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 Table of Contents  
CASE REPORT
Year : 2022  |  Volume : 28  |  Issue : 2  |  Page : 171-173

“Itch” gratification-Insect polyembolokoilamania of the ear


Department of Otolaryngology, SSIMSRC, Davangere, Karnataka, India

Date of Submission12-Jul-2021
Date of Acceptance25-Jul-2021
Date of Web Publication21-Sep-2022

Correspondence Address:
Dr. Venkatesha Belur Keshavamurthy
Department of Otolaryngology, SSIMSRC, Davangere - 577 005, Karnataka
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/indianjotol.indianjotol_103_21

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  Abstract 


Foreign body in the ear is one of the most common conditions encountered at the otorhinolaryngology outpatient clinic. Insects, especially live insects present as painful foreign bodies of the external ear. Insects that are most frequently recovered from the ear canal include ticks, bees, beetles, and cockroaches. We present the case report of a 17-year-old girl with recurrent right ear foreign body (live insect) five times in a span of 6 months. This recurrent presentation of the patient on the same side (right) led us to suspect behavioral abnormality. She was diagnosed to have mild intellectual developmental disorder with obsessive compulsive disorder and was treated accordingly. Behavioral problems must be ruled out in recurrent cases of unilateral foreign body ear.

Keywords: Behavioral abnormalities, ear foreign body, intellectual developmental disorder, recurrent


How to cite this article:
Keshavamurthy VB, Ramya K, Manjunath S. “Itch” gratification-Insect polyembolokoilamania of the ear. Indian J Otol 2022;28:171-3

How to cite this URL:
Keshavamurthy VB, Ramya K, Manjunath S. “Itch” gratification-Insect polyembolokoilamania of the ear. Indian J Otol [serial online] 2022 [cited 2022 Oct 7];28:171-3. Available from: https://www.indianjotol.org/text.asp?2022/28/2/171/356440




  Introduction Top


Foreign body in the ear is one of the most common conditions encountered at the otorhinolaryngology outpatient clinics. The incidents of foreign-body insertions are common in the pediatric age group than in the adult population.[1] Unlike the pediatric age group who intentionally insert foreign objects found at home into the ear out of curiosity, cases involving adults are either accidental or due to underlying mental disorder. Patients present with pain, bleeding, itching, sleep disturbances, discomfort, depending on the nature of the foreign body.

Rare presentation, nature of the foreign body, techniques of the foreign body although have been commonly seen in the literature, less has been written about the predisposing factors, complications and management of underlying psychiatric conditions. We hereby report an unusual case of intellectual developmental disorder (IDD) patient presenting to otorhinolaryngology clinic with a history of repeated insect insertion into the ear.


  Case Report Top


A 17-year-old girl came to the outpatient department (OPD) with complaints of right earache, with no history of upper respiratory tract infection, ear discharge or ear manipulation. Outpatient hospital record revealed a history of foreign body removal from the right ear (insect) 15 days ago. On otoscopic examination – foreign body (dead insect) was noted in the bony part of the external auditory canal adjacent to Total Mastectomy with Tympanic Membrane (TM) [Figure 1]. Foreign body was removed using crocodile forceps. The patient was advised to keep ear dry and to avoid ear manipulation. She presented with the similar complaints to OPD after 10 days. On otoscopic examination, there was evidence of foreign body dead insect in the cartilaginous part of right External Auditory Canal (EAC) which was removed with the forceps [Figure 2]. Advised to keep ear dry and to avoid ear manipulation and to plug the ears at night during sleep. Furthermore, we took psychiatrist opinion i/v/o history of recurrent foreign body in the right ear and she was diagnosed with mild intellectual development disorder (intelligence quotient = 53) with behavioral changes and treated.
Figure 1: Insect foreign body found in the 2nd visit

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Figure 2: Insect foreign body found in the 3rd visit

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She presented again with the history of ear ache after 1 month of the third episode. On otoscopic examination, there was evidence of the plastic cover in the cartilaginous part of right EAC, upon removing the same, dead insect noted behind it which was removed [Figure 3]. Psychiatry review was done and they elicited a history of insertion of insect by patient herself as she enjoys the tingling sensation due to the movement of insect in the EAC. Furthermore, there was a history of repeated manipulation of the ear with ear buds 15–20 times/day and history of spending more than 2 h for bathing and mopping house 4–5 times a day. History of anger outbreaks, irritability, and stubbornness present since childhood. Mental status examination of the patient was guarded to some extent and denied any obsessional thoughts/impulses/urges. Hence, she was diagnosed with mild IDD with obsessive compulsive disorder and treated accordingly. Again for the fifth time, the patient came to OPD after 4 months of last episode with complaints of cold since 1 week with no aural complaints. On ear, nose, and throat examination, dead insect was found in the bony part of right EAC in the anterior recess area, [Figure 4] which was removed by syringing, followed by dry mopping. Psychiatry review was obtained for the third time and continued antipsychotic medications, along with cognitive behavioral therapy. She is under follow-up since then. There were no similar episodes for the past 10 months.
Figure 3: Insect and plastic wrapper foreign body found in the 4th visit

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Figure 4: Insect foreign body found in the 5th visit

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  Discussion Top


“Psychogenic itch” is synonymously being used for functional itch disorder (FID) and has to be differentiated from other diagnoses based on French psycho dermatology group criteria, which states three compulsory and three of seven optional criteria are necessary to define FID[2] psychogenic itch may accompany other psychiatric conditions such as depression, anxiety, obsessive compulsive disorders, and substance abuse.

Individuals who insert foreign objects into their own bodily orifices have varied backgrounds and span across all age groups. Although uncommon in children who inserts foreign body out of curiosity, accidental insertion is more common in children. Accidental insertions/ingestions are common in the age group of 6 months to 4 years;[1],[3] however, in adolescents, intentional foreign body insertion is usually related to risk taking, attention-seeking behaviors, and having psychological abnormalities. Intentional foreign body insertion into the bodily orifices is known as polyembolokoilamania.[3] Motivation behind insertion of the foreign body is an important element in the treatment of the disease. It varies from sexual gratification, paraphilic disorder, nonsuicidal self-injurious behaviour, borderline personality disorder, psychotic disorders, depressive disorders, factitious disorder, malingering, exploratory misadventure, etc.[3] Majority of these may get unnoticed as they are done on regular intervals for gratification. Those who seek medical attention are the ones with complications where in self-inflicted harm has gone beyond the gratification levels.

From otorhinolaryngologist perspective, it is necessary to document the findings before and after the removal of the foreign body. Any preremoval trauma, complications arising out of the foreign body removal have to be documented. Excoriations and lacerations of the EAC skin are the common findings after foreign body (FB) removal. Emphasis should be given during the counseling of the patient and their wards about the risks involved and complications that occur due to foreign body itself or during removal. Attempting the foreign body removal without due care might lead to worse complications including ossicular discontinuity and TM rupture. Failed attempts of removal of foreign bodies resulted in higher complication rates.[4]

Care should be exercised while removing the foreign body from the ear. Killing the live insect in the first step allows the patient to be more comfortable and cooperate for insect removal of the insect thereafter. Various types of mineral oils, salt water, plain water, and lignocaine are utilized for killing the insect.[5] Lignocaine applied topically relieves the pain and assists in patient cooperation due to its anaesthetic effect. Later, foreign body can be removed under visualization, (otomicroscopy/endoscopy) by instrumentation, irrigation, or suction.[1] A high index of suspicion about underlying psychiatric evaluation is needed in recurrent foreign bodies and multidisciplinary care involving the referring physician, treating surgeons and psychiatrists is needed to obviate the impending risky behaviors in such patients.


  Conclusion Top


Recurrent episodes of foreign body in the bodily orifices should prompt thorough psychiatric evaluation and follow-up.

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.

Acknowledgment

We would like to acknowledge Dr. Mruthunjay, Consultant, Department of Psychiatry, SSIMS and RC, for his contribution to the treatment of the said patient in this study. The authors wish to thank all doctors, nurses, and staff at Department of ENT, SSIMSRC for helping to make this study a success.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Lotterman S, Sohal M. Ear Foreign Body Removal. In: StatPearls. Treasure Island (FL): StatPearls Publishing; 2020.  Back to cited text no. 1
    
2.
Misery L, Dutray S, Chastaing M, Schollhammer M, Consoli SG, Consoli SM. Psychogenic itch. Transl Psychiatry 2018;8:52.  Back to cited text no. 2
    
3.
Unruh BT, Nejad SH, Stern TW, Stern TA. Insertion of foreign bodies (polyembolokoilamania): underpinnings and management strategies. Prim Care Companion CNS Disord 2012;14:doi:10.4088/pcc.11fo1192.  Back to cited text no. 3
    
4.
Schulze LS, Kerschner J, Beste D. Pediatric external auditory canal foreign bodies: A review of 698 cases. Otolaryngol Head Neck Surg 2002;127:73-8.  Back to cited text no. 4
    
5.
Leffler S, Cheney P, Tandberg D. Chemical immobilization and killing of intra-aural roaches: An in vitro comparative study. Ann Emerg Med 1993;22:1795-8.  Back to cited text no. 5
    


    Figures

  [Figure 1], [Figure 2], [Figure 3], [Figure 4]



 

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