history of any of these complaints were scored "Yes" for that complaint for the purposes of the statistical evaluations. In this way, a comparison could be made between HIV-positive patients reporting specific otologic complaints and HIV-positive patients not reporting those complaints. There were no statistically significant differences between mean hearing thresholds from 250 through 8,000 Hz for HIV-positive patients who complained of tinnitus, aural fullness, or dizziness w h e n compared with those HIVpositive patients who did not report such complaints (Fig 2). By contrast, the analyses of variances for the complaint of hearing loss showed statistical significance at all frequencies except 1,000 Hz (F[1, 98] = 3.67, P > .05), indicating that HIV-positive patients who reported hearing loss had significantly worse hearing than HIV-positive patients who had no complaint of hearing loss (Fig 2). The F(1, 98) ratios for the statistically significant results ranged from 5.81 to 8.56 with power values ranging from 0.66 to 0.86. There were no significant differences between the mean SDS of the 2 patient groups tested for all 4 otologic symptoms. There were no statistically significant differences between patients who reported tinnitus, aural fullness, and dizziness and those who did not for either OAE parameter (echo and reproducibility data). However, the patient groups differed significantly on both OAE parameters for the hearing loss symptom. The mean echo was CDC Group Hearing Levels

30 20,

~

Fig 1. A v e r a g e a u d i o m e t ric hearing levels as a function of C D C group (white bar = CDC-A; gray bar = CDCB; black bar = CDC-C).

20

0

'

250 Hz

500 Hz

1000 Hz

*

2000 Hz

Frequency (Hz)

4000 Hz

8000 Hz

6

CHANDRASEKHAR ET AL

Hearing Level for Tlnnitue 25, ~2o,

i

15,

~

i,m,|

10,

o

4000

8o0o

F r ~ m ~ c y (Hz)

Hearing Loss for Aural Fullness 25 •

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Hearing Level for

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25.

5

....

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Haarlng Levels for Hearing L o s t 30

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-

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Fig 2. Average audiometric hearing levels as a function of otologic complaint (white bar = Yes [positive otologic complaint]; black bar = No [negative otologic complaint]).

5.37 dB (SD = 5.72 dB) for patients c o m p l a i n ing of hearing loss and 8.64 dB (SD = 4.68 dB) for p a t i e n t s w i t h o u t the c o m p l a i n t (F[1, 98] = 9.76, P < .05; p o w e r = 0.87). M e a n rep r o d u c i b i l i t y was 56.1% (SD = 37.4%) for patients w i t h the hearing loss c o m p l a i n t a n d 80.8% (SD = 24.7%) for patients w i t h o u t the c o m p l a i n t (F[1, 98] = 15.8, P < .05; p o w e r = 0.98). Age Effects. Each patient's age in years was c o n v e r t e d to his or her age-decade so thai patients in their 20s w e r e assigned an age-

d e c a d e of 3, and those in their 40s w e r e assigned an age-decade of 5, and so on. Statistically significant differences in m e a n puret o n e hearing t h r e s h o l d w e r e f o u n d as a function of age for 250 Hz (F[3, 96] = 3.04, P < .05), 500 Hz (F[3,96] = 3.48, P < .05), and 2,000 Hz (F[3, 96] = 2.84, P < .05). It is interesting that those patients in their 30s h a d significantly better hearing t h r e s h o l d s at these frequencies t h a n older as well as y o u n g e r patients, and that patients in their 20s h a d m e a n hearing t h r e s h o l d s closer to those of patients in their 40s a n d 50s. T h e r e w e r e no statistically signifi-

EVALUATION OF HIV-INFECTED PATIENTS

7

cant differences in mean hearing thresholds as a function of age for frequencies 1,000 Hz, 4,000 Hz, and 8,000 Hz. These data are summarized in Figure 3. There were no statistically significant differences in mean age for those patients who did or did not complain of aural fullness, dizziness, or hearing loss. There was a significant effect of age on the presence or absence of tinnitus (F[1, 98] = 8.45, P < .05), with a mean age of 36.7 years (SD = 9.2 years) for patients who complained of tinnitus and 42.1 years (SD = 8.7 years) for patients who did not report that symptom. There were no statistically significant age effects for echo or for reproducibility OAE data. DISCUSSION Our findings indicate that one third of patients who are HIV infected may have significant otologic complaints or findings. This is a significant percentage and is probably higher than has been perceived in the otolaryngologic

and infectious diseases communities. In addition, there are trends in the audiometric data that imply worsening hearing loss with worsening HIV infection and earlier high-frequency hearing loss overall than is expected. This study is somewhat hampered by its small sample size of 50 patients (100 ears). Although we were able to show statistically significant findings, some data indicated trends that may have proved to be statistically significant if larger numbers of patients had been studied. This study is unlike most studies on HIV in that most of our patients were women. The figures from the CDC indicate that 20.5% of HIV/AIDS patients are female. 8 Because of this factor, and because the average age in our study population was 40 years, we did not expect to see the high-frequency hearing loss that was noted. The general rule for the population as a whole is that, as age increases from 20 to 90 years, average pure tone sensitivity may decline about 30 dB. 15 There is some controversy over sex difference in presbycu-

Hearing L e v e l s By A g e 30

25

--I "I" 20

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==TWENTIES

..I ol c ,n

==THIRTIES [ ] FORTIES

t,,,

• q-

10

[] FIFTIES

5

0 250

500

1000

2000

4000

8000

Frequency (Hz) Fig 3. Average audiometric hearing level as a function of subject age (white bar = twenties; dark gray bar = thirties; light gray bar = forties; black bar = fifties).

8

sis. Studies either show no difference between males and females, or a higher prevalence of presbycusis in males. 16 "Ultra-audiometric" pure tone testing has been performed at frequencies ranging from 4 KHz through 20 KHz and shows increasing (worsening) threshold levels with increase in age and frequency for both genders. 17 There are no normative data to explain the drop in hearing in our patients in the 3rd decade (the 20s), as this is in fact the age-group in which the normal data were established. The frequency spectrum for speech is between 500 Hz and 3,000 Hz. It is disconcerting to note the drop in hearing in the speech spectrum for the patients in the 3rd, 5th, and 6th decades. This study population is also unusual in that it contains more severely HIV-infected patients: 38% of the 50 patients are classified as CDC-C3, the most severe HIV subcategory. Patients in categories CDC-B and CDC-C have significantly higher (worse) pure tone thresholds than CDC-A patients. There is a statistically significant elevation in pure tone thresholds in patients who reported hearing loss as an otologic complaint. Interestingly, tinnitus was a complaint of younger rather than older patients. There are no normative values available in the literature for findings of hearing loss by otologic complaint in the general population. However, it is known that subjective complaints of hearing loss are generally not reported by patients until a hearing loss of more than 25 dB HL occurs at a frequency below 3,000 Hz. 15 Clinicians should be aware that HIV-infected patients who are complaining of auditory symptoms may indeed have an otologic problem, not solely a central processing dysfunction, and should be referred for otologic evaluation and treatment. CONCLUSIONS Otologic disease affects as many as 33% of HIV-infected patients. Otitis media, which is extremely u n c o m m o n in normal adults, affects up to 23% of HIV-infected patients. Sensorineural hearing loss is more severe in patients with more severe HIV infection but does not correlate with routine medications used in the outpatient management of HIV. Younger

CHANDRASEKHAR ET AL

and older patients have more hearing loss. Patients with otologic complaints had demonstrable otologic or audiologic pathology, and the clinician should be alert to these complaints to refer patients for evaluation in a timely and appropriate fashion. Continuation of prospective otologic and audiologic evaluation of randomly selected HIV-infected patients will allow further quantification and qualification of the incidence of otologic disease in this population. ACKNOWLEDGMENTS The authors thank Nancy Schneider, MA, CCC-A, and Lisa Bell, MA, CCC-A, for performing all of the audiologic evaluations. The authors thank Patricia K. Correll, RN, for collecting all of the medical information. REFERENCES 1. Lucente FE. Otolaryngologic aspects of acquired lmmunodeficiency syndrome. Med Chn North Am 75: 1389-1398, 1991 2. Kohan D, Rothstein SG, Cohen NL: Otologic disease m patients with acquired immunodeficlency syndrome. Ann Otol Rhinol Laryngo197:636-639, 1988 3. Breda SD, Glgliotti F, Hammerschlag PE, et al: Pneumocystls carinii in the temporal bone as a primary manifestation of the acquired immunodeficiency syndrome. Ann Otol Rhinol Laryngol 97:427-430, 1988 4 Schinella R, Breda SD, Hammerschlag PE: Otic infection due to Pneumocystls carinil in an apparently healthy man with antibody to the human immunodeficiency virus. Ann Intern Med 106:399-400, 1987 5. Smith ME, Canalis RF: Otologic mamfestations of AIDS: The otosyphilis connection. Laryngoscope 99:365372, 1989 6. Timon CI, Walsh MA: Sudden sensorineural hearing loss as a presentation of HIV infection. J Laryngol Otol 103:1071-1072, 1989 7. Real R, Thomas M, Gerwin JM. Sudden hearing loss and acquired immunodeficiency syndrome. Otolaryngol Head Neck Surg 97:409~412, 1987 8 Statistics from the Centers for Disease Control and Preventmn. HIV/AIDS Surveillance Report 8:1-35, 1996 9. Phillips AN, Sabin CA, Elford J, et al. Use of CD4 lymphocyte count to predict long term survival free of AIDS after HIV infection. Br Med J 309:309-313, 1994 10. Bacchetti P, Segal MR, Hessol NA, et al. Different AIDS incubation periods and their impacts on reconstructing human immunodeficiency virus epidemics and projecting AIDS incidence. Proc Natl Acad Sci USA 90:21942196, 1993 11. Green TA, Karon JM, Nwanyanwu OC" Changes in AIDS incidence trends in the United States. J Acquir Immune Defic Syndr 5:547-555, 1992 12. 1993 Revised Classification System for HIV Infection and Expanded Surveillance Case Definition for AIDS Among Adolescents and Adults. MMWR 41(RR-17)'1-13, 1993

EVALUATION OF HIV-INFECTED PATIENTS

13. Chandrasekhar SS, Siverls V, Chandra Sekhar HK. Histopathologlc and ultrastructural changes in the temporalbones ofHIV-infected human adults A m J O t o l 13:207214, 1992 14. Pappas DG, Chandra Sekhar HK, Lira J, et al: Ultrastructural findings in the cochlea of AIDS cases. Am J Oto] 15:456-465, 1994 15. Lebo C, Reddell R: The presbyacusis component in

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occupational hearing loss. Laryngoscope 82:1399-1402, 1972 16. Jerger S, Jerger J: in Auditory Disorders' A Manual for Clinical Evaluation. Boston, MA, Little, Brown, 1981, pp 147-152 17. Osterhammel D, Osterhammel P' High-frequency and audiometry: Age and sex variation. Scand Audiol 8:73-81, 1979