Myiasis in Ear Nose Throat and HNS .pptx

EAR NOSE THROAT AND HEAD NECK SURGERY

1. Myiasis in ENT practice Dr. Satish Kumar Ray 2nd Year Resident ENT-HNS P oAHS

2. Overview INTRODUCTION TYPES ENT MYIASIS O ral myiasis A ural myiasis N asal myiasis T hraot myiasis T racheostomy myiasis

3. INTRODUCTION Myiasis →derived from Greek(mya,or fly) F irst proposed by Hope to define diseases of humans caused by dipterous larvae Myiasis →defined as infestation of live vertebrates(humansand/oranimals) with dipterous larvae

4. True Flies (Diptera) Definition ," only those having one pair of wings belong to the insect Order Diptera ” includes many common insects such as mosquitoes, midges, sand flies, blowflies and the House Fly Dipteran insects have 4 stages in their life cycle ( adult, pupae, larvae and egg ). Name of larval stages of these insects is “ maggot ”

5. D ipterous larvae can feed on the host’s living or dead tissue , liquid body substance, or ingested food ↓ cause broad range of infestations →depending on the body location and the relationship of the larvae with the host The distribution of human myiasis is worldwide G reater abundance in poor socioeconomic regions of tropical and subtropical countries .

6. Most common flies causing human myiasis Order: Diptera Family: Calliphoridae , Species: calyptratae - Chrysomya bezziana (named to honour Italian entomologist Mario Bezzi ) seen in South Asia,India , Africa, Saudi Arabia, Indonesia, Guinea and the Persian Gulf.

7. Types of Myiasis Cutaneous myiasis Furuncular myiasis Migratory myiasis Wound myiasis Cavitary myiasis Opthalmomyiasis ENT myiasis Urogenital myiasis Intestinal myiasis Cerebral myiasis Tracheopulmonary myiasis Accidental myiasis or Pseudomyiasis Myiasis in special clinical setting

8. ENT myiasis Ear-nose-throat (ENT) myiasis →term used to group myiases affecting N ose E ars O ral cavity L arynx T rachea

9. Oral myiasis F irst described in the literature in 1909 → kind of wound myiasis associated with P oor oral hygiene A lcoholism S enility S evere halitosis S ocket orifice S uppurating lesions G ingival disease T rauma M ental debility P eople who maintain their mouths open for a long period of time

10. Infants who were breastfed by mothers with breasts infected by C. Anthropophaga ↓ P resented with larvae in the upper and lower lips and in other parts of the body Poor hygiene is the most important risk factor and is present in almost all cases

11. Fig:Patient with myiasis of a large growth of the floor of mouth invading the skin Fig;Maggots in oral cavity

12. T ransmission O ccur through direct infestation in cases → lesions are at the anterior mandibular or maxillaryregion Infestation into the buccal gingiva of the mandibular molar region supports the possibility by which the ingestion of contaminated food may be the way of transmission

13. C linical features Pain and swelling of the mouth, the teeth, the lips, or the palates S ensation of movement In some cases →larva died in submucosa and manifested clinically like a salivary gland adenoma

14. D iagnosis E asy and should be made at an early stages ↓ I nvolvement of deeper tissues can be prevented L ack of regular oral care →lesions go unnoticed →extensive tissue involvement occurs Destructive complications are possible CT scan should be performed when those complications are suspected

15. Species reported to cause this clinical picture are C. H ominivorax W. M agnifica M. D omestica C. B ezziana O. O vis H. B ovis H. T arandi Musca nebulo G.intestinalis C.vicina

16. Extensive tissue destruction may follow infection, and palatal perforation is a possible complication

17. Treatment of oral myiasis S urgical removal of maggots An alternative treatment →creation of an anaerobic environment inside the wound to kill or expulse the maggots Turpentine solution may help the extraction of maggots D rugs to treat oral myiasis is incipient Nitrofurazone (0.2%; 20 ml) topically →infested wound 3 times per day during 3 days →successful I vermectin→ partial or complete response reported

18. Aural myiasis( otomyiasis ) I nvolves infestation of the external ear and/or middle ear E ggs or larvae →deposited around the aural cavity → widened canal facilitate the process U sually seen in children <10 years of age or in debilitated individuals R isk factor Chronic otorrhea  healthy, mobile patients Bilateral disease is an exception

19. Aural myasis (A) Maggots visible in external auditory canal (B) Manual extraction of maggots (C) Maggots for identification (Insert – extracted maggots)

20. Clinical presentation of aural infestation F oreign-body sensation O talgia O torrhea B leeding I tching aural malodor T innitus V ertigo R estlessness I mpaired hearing P erforation of tympanic membrane Fig: Several active maggots and purulent secretion completely filled the left external auditory canal

21. On examination Diffuse inflammation of the skin of the external auditory canal may be found Otoscopy  reveal maggots Some cases  tympanic membrane perforation  visualized Fig:(A) a small central perforation of the tympanic membrane, (B) no larvae or pathological findings in the middle ear except mucous edema.

22. Imaging studies (computed tomography) indicated →evaluate possible complications other than tympanic membrane perforation →invasion and destruction of the mastoid cavity C omplications D eafness P enetration within the central nervous system → meningitis & death

23. The most important species causing aural myiasis are C. H ominivorax W. M agnifica C. B ezziana C. M egacephala Sarcophaga Parasarcophaga crassipalpis

24. T reatment of aural myiasis M anual extraction of larvae I rrigation of the ear with saline, 70% ethanol,10% chloroform, normal saline, oil drops, urea, dextrose, creatine, topical ivermectin, or iodine saline →used to remove the maggots Suctioning

25. Nasal myiasis I nfestation of nasal cavity by flies ovipositing either directly within the nasal cavity or in the vicinity while the patient is sleeping I t represent most cases of ENT myiasis Infest nose, nasopharynx and paranasal sinuses causing extensive destruction R isk factors O ld age low socioeconomic status poor nutritional status (A) The maggot. (B) The fly responsible for maggots

26. Flies, particularly of the genus Chrysomyia ↓ Attracted ↓ foul-smelling discharge(atrophic rhinitis, syphilis, leprosy or infected wounds) ↓ lay eggs, about 200 at a time ↓ within 24 h hatch into larvae

27. Nasal myasis (A patient with nose filled with maggots (B) Turpentine wick inside nose (C) Nasal endoscopy showing maggots (D) Impending palatal perforation

28. predisposing factor atrophic rhinitis →most common Leprosy patients Tuberculosis R hinoscleroma

29. C linical features F oreign-body sensation, with or without movement sensation N asal pain F acial pain B lood-stained or mucopurulent nasal discharge E pistaxis F oul smell A nosmia

30. History of maggots coming out of the nose Rarely, symptoms may be allergic in origin ↓ When maggots fall into the throat ↓ Manifests as cough, laryngospasm, dyspnea, and stridor

31. C omplications O rbit or facial cellulites ulceration of the posterior pharyngeal wall S eptal perforation with saddle nose P alatal perforation P enetration into central nervous system →meningitis, pneumocephalus or death Fig:(A) Swelling of the nose and puffy eyelids with serosanguinous nasal discharge. (B) Maggots have practically destroyed the cheek and eye in this old and neglected lady. (C) Perforation of the palate

32. Rhinoscopy examination B oth diagnostic and therapeutic →removal of the maggots with forceps M ucosal edema,congestion, and ulcers are possible findings Sometimes →larvae not noticed →photophobic and tend to hide in the deepest parts of the nasal cavity.

33. The agents reported to cause nasal myiasis are C. H ominivorax C. B ezziana Oestrus ovis W. M agnifica Lucilia sericata Drosophila melanogaster C. vicina

34. T reatment The goal of the treatment is the prompt removal of the parasites and limiting tissue destruction. The endoscopic use of forceps considered superior to manual extraction Some authors used a turpentine solution to facilitate the extraction by killing the maggots The treatment of atrophic rhinitis is also advisable

35. Nasal douche with warm saline ↓ Remove slough, crusts and dead maggots Isolated with a mosquito net to avoid contact with flies which can perpetuate this cycle All patients should receive instruction for nasal hygiene before leaving the hospital

36. Throat myiasis M ainly by O.ovis affecting people in close contact with sheep and goats C onsidered occupational disease in countries where the disease is endemic, such as Iran and Italy O ccur between April and September

37. C linical features F oreign body sensation in throat B urning sensation itching followed by cough Rhinorrhea; sneezing; ear, nose, and throat itching; wheezing; and lacrimation are all included as allergic symptoms.

38. T reatment S praying the throat with lidocaine ↓ washing out the larvae with normal saline (simply by asking the patients to gargle and spit)

39. Tracheostomy myiasis Tracheostomy myiasis is not common Fig:1Myiasis of tracheostomy. Figure 2: Removed maggots. Figure 3: Chrysomya bezziana . Proper patient education about tracheostomy care, habit of regular cleaning and keeping the area covered is essential for prevention of this problem

40. Tracheostome myasis (A) Visible maggots around tracheostome (B) Cleaning with turpentine and manual removal (C) Healed wound after one week (D) Extracted maggots

41. Cutaneous Myiasis Furuncular myiasis occurs after penetration of the dipteran larva into healthy skin Erythematous, furuncle-like nodule develops, with one or more maggots within it Pruritus, pain, and movement sensation Treatment ( i )the application of a toxic substance to the larva and egg production of localized hypoxia to force the emergence of the larva (iii) the mechanical or surgical removal of the maggots Furuncular myiasis on the scalp lesion on the face.

42. Migratory myiasis Occurs when a dipteran maggot starts to migrate, aimlessly, through burrows in the skin, producing the migratory pattern of the lesions Treatment Identification of the position of the larvae and its removal with a needle.

43. Wound myiasis Occurs when fly larvae infest open wounds of a mammalian host Flies oviposit in necrotic, hemorrhaging, or pus-filled lesions Wounds with alkaline discharges (pH 7.1 to 7.5)  attractive to blow flies Presence of necrosis is also an important factor Fig:Wound myiasis

44. Treatment Mechanical removal of maggots surgical debridement of the infested wound bed intensive rinsing with antiseptic solutions Dressing changes on a daily basis Oral treatment Ivermectin is the most commonly used drug

45. Bibliography Diseases of Ear, Nose and Throat-by P. L. Dhingra , Shruti Dhingra Otorhinolaryngological myiasis: the problem and its presentations in the weak and forgotten: Amit K. Rana1, Rohit Sharma1, Vinit K. Sharma1, Ashish Mehrotra1 and Rachana Singh2 American Society for Microbiology doi:10.1128/CMR.00010-11 Aural Myiasis: A Case Report and Literature Review: sagepub.com/ journals -permissions :DOI: 10.1177/0145561320966072 Myiasis of the Tracheostomy Wound: A Case Report with Review of Literature:DOI : 10.4172/2161-119X.1000198

46. Next presentation Otosclerosis II Dr. Bimal Pokharel 2080/04/30

47. Thank you