Indian Journal of Otology

ORIGINAL ARTICLE
Year
: 2019  |  Volume : 25  |  Issue : 4  |  Page : 180--183

A clinico-etiological study of aural myiasis


Pradip Mallik, Vikas Sinha, Sushil Jha, Jigna Swani, Naimish Maniya, Sandeep Yadav 
 Department of ENT and Head and Neck Surgery, Government Medical College, Bhavnagar, Gujarat, India

Correspondence Address:
Dr. Pradip Mallik
Department of E.N.T., Sir. T. Hospital, Bhavnagar - 364 001, Gujarat
India

Abstract

Introduction: Human Myiasis is found among elderly and neglected patients. It occurs in skin and mucosa and causative agent maggot derived from families of Cuterbridae and Hypodermatidae. It otolaryngology it is found in ear nose and paranasal sinus and oral cavity and aural myiasis is found in patients with prolong systemic disease, otitis externa, otitis media, malignancy and other imunocompromised patients. Methodology: In this study we will discuss about aural Myiasis found in department of ENT for a period of 21 months. After taking proper history and examination all maggots were removed after putting turpentine oil soaked gauge piece and manually removing all by forceps. Regular dressing done under vision of endoscope and microscope. Results and Discussion: In this study it was found that females are more in numbers and geriatric age group is largely affected. People from slum areas were largely affected and mostly they were from lower socioeconomic background. Conclusion: Most of the aural myiasis found in external auditory canal however pre and post auricular regions also were affected. Most of the patients were anemic and also some patients were imunocompromised. So this study helps us to know the causative factors and how to treat the condition.



How to cite this article:
Mallik P, Sinha V, Jha S, Swani J, Maniya N, Yadav S. A clinico-etiological study of aural myiasis.Indian J Otol 2019;25:180-183


How to cite this URL:
Mallik P, Sinha V, Jha S, Swani J, Maniya N, Yadav S. A clinico-etiological study of aural myiasis. Indian J Otol [serial online] 2019 [cited 2020 Jul 2 ];25:180-183
Available from: http://www.indianjotol.org/text.asp?2019/25/4/180/272224


Full Text



 Introduction



“Myiasis” is derived from the Greek word “myia” which means “fly.” Myiasis is defined as infestation by diphterian larvae that feed on dead, necrotic, or immunocompromised living host tissue. It may affect the skin, body cavities, and internal organs.[1],[2] Human myiasis is found among the elderly and abandoned individuals, as well as in patients of geriatric hospitals and mental institutions presenting a poor hygienic habits.[3] Myiasis occurs in the skin and mucosa, and causative agent is maggot from the families of Cuterbridae and Hypodermatidae and a few Calliphoridae and Sacrophagidae species. Based on the degree of dependence on the host, myiasis is classified as: (1) “obligatory myiasis” where fly larvae are completely parasitic and depend on the host for completion of their life cycle and (2) “facultative myiasis” in which the fly larvae are free living and only acquired adaptation themselves to parasitic dependence to a host. An accidental infestation is defined as when the fly larvae infest a host that is not involved in their living cycle. Most cases of human myiasis are facultative or accidental.[4] Cutaneous myiasis is the most prevalent form and furuncular lesions are a relatively common dermatological condition.[5] In the field of otolaryngology, it may affect the ears, nose and paranasal sinuses, nasopharynx, oral cavity, and skin of the head and neck region. In this article, we will discuss about aural myiasis. Risk factors for aural myiasis are (1) systemic comorbidities such as diabetes mellitus and immunocompromised condition; (2) local comorbidities such as carcinomatous lesions, chronic otitis media, otitis externa, malignant otitis externa, poor hygiene, chronic nonhealing ulcerative lesions, neglected ruptured abscess, neglected injury wound, and local granulomatous disease; and (3) social factors such as lower socioeconomic class (SEC), low rate of literacy, habitant between animals, psychiatric illness, and neglected mentally retarded persons. Sign and symptoms include common manifestations such as bleeding, foul-smelling discharge, crusting, creeping sensation, headache, facial weakness, cellulitis in peripheral regions, perichondritis, tinnitus, and vertigo. Complication like intracranial involvement through ear may have grave prognosis. Hence, the purpose of the present study was to review cases of aural myiasis, to assess the clinico-etiology and the relationship with social factors, to highlight the preventive and treatment concepts in such cases, to avoid complications such as facial weakness, mastoiditis, hearing loss, and intracranial complication, and to reduce morbidity.

Aims and objectives

To study the clinico-etiological pattern and management of aural myiasis.

 Methodology



The study was conducted in the Department of Otorhinolaryngology, Sir T. Hospital, Bhavnagar. It is a retrospective observational study conducted for a period of 21 months (January 2016–October 2017). Eighteen cases of myiasis associated with ear were taken for the study. All the patients with maggots in relation to ear were included in the study after taking proper informed and written consent. Patients who did not give consent for the study were excluded.

The patients in this study were categorized by the following parameters: age, gender, address, SEC and occupation, systemic comorbidities, site of myiasis, local comorbidities, mental status, hospital stay, and complication and numbers of maggots removed.

Data collection procedure

Examination

Each patient thoroughly examined for otorhinolaryngological and general condition. Any history regarding ear discharge, aural pain, aural bleeding, hard of hearing, roaring or ringing sensation and passing of maggots from the ear and surrounding the head and the neck region, otological malignancy, ruptured or surgically created wound, history of chemotherapy or radiotherapy, prolonged steroid therapy, HIV, diabetes mellitus, and anemia were taken. Detailed inquiry about social status, condition of surrounding, and sanitation was taken.

Observation

A brief general examination was conducted to assess the nutritional status and built of the patient, degree of dehydration, anemia or any central nervous system examination done with complicated cases. A detailed ENT examination was carried out and any abnormality was noted down. Complete hemogram, blood sugar level, liver and kidney function test and urine routine microscopy, and X-ray mastoid Schuller's view were carried out. In aural myiasis, turpentine oil-soaked wick was kept in external auditory canal and maggots were removed with Tilley's forceps [Figure 1]. After removal of maggots, antibiotic drops were instilled and regular aural toileting was done under microscopic and endoscopic vision[6] [Figure 2].{Figure 1}{Figure 2}

All patients were treated with systemic antibiotic and intravenous fluids. After removing the maggots, they were disposed off after putting them in boiling water.[7]

 Results and Discussion



Infestation of myiasis is rare in ears. According to recently published review article, there are only 45 of aural myiasis cases reported.[8]

In our study, out of 18 patients, 8 (44.4%) were male patients and 10 (55.5%) were female patients. A study conducted by Singh et al. in 1993 on myiasis found that 57.8% cases were females and 41.8% cases were males.[9]

Age varies between 3 and 80 years with slightly higher distribution in geriatric age groups [Table 1]. The mean age is 35.3 years. The mean age in female was 43.9 years and in male was 45.7 years. The age distribution is bimodal in pediatrics and geriatrics with slightly higher predilection in female. According to a study done by Singh et al., there was no sex predilection.[9]{Table 1}

Myiasis is an uncommon disease in humans and common in rural areas compared to urban areas. All patients' social details were collected and analyzed thoroughly. There were 10 (55.55%) cases residing in urban slum area, 5 (27.77%) cases were from rural slum area, and 3 (16.66%) cases were from well-urbanized areas. Sixteen (88.88%) patients were Hindu by religion, whereas 2 (11.11%) were Muslims. Seven (38.8%) cases have occupation related to animal and farming. Six (33.33%) were homemakers, 3 (16.66%) were students, and 2 (11.11%) were nonworkers. Seventeen (94.44%) cases were from lower SEC, whereas only 1 (5.5%) belonged to upper SEC. Eight (44.44%) patients were mentally retarded. A study by Gabriel et al. in 2008 on oral myiasis and a case report by Al Jabr in 2015 on aural myiasis also support that poor SEC, illiteracy, and poor hygiene were significant predisposing factors for myiasis.[10] On the other hand, another study conducted by Aroraet al. in 2009 on myiasis also mentioned that 60% homemakers, 25% laborers, 5% farmers, 7.5% students, and 2.5% businessman were reported.[8]

It was noted that average maggot load was 43.3 per patient. Highest numbers of maggots (approximately 150) were reported with left-sided perichondritis secondary to malignant lesion over it.

In aural myiasis, the main symptoms included passage of worms (77.77%), ear discharge (50%), and pain in the ear (55.5%) [Table 2] Examination revealed maggots in all cases, perforation of tympanic membrane (50%), blood-stained discharge (50%), otitis externa (22.2%), and ulcer over pinna (11.11%), preauricular ulcerative lesion (5.5%), postauricular ulceration and maggots were found in (5.5%) [Table 3]. According to a study, patients generally present to the hospital with a complaint of ear pain, hearing loss, purulent or bloody ear discharge, itching in the ear, and/or tinnitus.[11]{Table 2}{Table 3}

All the patients were admitted in Sir T. Hospital, Bhavnagar, and managed with frequent manual and endoscopic removal of maggots, regular dressing with antibiotic cover which covers Gram-positive and Gram-negative bacteria, and mosquito netting during sleep to prevent the further laying of eggs.[10] The number of maggots significantly reduced on 3rd day of admission. The average hospital stay encountered was 3.9 days.

We have observed that myiasis commonly encountered during the period of October to December [Table 4]. A study conducted by Singh et al. in 1993 on aural myiasis have similar findings.[9]{Table 4}

Systemic comorbidities which correlated were uncontrolled diabetes (5.5%) and immunocompromised status (11.11%),[10] whereas 77.77% presented with anemia.

Out of 18 cases of aural myiasis, slightly sex predilection was observed toward female. The aural myiasis can be easily diagnosed by otoscopic examination. In cases with tympanic perforation, patient were examined for auditory function before and after maggot removal.[2],[12] The cases with chronic otitis media should be closely followed.

Intracranial extension, at least theoretically, is a possible dangerous complication of aural myiasis. A review study of the 45 reported cases of aural myiasis did not show any intracranial involvement secondary to an infested ear.[8] In our study, one patient of pinna myiasis expired due to cardiac arrest.

 Conclusion



Aural myiasis is commonly affecting geriatrics and pediatrics patients. Slightly higher predilection was found in female. In general, people residing in slum area have higher chances of getting infested due to poor personal hygiene, overcrowding, illiteracy, animal contact, and poor sanitation. Flies were attracted by foul-smelling discharge and layed eggs. As per the observation, the most common local risk factor in aural myiasis is chronic otitis media. As such, death due to aural myiasis is very rare. Treatment part consists of frequent manual and endoscopic removal of maggots, with topical and systemic antibiotic cover and mosquito netting during sleeping.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

References

1Werminghaus P, Hoffmann TK, Mehlhorn H, Bas M. Aural myiasis in a patient with Alzheimer's disease. Eur Arch Otorhinolaryngol 2008;265:851-3.
2Yuca K, Caksen H, Sakin YF, Yuca SA, Kiriş M, Yilmaz H, et al. Aural myiasis in children and literature review. Tohoku J Exp Med 2005;206:125-30.
3Gabriel JG, Marinho SA, Verli FD, Krause RG, Yurgel LS, Cherubini K, et al. Extensive myiasis infestation over a squamous cell carcinoma in the face. Case report. Med Oral Patol Oral Cir Bucal 2008;13:E9-11.
4Francesconi F, Lupi O. Myiasis. Clin Microbiol Rev 2012;25:79-105.
5Terterov S, Taghva A, MacDougall M, Giannotta S. Posttraumatic human cerebral myiasis. World Neurosurg 2010;73:557-9.
6Jervis-Bardy J, Fitzpatrick N, Masood A, Crossland G, Patel H. Myiasis of the ear: A review with entomological aspects for the otolaryngologist. Ann Otol Rhinol Laryngol 2015;124:345-50.
7Sinha V, Shah S, Ninama M, Gupta D, Prajapati B, More Y, et al. Nasal myiasis. J Rhinol 2006;13:120-3.
8Arora S, Sharma JK, Pippal SK, Sethi Y, Yadav A. Clinical etiology of myiasis in ENT: A reterograde period – Interval study. Braz J Otorhinolaryngol 2009;75:356-61.
9Singh I, Gathwala G, Yadav SP, Wig U, Jakhar KK. Myiasis in children: The Indian perspective. Int J Pediatr Otorhinolaryngol 1993;25:127-31.
10Al Jabr I. Aural myiasis, a rare cause of earache. Case Rep Otolaryngol 2015;2015:219529.
11Magliulo G, Gagliardi M, D'Amico RA. Human aural myiasis. Otolaryngol Head Neck Surg 2000;122:777.
12Cho JH, Kim HB, Cho CS, Huh S, Ree HI. An aural myiasis case in a 54-year-old male farmer in Korea. Korean J Parasitol 1999;37:51-3.