|Year : 2018 | Volume
| Issue : 3 | Page : 128-131
Nasal myiasis in clinical practice
Santosh Kumar Swain1, Mahesh Chandra Sahu2, Manash Ranjan Baisakh3, 4
1 Department of Otorhinolaryngology, IMS and SUM Hospital, Siksha “O” Anusandhan University, Siksha “O” Anusandhan University, Bhubaneswar, Odisha, India
2 Directorate of Medical Research, IMS and SUM Hospital, Siksha “O” Anusandhan University, Siksha “O” Anusandhan University, Bhubaneswar, Odisha, India
3 Department of Pathology, Apollo Hospital, Bhubaneswar, Odisha, India
4 , India
|Date of Web Publication||10-Sep-2018|
Santosh Kumar Swain
Department of Otorhinolaryngology, IMS and SUM Hospital, Siksha “O” Anusandhan University, K8, Kalinga Nagar, Bhubaneswar - 751 003, Odisha
Source of Support: None, Conflict of Interest: None
Nasal myiasis is an opportunistic parasitic infestation of human as well as animals. Infestation of the nasal cavity by dipterous larvae is called nasal myiasis which is commonly seen in developing countries where health and sanitation are poor. Different predisposing factors associated with nasal myiasis are atrophic rhinitis, diabetes with purulent nasal discharge, midline granulomatous lesions or malignancy, and poorly nourished patients with poor hygiene. Other possible predisposing factors causing nasal myiasis include neglected children, mental retardation, and elderly age. Nasal endoscopy is a better method for removal of maggots under direct vision. Nasal endoscopic method is a better technique for the removal of maggots than conventional manual method. The maggots which are often located in deep and inaccessible areas are easily identified and removed.
Keywords: Endoscopic method, house fly, maggots, nasal infestation, nasal myiasis
|How to cite this article:|
Swain SK, Sahu MC, Baisakh MR. Nasal myiasis in clinical practice. Apollo Med 2018;15:128-31
| Introduction|| |
The term “myiasis” is derived from the Greek word “myiasis” which means fly. Rev F.W. Hope coined the term “myiasis” in 1840. Stecle proposed that there is presence of fly in the nasal cavities leading to myiasis. In 1919, Castellani and Chalmer described the nasal myiasis and called as Peenash in India due to Chrysomya (previously pycnosoma).
Infestation of vertebrate animal and human being by larvae of insects is called as myiasis. These larvae feed on the dead and living tissue or on the fluid substance at the affected area. The presence of larvae within the nasal cavity is called as nasal myiasis. Nasal myiasis is embarrassing situation of the patient which creates a social stigma still in this time. Nasal myiasis is common in developing countries where sanitation is a problem. Nasal myiasis is a nasal infestation caused by house fly larvae (maggots). It is a common clinical entity in tropical countries and is an opportunistic parasitic infestation of human being and also some animals. The nasal myiasis is commonly seen among low socioeconomic status, mental retarded person, immunocompromised patients, chronic sinonasal diseases, and unhygienic living status. Myiasis can occur at any tissues, organs, and body cavities of human being or animals when it is invaded and infested by the larval of nonbiting flies of the order Diptera. The larva that cause myiasis can act as parasites in the nose, ears, eyes, skin, mouth, soft tissue, urogenital tract, stomach, and intestine. Nasal myiasis is prevalent more in developing and tropical countries.
| Epidemiology|| |
Nasal myiasis is commonly seen in tropical regions where warm weather and humidity provide a very good environment for this infestation. Nasal myiasis is rare in developed country and Europe but not uncommon in developing and tropical countries like India and African countries. Clinicians in a developed country may be unfamiliar with nasal myiasis, thus may miss the diagnosis, and eventually may lead to inappropriate treatment. It may be mistaken for allergic rhinitis, cellulitis, and insect bite even malignancy. Myiasis is common during the month of March–June in tropical countries. The most common genera causing myiasis in India is Chrysomya.
| Etiopathogenesis|| |
Nasal myiasis is often considered accidental nasal infestation. Myiasis is commonly seen among mammals, whereas in human beings it is more in rural areas where people have often direct contact with animals. Nasal myiasis is a disease caused by the larvae of the Diptera or two-winged flies. It is often seen in hot and humid climate. It is usually prevalent among low socioeconomic group. Development of larvae from eggs depends on the surrounding humidity and temperature. Female house flies are often attracted toward odoriferous suppurative lesions and lay their eggs on mucosal surface, soft skin, and different body parts that are contaminated by mucus discharge or blood. Many species of dipterous flies among genera Chrysomya are important obligatory myiasis causative agents among humans and animals. In the order Diptera, the common families causing myiasis are the Oestridae (bot flies), Sarcophagidae (carrion flies), and Calliphoridae (screwworm flies). There may be an erosion of the nasal bridge and adjacent area of the face causing orbital cellulitis and diffuse cellulitis of the face.
| Life Cycle of House Fly (Musca Domestica )|| |
The most common flies causing human infestations are Dermatobia hominis (human botfly) and Cordylobia anthropophaga (tumbu fly). The order Diptera is a large order which is commonly called as true flies. Each female fly [Figure 1] lays their eggs up to 500 eggs in several batches of about 75–150 eggs. The eggs hatch by 10–24 h in a warm environment. Then, the legless maggots feed decomposed tissue and go through three instars and to reach full size in 5 days. The mature maggot is 3–9 mm long, creamy white in color, and cylindrical with the tapering head. The fully matured larva leaves the tissues and goes toward cooler and dry environment to pupate. The pupal stage usually lasts again 5 days. The emerging fly comes from the pupal case through the use of an alternately shrinking and swelling sac, known as ptilinum on the front of its head, which often it uses like a pneumatic hammer. The order Diptera which causes nasal myiasis is classified into two suborders: Nematocera and Brachycera. The Nematocera families are bloodsucking flies and serve as vectors for different protozoan, viral, and helminthic diseases. Rarely do they cause myiasis. The Brachycera consists of infraorders: Muscomorpha or Cyclorrhapha and is responsible for facultative myiasis, especially the species within the Calyptrate. The Calyptrate is again classified into families of Muscidae, Fanniidae, Oestridae, Sarcophagidae, and Calliphoridae. In nasal myiasis, common larvae reported are Cochliomyia hominivorax, Chyrsomya bezziana, Wohlfahrtia magnifica, Oestrus ovis, Lucilia sericata, and Drosophila melanogaster.
| Maggots|| |
The maggots [Figure 2] are pinkish bright brown and measured around 16–18 mm in length and 2–3 mm in width. The body surface of the maggot is covered by tough and nonsclerotic integument stripped with black bands with thorn-like robust spines. The anterior part of the maggot has five fingers like projections, whereas the posterior part has a cleft and the anal part has straight slit-like openings with lateral bulging of the sides. The maggots are photophobic in nature and prefer to stay in the deepest part of the nasal cavity even in the eustachian tube.
The myiasis is of two forms: obligate, where maggots feed on living tissues, and facultative where flies opportunistically utilize necrotic wound as a location in which flies oviposit and incubate the larvae.
| Clinical Presentation|| |
Nasal myiasis affects individuals of any age group and often seen in middle-aged and older patients and both sexes are equally affected. The maggots tunnel deep into the soft tissue and separate the epithelium and mucoperiosteum from the bone and get their nutrition from surrounding tissue. The myiasis occurs when the female fly lays their eggs, which shortly lead to clinical manifestations which are related to body site involved. The common sites in the head and neck area affected are ears, nose, nasopharynx, paranasal sinuses, and skin. The risk factors for myiasis are chronic suppurative otitis media, low socioeconomic status, diabetes mellitus, and swimming in stagnant water. The severity of clinical manifestations in nasal myiasis depends on the location of infestation, lesions, and tissue inflammation. The maggots may cause extensive necrosis, destruction, slough formation, and destruction of intranasal area. It may reach to deeper tissue of nose and paranasal sinuses. The patients of nasal myiasis often present with epistaxis, facial pain, foul smell, nasal obstruction, nasal discharge, headache, sensation of foreign body inside the nose, and dysphagia. Bleeding may occur from the infested intranasal lesion where the surrounding tissue becomes edematous, tense and emits characteristic pungent smell. Sometimes, nasal myiasis causes severe pain, but in carcinomatous lesions or radiation-induced tissue, necrosis may damage nerve endings inside the nasal cavity which again destroyed by maggots during invasion of the maggots, so there may be no pain. Right nostril is more commonly affected than the left one; this may be due to the tendency to sleep in the right lateral position and putting finger in the right nostril by a right-handed person. A single fly cannot lay eggs in both the nostrils at the same time; however, migration of maggots may occur through choana to opposite nostril. The maggots inside the nose may cause orbital complications. There are certain weak areas in the orbital wall such as lamina papyracea and infraorbital canal at the floor of the orbit where the spread of maggots occurs to orbit. Infestation of maggots in the nose is an extremely dangerous clinical situation as there is possibility of penetration into the intracranial space. The maggots may penetrate laterally to the paranasal sinuses and orbit and in few instances go inferiorly and perforate the palate. Nasal myiasis is often mistaken for cellulitis, allergic rhinitis, insect bites, subcutaneous cysts, or even malignancy inside the nasal cavity. The intracranial extension of the maggots is a dangerous complication and may further lead to meningitis.
| Investigation|| |
Diagnostic nasal endoscopy [Figure 3] will reveal crawling maggots inside the nasal cavity. Edematous and ulcerated mucous membrane of the nasal cavity with necrotic tissue may be seen during nasal endoscopy. Septal perforation may occur with nasal myiasis which will be seen by diagnostic nasal endoscopy. Computed tomography (CT) scan of the nose and sinus is helpful to know the bony erosion and spread of maggots beyond the sinonasal area. Coronal and axial section of CT paranasal sinuses often shows soft tissue thickening of palatal area, nasal septum, and erosion of the bony wall of the nose and sinus, hard palate, and ethmoidal air cells. Magnetic resonance imaging is imaging of the choice in cases of nasal myiasis to find any infiltration of the larvae into the facial, orbit, and brain.
| Treatment|| |
The aim of the treatment of nasal myiasis is to completely remove the invading parasites. The patient of nasal myiasis needs immediate hospitalization. The treatment in nasal myiasis is often surgical removal of the maggots. Treatment of nasal myiasis includes local and systemic measures. Systemic treatment in nasal myiasis includes broad-spectrum antibiotics such as amoxicillin or amphicillin when the lesion is secondarily infected. Topical or local treatment includes application of turpentine oil, ether, chloroform, mineral oil, ethyl chloride, mercuric chloride, creosote, saline, systemic butazolidine, or thiabendazole for the removal of larvae. Nasal endoscopy is often done for the removal of crawling maggots by direct vision with the help of forcep. Maggots can cause extensive necrosis, sloughing, and destruction of intranasal soft tissue and spread to inaccessible areas of the nose and paranasal sinuses. In such cases, all maggots may not be removed in a single sitting, so multiple sittings needed for the removal of maggots. Nasal endoscopic procedure is superior to the manual extraction of maggots from the nasal cavity. Hence, the treatment includes removal of maggots, broad-spectrum antibiotics, and oral ivermectin a semisynthetic macrolide antibiotic. In nasal myiasis, the removal of the maggots by the instillation of anesthetic ether and turpentine oil locally in the ratio of 1:4 and careful removal of maggots are the best treatment. The turpentine oil does not kill the maggots but helps them to come out from the deeply seated necrotic tissue. All maggots from the nasal cavity cannot be removed in a single sitting as the larvae often try to hide in the deeper tissue, so complete removal needs many sitting. Endoscopic removal of the maggots is better than manual extraction, and in the endoscopic technique, the disease can be controlled in shorter time. Care must be given for the removal of larva in whole; otherwise, a foreign body reaction may occur inside the nasal cavity. In case of secondary pyogenic infections, appropriate antibiotics must be added. Thus, quick and complete removal of maggots from the nasal cavity is possible before they are causing irreparable damage to the surrounding tissue. The serious complications of nasal myiasis can be prevented by prompt treatment. Along with prophylactic broad-spectrum antibiotics are usually prescribed for controlling secondary infections, vaccination can be considered in this disease as nasal myiasis can act as a portal entry for Clostridium tetani.
| Conclusion|| |
Nasal myiasis is nowadays uncommon in human beings due to improved living standards, but it still exists in developing and underdeveloped country. The restricted mobility of the patients, unprotected exposed necrotic tissue, and hidden part or orifices of the body such as ear, nose, and throat favor the growth of the maggots. Maintenance of good hygiene helps to prevent myiasis. The maggots located at inaccessible areas and deep tissue can be easily identified and removed easily by endoscopic method. Quick and complete eradication of myiasis makes less damage to the intranasal tissue without any complications.
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