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Tick on the tympanic membrane/Krpelj na bubnoj opni.

Introduction

Different foreign bodies can reach the lumen of the external auditory canal. Clinical presence of foreign bodies depends on a few factors (the nature of foreign body, localization, morphological features, and the presence of pathological process). Identification, determination of the nature of the foreign body and the way of extracting it depend on the application of adequate diagnostic and therapeutic approaches.

The aim of this case report is to present a rare foreign body - a tick on the eardrum in a seven-year old girl, who was admitted to hospital after one-month outpatient treatment due to repeated bleeding from the ear. This is a very rare case of tick on the eardrum in European countries.

Case Report

A seven-year old girl was an outpatient in the regional medical centre for a month due to repeated bleeding from the right ear.

The child was treated with local therapy and unsuccessful removal of an unidentified foreign body. During the intervention, massive bleeding occurred and then she was sent to the Ear, Nose and Throat (ENT) Department with the glomus tympanicus diagnosis.

The patient did not complain of discharge, tinnitus or hearing loss.

Otoscopic and otomicrosopic check-up showed a foreign body, situated in the upper part of the right external auditory canal, next to eardrum. Since a leg had been identified, it was concluded that the foreign body was an insect. The external auditory canal and tympanic membrane showed normal morphology, without any sign of bleeding and hematoma. A blood sample was taken for serology.

Both otomicroscopic examination and extraction of the foreign body by microforceps were carried out under short general anesthesia. A dead tick was identified in the upper posterior region of the eardrum near to annulus, without perforation. Parasitological analysis confirmed a hard tick Rhipicephalus sanguineus (female) (Figure 1).

Systemic antibiotic therapy (ceftriaxone) and local treatment were administered postoperatively. The postoperative course had no complications, and audiometry confirmed normal hearing. During the six-month follow-up period, the child's condition was good.

Serological analysis on Borrelia burgdorferi was negative and further serological analyses were not suggested by infectologist.

Informed consent had been obtained from the child's parents prior to the procedures performed.

Discussion

Ticks are blood-sucking ectoparasites of the class Arachnida. They are classified as hard ticks and soft ticks, depending on their covering cuticles. They feed with human and animal blood, and can transmit pathogens such as rickettsiae and spirochetes, which induce spotted fever, Lyme disease, and spirochetal infectious disease. There is not much data about this kind of foreign bodies in the external ear canal and eardrum, and the most common cases have not been reported in European countries [1-8].

Careful otoscopy and otomicroscopy are necessary to identify foreign bodies. The shape and diameter of the outer ear canal can present an obstacle.

One of the most distressing experiences in case of a foreign body is having a live insect in the ear canal, especially in children. The insect's movement can cause a buzzing in the ear and may be quite uncomfortable. In some cases, a foreign body in the ear canal will go undetected. Sleeping on the floor or outdoors would increase the chance of this unpleasant experience.

Successful removal of foreign bodies depends on a number of factors such as the nature of foreign body, the cooperation of the patient during removal, the ability to visualize the foreign body, the equipment and tool available for the removal of foreign body, the experience and skill of otorhinolaryngologist [9].

Literature recommends different therapeutic procedures, such as mere inaction until a tick falls off spontaneously [4], extraction by microforceps [1, 2, 5], extraction with the skin around it, and extracting the abdomen of tick along with suction of the body fluid and the extraction of the whole body of the tick after three days [4].

Some authors recommend killing the tick by pouring warm water, mineral oil [2], 4% solution of lidocain [2] or glicerin [5] into the outer ear canal before the extraction of the tick .

The tick can be extracted from the canal under local anesthesia, while general short-term anestehesia is recommended for its removal from an eardrum in the pediatric population. Antibiotic therapy is recommended after extracting the tick [5, 6], or to treat complications [4].

Ticks and other foreign bodies in the outer ear can damage the eardrum and lead to inflammation of the middle ear [2].

There are reports of luxation of the incudomalleal or incudostapedial joints and the dislocation of the stapes from the oval window [7], but they are mostly the consequence of an attempt of extraction by inexperienced clinician.

Less common is the paralysis of a facial nerve as an effect of neurotoxin [2, 8]. Inadequate extraction, due to the pressure on the abdomen of a tick, can cause regurgitation of the content and cause the infection of the host [4].

Conclusion

In conclusion, in case of ear bleeding a differential diagnosis should include the existence of a tick on the tympanic membrane, and the accurate diagnosis is given with careful direct otoscopy and otomicroscopy. The right diagnosis and urgent treatment in referral centers prevent possible complications.

Our recommendation is extraction of a tick under general anesthesia by an experienced clinician.

Rad je primljen 12. III 2014.

Recenziran 16. IX 2014.

Prihvacen za stampu 27. IX 2014.

BIBLID.0025-8105:(2014):LXVII:11-12:404-406.

DOI: 10.2298/MPNS1412404D

References

[1.] Rahmat O, Prepageran N, Loganathan A, Raman R. Tick in the ear. Ear Nose Throat J. 2006; 85(12):796.

[2.] Indudharan R, Ahamad M, Ho TM, Salim R, Htun YN. Human otoacariasis. Ann Trop Med Parasitol. 1999; 93(2): 163-7.

[3.] Ryan C, Ghosh A, Wilson-Boyd B, Smit D, O'Leary S. Presentation and management of aural foreign bodies in two Australian emergency departments. Emerg Med Australas. 2006; 18(4):372-8.

[4.] Iwasaki S, Takebayashi S, Watanabe T. Tick bites in the external auditory canal. Auris Nasus Larynx. 2007; 34:375-7.

[5.] Edussuriya BDP, Weilgama DJ. Case reports: intra-aural tick infestations in humans in Sri Lanka. Trans R Soc Trop Med Hyg. 2003; 97:412-3.

[6.] Dilrukshi PR, Yasawardene AD, Amerasinghe PH, Amerasinghe FP. Human otoacariasis: a retrospective study from an area of Sri Lanka. Trans R Soc Trop Med Hyg. 2004; 98(8):489-95.

[7.] Vukadinov J, Sevic S, Canak G, Madle-Samardzija N, Turkulov V, Doder R. Lyme disease-new findings on its physiopathology, diagnosis, therapy and prevention. Med Pre gl. 2002; 55(5-6):207-12.

[8.] Naude TW, Heyne H. Spinose ear tick as the cause of an incident of painful otitis externa. S Afr Med J. 2002; 92:72-3.

[9.] Topolac R, Udovicki J. Errors in treatment of foreign bodies of respiratory tract. Med Pregl. 1969; 22(5-6):329-31.

Dragoslava DERIC, Bojan PAVLOVIC, Miljan FOLIC, Srbislav BLAZIC and Ljiljana CVOROVIC

University of Belgrade, Faculty of Medicine

Clinical Center of Serbia, Belgrade

Clinic for Otorinolaryngology and Maxillofacial Surgery

Corresponding Author: Prof. dr Dragoslava Deric, Klinicki centar Srbije, Klinika za otorinolaringologiju i maksilofacijalnu hirurgiju, 11000 Beograd, Pasterova 2, E-mail: dragadj@beotel.net
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Title Annotation:Case report/Prikaz slucaja
Author:Deric, Dragoslava; Pavlovic, Bojan; Folic, Miljan; Blazic, Srbislav; Cvorovic, Ljiljana
Publication:Medicinski Pregled
Article Type:Case study
Date:Nov 1, 2014
Words:1167
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