Ear Mites as an Overlooked Source of Ear Itching and Tinnitus - A Case Series

Abstract

Otoacariasis is a rare condition characterized by ticks and mites in the ear canal. Human otoacariasis remains underrepresented in literature as otoacariasis is more common in animals. Systemic diseases being transmitted by these arachnids pave the way for potential complications. This case series sheds light on this uncommon condition by highlighting the diverse symptomatology and difficulties in diagnosis and treatment. Three different presentations highlight the diversity of this condition. A 40-year-old male exhibited itching and tinnitus, revealing a mite on the tympanic membrane on otoscopy. A 35-year-old female with persistent itching and tinnitus showed multiple whitish mites on examination. A 50-year-old female complained of ear pain and was found to have a tick attached to the external auditory canal. The relevance and rarity of human otoacariasis are highlighted in this study, thereby encouraging caution in situations of earache. We aim to increase clinician awareness about this condition and the necessary interventions required by conducting a thorough literature review.

Introduction

Mite in the ear is common in animals but rarely reported in the literature in human ears. Otoacariasis is the presence of ticks and mites in the ear canals of humans or animals [1]. The external auditory can become infested by these microscopic arachnids. They produce a variety of symptoms, including discomfort, itchiness, tinnitus, and ear pain, and can have more severe implications that make the diagnosis and treatment difficult [2]. Systemic diseases transmitted by mites should be considered when a patient is diagnosed with otoacariasis [3]. If ticks or mites are discovered in the ear canal, a comprehensive examination of the patient should begin to rule out any potential infections.

Mites are arachnids that belong to the subclass Acari. Otodectes cynotis is the most common mite species implicated in humans. The life cycle of the mites begins with eggs laid by adult female mites in the external ear canal of the host. After incubation, the eggs hatch into larvae, and the larvae undergo molting to develop into nymphs. They mature into adult mites, which then rely on the host for their life cycle, lasting for about three weeks, by feeding on skin debris, earwax, and other organic matter within the ear canal [4].

Ticks are arachnids in the order Ixodida and have a more complex life cycle than mites, which varies depending on the species. The life cycle begins with eggs laid by adult female ticks in the environment. The eggs hatch into larvae, which attach to a host for a blood meal. After undergoing sequential molting and finding another host, they develop into nymphs and adults, which attach to larger mammals, including humans [5].

We present to you a case series with mites in the human ear. Our primary objective in this series of cases is to shed light on the rarity of otoacariasis, a condition that can manifest in a variety of symptoms, and explore the different treatments available for this disorder. It is essential to consider otoacariasis as a possible diagnosis for individuals who are experiencing discomfort or itchiness in their ears. To accomplish this goal, we conducted an exhaustive review of relevant literature on PubMed, using keywords such as “human otoacariasis,“ “mites,“ “ticks,“ and “external auditory canal infestations.“ By presenting these cases and analyzing past research, we aim to contribute to the existing knowledge on this intriguing ailment and its management. Our detailed analysis will provide a comprehensive understanding of otoacariasis, making it easier for healthcare professionals to diagnose and treat patients with this condition.

Case Series

Case 1

A 40-year-old male with a history of itching and tinnitus in the right presented to ENT OPD. On examination with otoendoscopy, the patient had small white patches over the drum and external auditory canal. On close observation of these white patches, it was found to be a mite moving over the ear drum. (Fig A)

Figure A: Tick biting the External auditory canal, Figure B: Microscopic appearance of tick Otodectes cynotis, Figure C: Tick crawling over the tympanic membrane, Figure D: Mite removed from the external auditory canal

Case 2

A female patient aged 35 visited the clinic to seek medical advice for her persistent symptoms of itching and ringing in her ears that have been bothering her for the past month. Upon thorough examination, it was observed that numerous small whitish mites were seen to be crawling on her eardrum, thus causing the discomfort. (Fig B, C)

Case 3

A 50-year-old woman came to the outpatient department with a complaint of pain in her left ear for the past ten days. She did not report any ear discharge or hearing difficulties. During the examination, a tick was found biting her external auditory canal. (Fig D)

Discussion

Otoacariasis is the presence or attachment of ticks and mites within the ear canal of humans and animals and is a common phenomenon, especially in rural areas. Ear mites commonly are caused by dog mites, which is Otodectes cynotis [4]. The typical symptom will be itching in the ear, ear-blocking sensation, tinnitus, and ear pain, or it can present with unusual symptoms like ear bleed, hearing loss, or facial palsy [2, 6]. Ticks may transmit a variety of pathogenic microorganisms, including protozoa, rickettsiae, spirochetes, and viruses. These ticks may be vectors of diseases, especially livestock, humans, and companion animals. Hence, systemic evaluation of patients presenting with otoacariasis is necessary as they may harbor an array of organisms ranging from the virus causing Crimean-Congo Haemorrhagic Fever to the bacteria causing Tularaemia [7]. The bite of H. marginatum species is reportedly a risk for the development of facial paralysis [8].

The first case report of ear mite was reported by van de Heyning et al. in 1977 for Otodectes cynotis [9]. Rossiter et al. reported that Dermanyssus gallina caused two cases of otitis externa in poultry workers, leading to its classification as an occupational hazard [10]. Sancassania (Caloglyphus) berlesei (Acaridae) was reported as a case of recurrent mastoid cavity infestation by Paleri et al. [11]. Several case reports of otoacariasis have been published thereafter from Sri Lanka, Turkey, Korea, and Malaysia.

In Sri Lanka, tick infestations are a major public health concern, and the risk factors include engaging in outdoor activities, wild animals near households, and proximity to forests. Most of these risk factors are present in our setting, even though the socio-ecological risk factors are more pronounced in Sri Lanka, which varies between regions [12, 13]. Studies conducted by Dilrukshi et al. and Kularatne et al. indicated the presence of otoacariasis due to various tick genera, including Amblyomma, Rhipicephalus, Hyalomma in the Sri Lankan population [14, 15]. Unlike mite infestation, tick infestation may cause zoonotic tick-borne illnesses like encephalitis and hemorrhagic fever, which cause high morbidity and mortality. The disease gets transferred via the bite of a tick through the blood meal they have.

Turkey, which has a suitable climate and vegetation for ticks, is a hotspot for otoacariasis, and the study conducted by Asya et al. in Turkey showed that adult tick infestations commonly presented with foreign body sensation while infestations caused by larvae presented with pain in the ear as the dominant symptom [1, 16]. Another case reported by Oner et al. demonstrated the presence of a tick larva in the cystic lesion of the tympanic membrane [17].

In a retrospective study conducted in Malaysia, several cases of aural foreign bodies presenting to the emergency department examined were diagnosed as otoacariasis [18]. Similarly, in a case report from Korea, where the patient had an uncommon presentation of otalgia, an insect occluding the tympanic membrane was revealed upon otoscopic examination. This was the first reported case of otoacariasis caused by Haemaphysalis longicornis in Korea [19].

Routine otoscopy can be used for the diagnosis of human otoacariasis. In cases where the diagnosis cannot be confirmed by routine otoscopy, the minimally invasive technique proposed by Nakao et al. for determining whether the tick is anchored to the ear canal is quite helpful [20].

The treatment for human otoacariasis involves a series of washes to the ear canal using saline and alcohol, followed by an administration of antibiotics. The mite infection can also be cleared using Crotamiton ear drops [21]. Alternatively, oral Ivermectin, successive ear irrigation, Deltamethrin ear drops, and mineral oil were proven effective in another human ear mite infestation case [22].

Although tick and mite infestation in the ear canal had been reported, it had not been reported in the Indian subcontinent. In our case series, dog mites (Otodectes cynotis) were humans’ most important cause of mite infestation. A mite takes three weeks to become an adult from the egg. An adult mite will live for two months. They continuously reproduce during this time. For their entire life cycle, they depend on the host. Mites can survive for a limited time in the external environment. Symptoms that are present can be itching, tinnitus, otalgia, and ear-blocking sensation. Treatment of this condition will be saline wash and reassuring the patient.

Conclusion

Ticks and mites, as the intra-aural foreign bodies in the ear canal, are relatively rare but should be considered cause for tinnitus, ear itching, and ear pain.

Authors’ contributions

All the authors have equally contributed to the case report. KR and VMS were the major contributor in writing the manuscript. VK, VS and AK participated in writing, editing and data interpretation along with KR and VMS. All authors have approved the manuscript.

Funding

There was no funding required to take up the study.

Data Availability

The datasets during and/or analyzed during the current study are available from the corresponding author upon reasonable request.

Declarations

Ethics approval and consent to participate

The study was taken after obtaining an Ethics committee approval from the Institution of Ethics Committee, JIPMER, Pondicherry, India.

Consent for publication

Written informed consent for publication of their clinical details and/or clinical images was obtained from the patient. A copy of the consent form is available for review by the Editor of this journal.

Competing interests

The authors declare that they have no competing interests.