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Nasal myiasis: The role of endoscopy.

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Human myiasis is caused by the parasitic maggots of flies. It is an uncommon disease in developed countries. (1) It is typically seen in tropical regions among people of low socioeconomic status. (2) In Hong Kong, the recent incidence has been approximately 10 to 15 cases per year.

We report a case of nasal myiasis in a 68-year-old man in Hong Kong. The patient presented with nasal pain and a blood-stained nasal discharge. Maggots were found in the left nasal cavity, where they had caused extensive damage to the maxillary sinus (figure, A). Part of the inferior medial maxillary wall was broken down, and the mucosa was being "melted" away by larvae. The larvae also created a palatal fistula (figure, B). A detailed endoscopic examination revealed that the lining of the nasal cavity was edematous and ulcerated (figure, C). The larvae were buried in the necrotic material, and their crawling gave the patient an unpleasant sensation. Because larvae are photophobic, they prefer to hide in the deepest part of the nasal cavity, and they were also discovered in the eustachian tube orifice (figures, D and E). The maggots were removed with a forceps (figure, F).

Some centers have reported that the local application of turpentine is effective in killing larvae and facilitating their removal. (1,3) However, we did not experience any difficulty in removing the living larvae with forceps. Therefore, we believe that the use of chemicals to kill maggots before removal is not only unnecessary, but unwise in view of the potential for harm to the patient.

The most common sites of maggot infestation are superficial wounds and orifices such as the ear, nose, and mouth. Debilitated patients are prone to be affected. The extent of the damage of the affected area is related to the number of living larvae, since they feed on both dead and living tissue in the host.

The goal of management is to limit tissue damage and minimize complications. Evaluation of the nasal cavity with the endoscope is an essential part of the management protocol. (4) Endoscopy is helpful in removing the larvae, especially in the deepest and most difficultly accessible parts of the affected area. Endoscopy is also useful for toileting the nasal cavity. Imaging studies such as computed tomography are indicated to document the extent of the disease and to identify any associated locoregional complications. Antibiotics are needed to control the infection. The possibility of a sinonasal malignancy and atrophic rhinitis should be investigated, as these conditions are commonly associated with nasal myiasis.

References

(1.) Sharma H, Dayal D, Agrawal SP. Nasal myiasis: Review of 10 years experience. J Laryngol Otol 1989;103(5):489-91.

(2.) Popov NE Myiasis of the nose. Arch Otolaryngol 1947;45(1):112-16.

(3.) Kuruvilla G, Albert RR, Job A, et al. Pneumocephalus: A rare complication of nasal myiasis. Am J Otolaryngol 2006;27(2): 133-5.

(4.) Badia L, Lund VJ. Vile bodies: An endoscopic approach to nasal myiasis. J Laryngol Otol 1994;108(12):1083-5.

Willis S.S. Tsang, FRCS(ORL); Dennis L.Y. Lee, FRCS(ORL)

From the Department of Otorhinolaryngology-Head and Neck Surgery, The Chinese University of Hong Kong.

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Title Annotation:RHINOSCOPIC CLINIC
Author:Tsang, Willis S.S.; Lee, Dennis L.Y.
Publication:Ear, Nose and Throat Journal
Article Type:Report
Geographic Code:9HONG
Date:Dec 1, 2009
Words:528
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