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\begin{document}

\title{Otomyiasis: A case report}



\author[1]{Telila Mesfin}%
\author[1]{kenbon seyoum}%
\author[1]{Sisay Dadi}%
\author[2]{Eshetu Tadesse}%
\author[1]{Neway Ejigu}%
\author[1]{Elias Sadik}%
\author[1]{Daniel Ayane}%
\affil[1]{Madda Walabu University}%
\affil[2]{ICAP at Columbia University}%


\vspace{-1em}



  
  \date{May 18, 2024}


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\selectlanguage{english}
\begin{abstract}
Abstract Myiasis is the infestation by dipteran fly larvae to feed on
the host's organs, bodily fluids, or ingested food. We report a 14 year
old grade 7 female patient who visited our hospital with a complaint of
right ear pain of two years duration. Keywords: Otomyiasis, myiasis,
aural myiasis, adult%
\end{abstract}%



\sloppy


\textbf{Introduction}

The term ''myiasis'' refers to the infestation of live people or animals
by flies {[}1, 2{]}. The word ''myiasis,'' which means ''fly,'' is
derived from the Greek word ''myia,'' which was first used in
1840{[}3{]}. Myiasis is the particular, semi-specific, or inadvertent
infiltration of living mammalian tissue by dipteran fly larvae to feed
on the host's organs, bodily fluids, or ingested food. The fly is
thought to be able to lay its eggs on an immobile person's skin, wounds,
or natural openings while in flight. Larvae that produce myiasis
primarily target the body's cutaneous tissue (furuncular and creeping),
bodily cavities, and organs {[}4{]}. Human myiasis can range from benign
to asymptomatic, or it can cause minor to severe problems, even death
{[}5{]}.

Because of the potential for brain penetration, infections of the nose
and ears are particularly deadly; the mortality rate is about 8\%. In
the tropics and subtropics, myiasis is a widespread parasite
infestation. Due to global travel, cases are also seen in Europe and
North America outside of the areas where it is endemic {[}4, 6{]}.
Children are more prone to developing aural myiasis than adults. It is
frequently observed in adults as well, particularly in mentally impaired
people. The Sarcophagidae family includes the majority of the recognized
causal agents. In the Mediterranean Basin, Southern Russia, Turkey,
Israel, the Middle East, and the Far East, Wohlfahrtia Magnifica, a
species of the Sarcophagidae, is frequently identified as the cause of
several forms of myiasis {[}7, 8{]}. For the otolaryngologist, aural
myiasis presents a rare but distinctive clinical entity.

The clinical spectrum covered a wide range of symptoms, including
maggots in the ear, otalgia, otorrhea, perforation of the eardrum,
bleeding, itching, roaring sound, tinnitus, furuncle of the external
ear, and restlessness. Clinicians must refer patients with maggot
species identification in order to gather epidemiological information on
cases of auditory myiasis {[}9{]}.

\textbf{Clinical presentation}

We present a 14 year old grade 7 female patient who visited our hospital
with a complaint of right ear pain of two years duration. She had been
complaining of intermittent type of ear ache over the past eight years
for which she visited a number of health facilities. The pain worsened
over the past two years which led her to get evaluated at our
institution. In addition, she complains headache, itching, roaring sound
in her ear, tinnitus, loss of sleep, difficulty attending her school
lesson, and minimal hearing loss. She tried to get rid of the discomfort
by inserting a cotton tip into her ear and applying the Valsalva
maneuver \textbf{(fig.1).} She observed plenty of worms coming out of
her ear after being triggered by the cotton tip and following which she
felt relief. Recently, she saw adult flies coming out of her right ear
and flew away\textbf{(fig.2} ). Otherwise, she has no fever, body
weakness and change in behavior. She is the 3\textsuperscript{rd} child
for her families and has four brothers and three sisters. She takes
shower once a week. She has no comorbid illnesses like diabetes mellitus
and neuropathy.\selectlanguage{english}
\begin{figure}[H]
\begin{center}
\includegraphics[width=0.70\columnwidth]{figures/image1/image1}

\end{center}
\end{figure}

Figure 1: A picture showing adult fly coming out of the ear.\selectlanguage{english}
\begin{figure}[H]
\begin{center}
\includegraphics[width=0.70\columnwidth]{figures/image2/image2}

\end{center}
\end{figure}

Figure 2: A picture showing an adult fly being removed with a cotton
tip.

On physical examination, vital signs were Blood pressure=100/60, pulse
rate=82 beats per minute, respiratory rate=16, temperature=36.5 degree
centigrade, and saturation 96\% off oxygen. On HEENT examination, the
conjunctiva was hyperemic and the sclera non-icteric. Otoscopic
examination revealed adult flies embedded in the right ear. The tympanic
membrane was not visualized. The left ear is normal except for certain
waxes on the wall of the external auditory canal. The Rinne test for the
right ear is negative because the patient feels the vibration of the
tuning fork while it was put on the mastoid process. There were no
pertinent positive findings in the remaining systems.

Laboratory investigations were done to assess for comorbidities and risk
factors. On complete blood count, white blood cells=5000,
neutrophil=55\%, hemoglobin=15gm/dl, and platelet=210000. Random blood
sugar was 120mg/dl, and HIV test=non-reactive.

After written informed consent was taken the ear was irrigated with
normal saline. There were about four adult flies that came out of the
ear while flushing with intravenous fluid \textbf{(fig.3).}\selectlanguage{english}
\begin{figure}[H]
\begin{center}
\includegraphics[width=0.70\columnwidth]{figures/image3/image3}

\end{center}
\end{figure}

Figure 3: An image showing freshly dead adult fly removed from the ear.

The contralateral ear was also irrigated to remove the wax. An otoscopic
examination was repeated after the procedure. The tympanic membrane was
intact and there were no remaining maggots or larvae
left\textbf{(fig.4).} Ciprofloxacin ear drops 0.2\%,0.25ml BID for seven
days to prevent secondary bacterial infection.\selectlanguage{english}
\begin{figure}[H]
\begin{center}
\includegraphics[width=0.70\columnwidth]{figures/image4/image4}

\end{center}
\end{figure}

Figure 4: An otoscopic picture showing intact tympanic membrane after
irrigation and removal was done.

\textbf{Discussion}

Aural myiasis is an uncommon infestation of the ears. Myiasis is
categorized as an obligatory or facultative infestation. In the former,
the host, most frequently a goat or sheep, is an essential component of
the maggots' life cycle, but in the latter, it is not {[}10{]}. Fly
species from the Calliphoridae, Sarcophagidae, Gastrophilidae,
Cuteribridae, Musca, Famina, Chrysomyia, and C. vicifiia families cause
myiasis.~The commonest genera causing myiasis belongs to Sarcophagidae
{[}11{]}. Myiasis is more common in tropical and subtropical regions,
and most cases recorded in the United States and Europe are in tourists
coming back from these regions. In moderate climates, the larvae of
cosmopolitan dipteran flies accidentally parasitize human skin
(Hypoderma bovis and Gasterophilus intestinalis), the nose, paranasal
sinuses, pharynx, and ears (Calliphora species, Lucilia sericata, and
Musca domestica), the alimentary tract and urogenital system (Fannia
canicularis), and the eyes, orbits, and periorbital tissues. {[}12{]}.
Medical entomologists, veterinarians, and doctors frequently find it
helpful to further categorize myiasis into several categories according
to the body area and tissue affected {[}13{]}. That means traumatic
myiasis, oral myiasis, aural myiasis, ophthalmomyiasis, enteric myiasis,
urogenital myiasis, and rectal myiasis. Previously, almost all
literatures have documented aural myiasis due to the infestation of fly
maggots. To our knowledge, no paper has been published on ear
infestation by adult flies. In contrast to those reports, this
particular case is worth reporting due to the rarest of all myiasis
cases.

According to the research, hosts are typically 60 years old, with a
male-to-female ratio of 5.5:1. The incidence of myiasis may be
associated with the level of sanitation currently in place, the density
of the current fly population, and the individual's economic situation.
Patients who are intellectually handicapped, elderly, diabetic, chronic
purulent otitis media, homelessness, alcoholism, psychological disorders
or unwell, peripheral vascular disease as well as drug users, are more
vulnerable to attack. {[}14-16{]}. In our case, the patient is only 14
years old school girl and has no comorbid illnesses. However, reports of
newborn myiasis cases have also been made {[}17{]}. Human myiasis can be
mild and asymptomatic or severe and potentially fatal since larval
infestations of the eye, nose, and ears can enter the brain {[}18{]}.
The same is true for this patient. She tolerated right ear pain over the
past eight years though she visited a number of health facilities.

Aural myiasis can cause a variety of distinct signs and symptoms, such
as otalgia, offensive otorrhea, aural fullness, bleeding, itching, a
roaring sound, tinnitus, vertigo, and furuncles of the external auditory
canal~when larvae are present in the ear. Meningitis and hearing loss
can result from damage to the auditory meatus {[}11, 12, 19{]}. The
larval attack may cause damage to the ear canal's surrounding tissue,
including the bones, and very rarely, death {[}7{]}. Either mechanical
tissue disruption or the larvae's synthesis of the enzyme collagenase
can result in tissue damage. Because the feeding maggots from a single
egg batch may entice many additional ovipositing flies of numerous
species, resulting in the aggregation of thousands of eggs and larvae,
small, early infestations frequently grow into massive infestations with
life-threatening implications {[}20{]}. After the deposited larvae begin
to feed on the surrounding tissues, the symptoms appear. Usually, the
history and clinical examination, which will reveal the larvae in the
ear, are used to identify the infestation. Due to the fact that the
larvae are typically found close to the external auditory canal because
they need air to breathe, further testing to diagnose it is unnecessary
{[}21{]}.

Most of the time, treating aural myiasis is as simple as removing the
larvae and irrigating the ear with one or more of the following
solutions: Alcohol, chloroform, normal saline, oil, ivermectin, or
iodine {[}9, 22-26{]}. Additionally, broad-spectrum preventive
antibiotics are typically used to stop subsequent infections. Under a
microscope, the larvae should be removed, and any remnants should be
thoroughly examined. Given that they all produce the same results, it is
difficult to determine which irrigation solution is better. The
irrigation's usual purpose is to kill and remove any remaining larvae,
especially those that are difficult to see or reach on examination
{[}21{]}. Sometimes patients require surgical investigation to determine
the extent of the disease or to check for residual disease. In these
situations, mastoid exploration is typically carried out to determine
the degree of the infestation and, if any residue is discovered, it will
be eradicated {[}27, 28{]}.

\textbf{Conclusion}

Otomyiasis is a very rare disease of the ear that is caused by an
infestation of fly larvae. The commonest genera causing myiasis belongs
to Sarcophagidae. The predisposing factors include mental impairment,
elderly, diabetes, chronic purulent otitis media, homelessness,
alcoholism, and peripheral vascular disease. The clinical manifestations
are otalgia, offensive otorrhea, aural fullness, bleeding, itching, a
roaring sound, tinnitus, vertigo, and furuncles of the external auditory
canal~when larvae are present in the ear. The management of aural
myiasis involves removing the larvae and irrigating the ear with normal
saline or chloroform solution.

\textbf{Author Contributions}

TM: Writing -- original draft. KS: writing patient history, EM and SD:
Supervision, review and editing. NE and EI: Conceptualization and
Design, DB: writing management done. All authors read and approved the
final manuscript.

\textbf{Acknowledgement}

None

\textbf{Conflict of Interest}

The authors declare that they have no conflicts of interest.

\textbf{Data Availability Statement}

Data are available from the corresponding author upon reasonable request

\textbf{Consent}

Written informed consent was obtained from the patient to publish this
report in accordance with the journal's patient consent policy

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