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CASE REPORT
Year : 2020  |  Volume : 26  |  Issue : 2  |  Page : 112-114

Tick-induced vestibular ototoxicity and facial nerve paralysis successfully treated with intratympanic steroid injections


Department of Otorhinolaryngology-Head and Neck Surgery, School of Medical Sciences, Universiti Sains Malaysia Health Campus, Kota Bharu, Kelantan, Malaysia

Date of Submission18-May-2020
Date of Acceptance01-Jun-2020
Date of Web Publication17-Jul-2020

Correspondence Address:
Dr. Senthilraj Retinasekharan
Department of Otorhinolaryngology-Head and Neck Surgery, School of Medical Sciences, Universiti Sains Malaysia Health Campus, 16150 Kota Bharu, Kelantan
Malaysia
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/indianjotol.INDIANJOTOL_95_20

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  Abstract 


Tick infestation causing facial nerve palsy has been reported especially in Southeast Asian (this) region of the world. However, there has not been a report of tick infestation causing vestibular ototoxicity. A detailed otology history and careful otoscopic examination is paramount when an abnormal presentation is seen. Timely and appropriate treatment will mitigate long-term sequelae of toxicity. We report a case of a patient presenting with dizziness, reduced hearing, and unilateral facial paralysis secondary to tick infestation. We outline the successful management of this condition.

Keywords: Facial paralysis, ototoxicity, tick paralysis


How to cite this article:
Retinasekharan S, Nadarajah S. Tick-induced vestibular ototoxicity and facial nerve paralysis successfully treated with intratympanic steroid injections. Indian J Otol 2020;26:112-4

How to cite this URL:
Retinasekharan S, Nadarajah S. Tick-induced vestibular ototoxicity and facial nerve paralysis successfully treated with intratympanic steroid injections. Indian J Otol [serial online] 2020 [cited 2020 Aug 12];26:112-4. Available from: http://www.indianjotol.org/text.asp?2020/26/2/112/289952




  Introduction Top


Ticks are blood-sucking arachnids that feed on all classes of vertebrates including birds, amphibians, reptiles, and mammals. Humans are often accidental hosts, and a blood meal by a tick results in the secretion of chemical compounds that allows it to feed for days. As a result, tick bites can often result in many detrimental effects, some of which can be severe allergic reactions or potentially life-threatening, such as tick paralysis.[1] Tick-induced isolated facial paralysis is a rare form of the disease that has been reported developing occurring between 3 days and 3 weeks after attachment to the external auditory canal or attachment behind the ear.[2] However, there have been no reports of tick-induced ototoxicity with facial paralysis. We report a case of a patient presented with giddiness, reduced hearing, and unilateral facial paralysis.


  Case Report Top


A 71-year-old female with underlying type II diabetes mellitus (DM) and hypertension was admitted to the general medical ward with the presentation of sudden-onset giddiness and left facial nerve palsy with progressive reduced hearing bilateral for a week duration. She was admitted for further workup to rule out acute ischemic stroke. However, she did not demonstrate any neurological deficits such as dysarthria or limb weaknesses. Her cerebellar signs were normal. Neuro-otological examinations revealed a spontaneous horizontal nystagmus. She displayed lower motor neuron left facial nerve palsy (House–Brackmann Grade IV). Upon further history, it was noted that she had left ear pain and itchiness past 1 week. Otoscopy examination revealed engorged looking tick at the posterior wall of the external ear canal near the tympanic membrane [Figure 1], together with its fecal material all over the canal.
Figure 1: Tick at posterior wall of external ear canal close to tympanic membrane

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The patient was subsequently referred to the otorhinolaryngology clinic. The tick and its fecal materials were removed with ear syringing as the tick was seen not attached to the ear canal [Figure 2]. The ear canal appeared erythematous and mildly edematous with no tick remnant left behind. Hearing assessment for this patient showed left profound sensorineural hearing loss with right mild-to-moderate sensorineural hearing loss. In view of her underlying DM, a short course of oral methylprednisolone 30 mg daily was given for 3 days followed by intratympanic steroid injection (12 mg/ml dexamethasone) in the left ear for 3 days. The repeated hearing assessment showed improved hearing of the left ear to moderate sensorineural hearing loss. Her giddiness resolved and the left facial nerve palsy improved progressively.
Figure 2: Removed tick

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  Discussion Top


Ticks are obligate blood-sucking arachnids.[3] They are easily transmitted through domestic animals and pets to humans. The two major orders of ticks, based on the absence or presence of a hard shield (scutum), are Argasidae (soft ticks) and Ixodidae (hard ticks).[4] Dermacentor and Ixodes species are the subgroup of hard ticks that seems to be the most potent of all the world's paralyzing ticks.[5] In Malaysia, both species have been encountered to cause localized facial nerve palsy.[6]

Diagnosis of intra-aural tick is relatively straightforward. The tick may be found in the ear or evidence by the presence of feces of tick in the ear canal. An engorged full fed tick is easy to detect at its site of attachment. The unfed tick situated at the anterior deeper part of the external ear canal is normally not easy to see with an ordinary otoscopy examination. The anterior bony hump of the ear canal may block the view to that particular area. Another obstacle to visualize ticks is the presence of excessive wax. The shiny appearance of the tick abdomen within the wax might be the only clue of its presence. The dark brown color of faces of tick might mix with earwax and would be difficult to differentiate. In doubtful cases, examination under microscope is warranted.[7] Attachment and nutrition process of a tick is painless because of local anesthetic agent produced by tick during attachment and anticoagulant production to feed and it is difficult to be realized.

The paralyzing effect of tick is attributed to a toxin secreted in their salivary gland. This toxin is found to interfere with the liberation or synthesis of acetylcholine at the motor end plate of muscle fibers.[4] The severity of paralysis is independent of the number of tick infested.[3]

Several theories have been put forward to explain the pathophysiology of localized facial nerve palsy in an intra-aural tick infestation. It is plausible that a presence of perforation in the tympanic membrane enabled the tick saliva (with toxin) to enter the middle ear and reach the facial nerve probably through a natural dehiscence of the  Fallopian canal More Details causing paralysis.[6] In cases that the tympanic membrane is intact, direct extension of the inflammatory process to the fallopian canal is via persistent dehiscence or direct invasion of the infectious organisms into the facial canal through the middle ear, which results in edema of the inflamed nerve within the canal.[5]

Although there have been reports of dizziness, tinnitus, and ear hemorrhage as other most encountered signs, there has not been a case reported of intra-aural tick infestation causing giddiness with marked hearing impairment.[8]

We postulate that toxins or secondary edema had affected the vestibule-cochlear nerve as the same way it affects the facial nerve in previous reports.

The management involves taking a comprehensive history and correctly identifying the tick with subsequent complete removal. To the unsuspecting clinician and patient, failure to recognize the tick may result in continued secretion of toxin, thus further prolonging paralysis and increasing morbidity.[1] Tick attaches to its host with its mouthpart, which not only is imbedded in the skin but is also glued into place with a cement-like secretion. The tick can voluntarily detach from its host, but when forced off, it may leave the attached mouthpart imbedded in the skin. As long as the mouthpart is attached to the patient, the patient remains at risk for tick-borne illnesses.[8]

Steroid may help counteract the effects of toxins such as edema. In ear cases, intratympanic steroid injection would be more efficient by achieving adequate local concentration. To our knowledge, this is the first case where intratympanic steroid was used to this matter.

In conclusion, swift and accurate diagnosis and appropriate removal of the offending tick are the key principles for the management of tick envenomation. Although uncommon, the presentation of facial paralysis with sudden onset of giddiness and hearing impairment should warrant a further detailed otology history and otoscopy examination.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Pek CH, Cheong CS, Yap YL, Doggett S, Lim TC, Ong WC, et al. Rare cause of facial palsy: Case report of tick paralysis by Ixodes holocyclus imported by a patient travelling into Singapore from Australia. J Emerg Med 2016;51:e109-14.  Back to cited text no. 1
    
2.
Uǧuz M, Erdoǧan NM, Eken E. Tick-induced facial palsy. Turkiye Parazitol Derg 2015;39:248-51.  Back to cited text no. 2
    
3.
Spach DH, Liles WC, Campbell GL, Quick RE, Anderson DE Jr., Fritsche TR. Tick-borne diseases in the United States. N Engl J Med 1993;329:936-47.  Back to cited text no. 3
    
4.
Vedanarayanan V, Sorey W, Subramony S, editors. Tick paralysis. In: Seminars in Neurology. New York, NY, USA: Copyright© 2004 by Thieme Medical Publishers, Inc; 2004.  Back to cited text no. 4
    
5.
Miller MK. Massive tick (Ixodes holocyclus) infestation with delayed facial-nerve palsy. Med J Aust 2002;176:264-5.  Back to cited text no. 5
    
6.
Indudharan R, Dharap AS, Ho TM. Intra-aural tick causing facial palsy. Lancet 1996;348:613.  Back to cited text no. 6
    
7.
Patil MM, Walikar BN, Kalyanshettar SS, Patil SV. Tick induced facial palsy. Indian Pediatr 2012;49:57-8.  Back to cited text no. 7
    
8.
Amin Z, Baharudin A, Shahid H, Din Suhaimi S, Nor Affendie MJ. Isolated facial palsy due to intra-aural tick (ixodoidea) infestation. Arch Orofac Sci 2007;2:51-3.  Back to cited text no. 8
    


    Figures

  [Figure 1], [Figure 2]



 

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