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Year : 2020  |  Volume : 13  |  Issue : 1  |  Page : 48-52  

Nasal myiasis among pediatric patients: Our experiences

1 Department of Otorhinolaryngology, IMS and SUM Hospital, Siksha ‘O’ Anusandhan University (Deemed to be), Bhubaneswar, Odisha, India
2 Department of Pediatrics, IMS and SUM Hospital, Siksha ‘O’ Anusandhan University (Deemed to be), Bhubaneswar, Odisha, India
3 Medical Research Laboratory, IMS and SUM Hospital, Siksha ‘O’ Anusandhan University (Deemed to be), Bhubaneswar, Odisha, India

Date of Submission13-Jun-2019
Date of Decision13-Jun-2019
Date of Acceptance13-Sep-2019
Date of Web Publication16-Dec-2019

Correspondence Address:
Santosh Kumar Swain
Department of Otorhinolaryngology, IMS and SUM Hospital, Siksha ‘O’ Anusandhan University (Deemed to be), Bhubaneswar - 751 003, Odisha
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/mjdrdypu.mjdrdypu_110_19

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Objective: The objective is to study the clinical profile, diagnostic method, treatment, and outcome of nasal myiasis among children at a tertiary care teaching hospital of east India. Materials and Methods: This is a prospective study on 28 children of either sex with the age group of 6–16 years suffering from nasal myiasis during the past 10 years. The details clinical pictures, treatment, and outcome of the nasal myiasis among children were studied. Nasal endoscopy was performed for the diagnosis and removal of crawling maggots by picking up with nasal forceps under direct vision. Results: The youngest child was of 6 years 3 months and oldest 16 years of age. More than half of the children (60.71%) were >10 years of age. Of 28 children, 18 (64.28%) were suffering from chronic rhinosinusitis, whereas 5 (17.85%) children with atrophic rhinosinusitis and 5 (17.85%) children were known case of sinonasal tumors. Main presenting symptoms were as follows: epistaxis (100%), a fouls smell (64.28%), passage or crawling sensation of worms (89.28%), and pain in the nose (75%). Endoscopic method was used in all cases for the removal of maggots from the nasal cavity. Conclusion: Nasal myiasis is an uncommon clinical condition in the pediatric age group due to improved living standards, but it still exists in developing and underdeveloped country. Quick and complete removal of maggots is needed for avoiding complications of nasal myiasis among children. The hygiene of the child should be improved for avoiding this dreaded clinical entity.

Keywords: Children, endoscopic approach, nasal myiasis, parasitic infestation

How to cite this article:
Swain SK, Sarangi R, Mohanty JN. Nasal myiasis among pediatric patients: Our experiences. Med J DY Patil Vidyapeeth 2020;13:48-52

How to cite this URL:
Swain SK, Sarangi R, Mohanty JN. Nasal myiasis among pediatric patients: Our experiences. Med J DY Patil Vidyapeeth [serial online] 2020 [cited 2021 Aug 4];13:48-52. Available from: https://www.mjdrdypv.org/text.asp?2020/13/1/48/272872

  Introduction Top

The word myiasis is derived from the Greek word called myiasis which means fly.[1] Rev F.W. Hope coined the word Myiasis in 1840. Stecle proposed that there is the presence of fly in the nasal cavities leading to myiasis. In 1919, Castellani and Chalmer described the nasal myiasis and called as “Peenash” or “Scholechiasis” in India due to Chrysomyia (Previously Pycnosoma).[2] Infestation of vertebrate animal and human being by larvae of insects is called as Myiasis. Although it is common in adults, it may affect children as well. 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 an embarrassing situation for the child, parents, and family, which creates a social stigma still in this time. It has a greater problem in tropical countries like India. Nasal myiasis is common in developing countries where sanitation is a problem.[3] 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.[4] The larva that cause myiasis can act as parasites in the nose, ears, eyes, skin, mouth, soft tissue, urogenital tract, stomach, and intestine.[5] Nasal myiasis is prevalent more in developing and tropical countries.[6]

  Materials and Methods Top

This is a prospective study conducted in 28 children of either sex in the age group of 6–16 years suffering from nasal myiasis from December 2009 to January 2019. This study was approved by the Institutional Ethics Committee (IEC) (letter no: IMS/CRL/IEC/35, Date: September 15, 2009). The clinical pictures, treatment, and outcome of the nasal myiasis among children were studied. The children presented with foul smell, itching, nasal bleeding, pain in nose, and headache. Almost all had a history of poor hygienic condition, chronic rhinosinusitis. Routine investigations such as differential count, total leukocyte count, hemoglobin percentage, bleeding time, clotting time, and computed tomography (CT) of nose and paranasal sinus were carried out in all children. Diagnostic rigid and flexible nasal endoscopy [Figure 1] was done in all cases for the confirmation of nasal myiasis. Nasal endoscopy was performed for removal of crawling maggots by picking up with nasal forceps under direct vision.
Figure 1: Endoscopic view of nasal cavity showing maggots

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  Results Top

The mean age of the patient in this study was 12.6 years (6–16). Of 28 children, 16 (57.14%) were males and 12 (42.85%) were females. The youngest child was of 6 years 3 months and oldest 16 years of age. More than half of the children (60.71%) were >10 years of age [Table 1]. Twenty-three children (82.14%) were from a rural/village and urban slum background. Twenty-one (75%) children presented with unilateral nasal myiasis, whereas seven (25%) were presented with bilateral nasal myiasis [Table 1]. Of 28 children, 18 (64.28%) were suffering from chronic rhinosinusitis, whereas 5 (17.85%) children with atrophic rhinosinusitis and 5 (17.85%) children were known case of sinonasal tumors [Table 2]. Diagnostic nasal endoscopic examination revealed maggots inside the nasal cavity (100%). In nasal myiasis, the main presenting symptoms [Table 3] were as follows: epistaxis (100%), a fouls smell (64.28%), passage or crawling sensation of worms (89.28%), and pain in the nose (75%). Endoscopic technique was used in all cases for removal of maggots from the nasal cavity. Complete clearance of maggots was done from anterior nares to choana. All the children with nasal myiasis were treated with turpentine oil and chloroform in the ration of 4:1 followed by endoscopic removal of the maggots by nasal forceps. All the children were maggots free by 3–4 days. Broad-spectrum antibiotics were given for preventing secondary infections. All the children were discharged from the hospital after 5–6 days. No complications were identified among the study group.
Table 1: Sex, age and site of the maggots among nasal myiasis suffering children

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Table 2: Predisposing conditions associated with children of nasal myiasis

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Table 3: Clinical presentations of nasal myiasis among children

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  Discussion Top

Nasal myiasis is often considered accidental nasal infestation. Myiasis is commonly seen among mammals whereas in human being, it is more in rural areas as these people have often direct contact with animals.[7] Nasal myiasis is a disease caused by the larvae of the Diptera or two-winged flies [Figure 2]. It is usually 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.[8] Female house flies are often attracted toward odoriferous suppurative lesions and lays their eggs on the mucosal surface, soft skin and different body parts that contaminated by mucus discharge or blood.[9] Many species of dipterous flies among genera chrysomyia are important obligatory myiasis causative agents among humans and animals.[2] In the order Diptera, the common families causing myiasis are the Oestridae (bot flies), Sarcophagidae (Carrion flies) and Calliphoridae (screwworm flies).[10] There may be destruction of the nasal bridge and adjacent area of the face causing orbital cellulitis and diffuse cellulitis of the face. The order Diptera is a large order which is commonly called as true flies. Each female fly lays their eggs up to 500 eggs in several batches of about 75–150 eggs. The eggs hatch by 10–24 h in 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 tapering head. The order Diptera which causes nasal myiasis is classified into two suborders: nematocera and Brachcera. The Nematocera families are blood-sucking flies and serves as vectors for different protozoan, viral and helminthic diseases. Rarely they cause nasal myiasis. The brachycera consists of infraorders: Muscomorpha or Cyclorrhapha and responsible for facultative myiasis, especially the species within the calyptrate. The calyptrate is again classified into families of Muscidae, Fanniidae, Oestridae, Sacrophagidae, and Calliphoridae. In nasal myiasis, common larvae reported are Cochliomyia hominivorax, Chrysomya bezziana, Wohlfahrtia magnifica, Oestrus ovis, Lucilia sericata, and Drosophila meanogaster.[11] The maggots [Figure 3] are pinkish bright brown in color and measured around 16–18 mm in length and 2–3 mm in width.[12],[13] The body surface of the maggot is covered by tough and nonsclerotic integument stripped with black bands with thorn-like robust spines. The maggots are photophobic in nature and prefer to stay in the deepest part of the nasal cavity even in the  Eustachian tube More Details.[14] 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.[15] Nasal myiasis is usually seen in tropical regions where warm weather and humidity provides a very good environment for this infestation. Nasal myiasis is rarely seen in developed country but not uncommon in developing and tropical country like India. Clinicians in the developed country may be unfamiliar with nasal myiasis thus may miss the diagnosis it and lead to inappropriate treatment. It may be mistaken for allergic rhinitis, cellulitis, insect bite even malignancy. Myiasis is common in the month of March to June in tropical countries.[16] The most common genera causing myiasis in India is Chrysomyia.[17] Nasal myiasis affects individuals of any age group and often seen in middle-aged and older patients and both sexes are equally affected.[18] The prevalence of nasal myiasis among pediatric patients is rare. The maggots tunnel deep into the soft tissue and separate the epithelium and mucoperiosteum from the bone and get their nutrition from surrounding tissue.[19] The myiasis occurs when the female fly lays their eggs, which shortly lead to clinical manifestations which are related to body site involved.[20] The common locations in the head-and-neck area affected are ears, nose, nasopharynx, paranasal sinuses, and skin.[21] The risk factors for nasal myiasis are chronic rhinosinusitis, low-socioeconomic status, diabetes mellitus, and swimming in stagnant water.[22] 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 the 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.[23] Bleeding may occur from the infested intranasal lesion where the surrounding tissue becomes edematous, tense, and emits characteristic foul smell. Sometimes, nasal myiasis causes severe pain, but in carinomatous lesions or radiation-induced tissue necrosis may damage nerve endings inside the nasal cavity which again destroyed by maggots during the invasion of the maggots, and hence there may be no pain.[24] Right nostril is more commonly affected than left one, maybe due to the tendency to sleep in the right lateral position and putting finger in the right nostril by right-handed children.[25] A single fly cannot lay eggs in both nostril at the same time; however, migration of maggots may be seen through choana to the opposite nostril. The maggots inside the nasal cavity may cause orbital complications. There are certain weak areas in the orbital wall like lamina papyracea and infra-orbital canal at the floor of the orbit where the spread of maggots occur to orbit. The infestation of maggots in the nose is an extremely dangerous clinical situation as there is a possibility of penetration into the intracranial space. The maggots may penetrate laterally to the paranasal sinuses and orbit and in few instances goes 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. Although intracranial complications like meningitis have been reported such clinical entity was not seen in our study. Diagnostic nasal endoscopy [Figure 2] will reveal crawling maggots inside the nasal cavity.[13] The edematous and ulcerated mucous membrane of the nasal cavity with necrotic tissue may be seen during nasal endoscopy. Nasal septal perforation may occur with nasal myiasis which will be seen by diagnostic nasal endoscopy. 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 choice in cases of nasal myiasis to find any infiltration of the larvae into the facial, orbit and brain. The objective of the treatment of nasal myiasis is complete removal of invading parasites. The patient of nasal myiasis needs immediate hospitalization. The treatment in nasal myiasis is often surgical removal of the maggots.[26] Treatment of nasal myiasis includes local and systemic measures. Systemic treatment in nasal myiasis includes broad-spectrum antibiotics such as amoxicillin or ampicillin when the lesion is secondarily infected. Topical or local treatment includes the application of turpentine oil, ether, chloroform, mineral oil, ethyl chloride, mercuric chloride, creosote, saline, systemic butazolidine, or thiabendazole for removal of larvae.[27] Nasal endoscopy is often done for 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.[28] In such cases, all maggots may not be removed in a single sitting, and hence, multiple sittings needed for 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 semi-synthetic macrolide antibiotic.[29] In nasal myiasis, removal of the maggots by 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 need many sitting.[30] Endoscopic removal of the maggots is better than manual extraction and in the endoscopic technique, the disease can be controlled in a 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 the 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 in pediatric patients can be prevented by prompt treatment. Prophylactic broad-spectrum antibiotics are usually prescribed for controlling secondary infections and vaccination can be considered in this disease as nasal myiasis can act as a portal entry for Clostridium tetani.
Figure 2: Female house fly causing myiasis

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Figure 3: Maggots removed from the nasal cavity

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  Conclusion Top

Nasal myiasis is now days uncommon in human due to improved living standards, but it still exists in developing and underdeveloped country. The restricted mobility of the children, unprotected exposed necrotic tissue and hidden part or orifices of the body like nose 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 make less damage to the intranasal tissue without causing any complications.

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