case report aural myiasis, a rare cause of earache

Case ReportAural Myiasis, a Rare Cause of Earache

Ibrahim Al Jabr

Department of Otolaryngology and Head and Neck Surgery, College of Medicine, King Faisal University,P.O. Box 66678, Al-Ahsa 31982, Saudi Arabia

Correspondence should be addressed to Ibrahim Al Jabr; [email protected]

Received 24 June 2015; Revised 7 August 2015; Accepted 9 August 2015

Academic Editor: Yorihisa Orita

Copyright © 2015 Ibrahim Al Jabr. This is an open access article distributed under the Creative Commons Attribution License,which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

Myiasis of the ear is an infestation of the ear by maggots (the larval stage of flies). In the literature, there are only few cases reportedabout auralmyiasis. It ismore common to occur in tropical regions, where humidity andwarmweather provide a good environmentfor this infestation. In this paper, a 12-year-old boy is reported to have unilateral earache for 3-day duration. Examination of thepainful ear showed a tympanicmembrane perforationwith larvae (maggots) in themiddle ear.Theywere removed byusing a forcepsand gentle irrigation of ear to expel any remnant. Furthermanagement included assessment of hearing, computed tomography (CT)scan, and outpatient follow-up.

1. Introduction

Myiasis is a common infestation among mammals. Inhumans, it is seen more in rural areas where people are inmore direct contact with animals [1].Thedisease occurswhenthe female fly lays eggs, which shortly will cause clinicalmanifestations that are related to the body site involved [2].In the field of otolaryngology, it may affect the ears, nose andparanasal sinuses, nasopharynx, oral cavity, and skin of thehead and neck region. Risk factors for myiasis in humans arechronic suppurative otitis media, low socioeconomic status,swimming in stagnant water, and diabetes mellitus [3]. Otherpossible predisposing factors include neglected children, oldage, mental retardation, and poor personal hygiene.

2. Case Report

A 12-year-old boy, previously healthy, presented to the emer-gency department complaining of right earache for 3-dayduration. This ear pain started suddenly and the patient hasdescribed it as beingmild tomoderate in severity.The patientis complaining also of minor decrease in hearing and itchingin the ear canal. There was no history of purulent, bloody, orclear ear discharge, tinnitus, vertigo, or facial weakness.Therewas no history suggestive of intracranial involvement. Social

history showed that the patient lives in dessert with his family,in a Bedouin culture.

General clinical examination, vital signs, and exami-nation of nose, throat, left ear, head, and neck were allwithin normal. Inspection of the right ear externally wasunremarkable; there is mild to moderate tenderness withpressure over the tragus or by gentle movement of the auricle.Examination by otoscope and microscope showed mildedema and erythema of the external auditory canal, a cleancentral perforation of the tympanicmembrane of about 5mm(Figure 1), and 2 larvae in the middle ear, protruding throughthe perforation. A crocodile forceps was used to remove these2 larvae (Figure 2). Irrigation of the ear with sterile waterwas done, after which 4 more larvae which were in the atticregion and not visible showed up and came out to the externalauditory canal through the perforation and were removed.Further carful inspection and irrigation were made but didnot show any more remnants. The removed larvae wereidentified by microbiologist to belong to the Sarcophagidaefamily, genusWohlfahrtia, and speciesWohlfahrtiamagnifica.It is also known as spotted flesh fly or Wohlfahrt’s woundmyiasis fly. The larvae are cylindrical in shape with flattenedventral surface, 8 to 12mm in length, white in color withgrayish tinge. Spines are separating the body segments ofthe larvae.They have the characteristic sarcophagid posteriorend, with the posterior spiracles set in a cavity.

Hindawi Publishing CorporationCase Reports in OtolaryngologyVolume 2015, Article ID 219529, 3 pageshttp://dx.doi.org/10.1155/2015/219529

2 Case Reports in Otolaryngology

Figure 1: Microscopic view of the right ear, showing a clean centralperforation of the tympanic membrane after the removal of thelarvae.

Figure 2: Three alive larvae removed from the patient ear.

The patient was admitted to the ward overnight forfurther management. He was started on mild analgesicsand prophylactic antibiotic treatment to prevent possiblesecondary infections. On the second day of admission,reexamination showed improvement of the pain, edema, anderythema and no more larvae in the ear.

The patient underwent audiological assessment (tym-panometry and pure tone audiogram), which showed flattympanogram (type B) and mild conductive hearing loss inthe involved ear. Also he underwent CT scan to rule out anyintracranial involvement, and it showed normal middle earand intracranial structures and intact roof for middle ear andmastoid.

After that the patient was discharged, and outpatientfollow-up was arranged for him. After 3 weeks of the dis-charge, the perforation healed completely, and the repeatedaudiological assessments were within normal.

3. Discussion

Aural myiasis is a rare infestation of the ears. According toa recent published review article, there are only 45 reportedcases of aural myiasis [4]. Myiasis can be classified into eitherobligatory or facultative infestation. In the former, the host,most commonly the goat and sheep, is an obligatory part ofthe life cycle of the maggots, while in the latter it is not [5].The infestation found in this patient (Sarcophagidae family,Wohlfahrtia magnifica species) is an obligate parasite. Thefemale fly is attracted to normal and pathological secretionsof the orifices of mammals [6].

Patients usually present to the hospital complaining of earpain, hearing loss, purulent or bloody ear discharge, itchingin the ear, and/or tinnitus [7–9]. Other possible presentationsmay include vertigo, facial weakness, and/or neurologicalmanifestations secondary to intracranial involvement. Thesymptoms start after the deposited larvae start to feed on thesurrounding tissues. The infestation is usually diagnosed byhistory and clinical examination, which will show the larvaein the ear. It is less likely to need further investigations todiagnose it, because the larvae are usually present near theexternal auditory canal because they need air for breathing.

The treatment for aural myiasis is usually simple in mostof the cases, requiring nothing more than removal of thelarvae and irrigation of the ear by one ormore of the followingsolutions: alcohol, chloroform, normal saline, oil, ivermectin,or iodine [7–9]. Also, prophylactic broad spectrum antibi-otics are usually prescribed to prevent secondary infections.

The larvae should be removed under microscope withcareful inspection for any residual. The best choice forirrigation solution is debatable as all of them achieve the sameoutcome.The goal of the irrigation is usually to kill and expelany residual larvae, mainly the ones not visible or accessibleon examination.

Surgical exploration is sometimes needed in patientswhen there is suspicion about the extent of the disease or forresidual disease. In these cases, usually mastoid explorationis performed and the extent of the infestation is identifiedand if any residual is found it will be removed [10, 11]. Inthe case reported here, there was no suspicion of any residualdisease and there were no manifestations that may raise thesuspension of intracranial extension. Also, CT scan showedintact bony landmarks andnormal intracranial space, with nosuspicion of any residual disease. We suggest that if a patientis going to have surgical exploration, CT scan should be donebefore. It may obviate the need for the surgical intervention,especially in patients with low suspicion, and if not it willbe useful as a preoperative preparation and assessment forsurgical landmarks.

Management of these patients should also include hearingassessment to document any change in the hearing level andfor future comparison.

Intracranial extension, at least theoretically, is a possibledangerous complication of aural myiasis. A review of the 45reported cases diagnosed to have aural myiasis did not showany intracranial involvement secondary to an infested ear[4]. Intracranial involvement of patients with aural myiasismust be looked after carefully in all patients, especially inthe presence of manifestations that may raise suspicion, forexample, clear otorrhea, headache, or seizure.

In conclusion, aural myiasis is a rare infestation of theear. It occurs usually in patients with risk factors like chronicsuppurative otitismedia, low socioeconomic status, neglectedchildren, old age, mental retardation, and poor personalhygiene. The clinical presentation may range from mild ear-ache to manifestation of intracranial extension like seizure.Treatment is usually simple, by removal of the larvae, earirrigation, and antibiotics to prevent any possible secondaryinfection.

Case Reports in Otolaryngology 3

Conflict of Interests

The author declares that there is no conflict of interestsregarding the publication of this paper.

References

[1] A. K. Ahmad, E. H. Abdel-Hafeez, M. Makhloof, and E. M.Abdel-Raheem, “Gastrointestinal myiasis by Larvae of Sar-cophaga sp. and Oestrus sp. in Egypt: report of cases, andendoscopical and morphological studies,” The Korean Journalof Parasitology, vol. 49, no. 1, pp. 51–57, 2011.

[2] I. Khan, A. Y. Muhammad, and M. Javed, “Risk factors leadingto aural myiasis,” Journal of Postgraduate Medical Institute, vol.20, no. 4, 2011.

[3] R. P. Lane and R. W. Crosskey, Medical Insects and Arachnids,Chapman & Hall, London, UK, 1993.

[4] J. Jervis-Bardy, N. Fitzpatrick, A. Masood, G. Crossland, and H.Patel, “Myiasis of the ear: a review with entomological aspectsfor the otolaryngologist,” The Annals of Otology, Rhinology, &Laryngology, vol. 124, no. 5, pp. 345–350, 2015.

[5] F. Francesconia and O. Lupi, “Myiasis,” Clinical MicrobiologyReviews, vol. 25, no. 1, pp. 79–105, 2012.

[6] J. Osorio, L. Moncada, A. Molano, S. Valderrama, S. Gualtero,and C. Franco-Paredes, “Role of ivermectin in the treatment ofsevere orbital myiasis due toCochliomyia hominivorax,”ClinicalInfectious Diseases, vol. 43, no. 6, pp. e57–e59, 2006.

[7] J. H. Cho, H. B. Kim, C. S. Cho, S. Huh, and H. I. Ree, “An auralmyiasis case in a 54-year-old male farmer in Korea,”TheKoreanJournal of Parasitology, vol. 37, no. 1, pp. 51–53, 1999.

[8] K. Yuca, H. Caksen, Y. F. Sakin et al., “Aural myiasis in childrenand literature review,” The Tohoku Journal of ExperimentalMedicine, vol. 206, no. 2, pp. 125–130, 2005.

[9] G. Magliulo, M. Gagliardi, and R. A. F. F. A. E. L. L. O.D’Amico, “Human aural myiasis,” Otolaryngology—Head andNeck Surgery, vol. 122, no. 5, p. 777, 2000.

[10] F. Panu, G. Cabras, C. Contini, andD. Onnis, “Human auricolarmyiasis caused by Wohlfahrtia magnifica (Schiner)(Diptera:Sarcophagidae): first case found in Sardinia,” Journal of Laryn-gology & Otology, vol. 114, no. 6, pp. 450–452, 2000.

[11] S. A. Talar, R. Dehghani, and M. A. Yeganeh, “Chrysomyabezziana infestation,” pp. 56–58, 2002.

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