Abstract
Background
Nasal myiasis is a rare parasitic infestation caused by fly larvae, which can lead to serious complications, such as orbital cellulitis, if not treated promptly. Early recognition and intervention are essential to prevent further complications.
Case presentation
We present a case of a 55-year-old Thai female with advanced-stage malignant melanoma of the right nasal cavity, treated with endoscopic tumor removal and 3 months of concurrent chemoradiation. The patient developed nasal myiasis and orbital cellulitis secondary to maggot infestation. A multidisciplinary approach, including adjunctive therapy with ivermectin, resulted in the successful resolution of both the infestation and its complications.
Conclusion
This case highlights the effectiveness of ivermectin in treating nasal myiasis and emphasizes the importance of a collaborative medical approach in managing complex cases. It also provides insights into the mechanism and clinical application of ivermectin for similar parasitic infestations.
Keywords: Nasal myiasis, Orbital cellulitis, Maggot infestation, Ivermectin, Case report
Background
Nasal myiasis is a rare condition characterized by the infestation of fly larvae in the nasal cavities, typically occurring in regions with poor sanitation and hygiene practices [1]. Orbital cellulitis is a potential sight-threatening complication of nasal myiasis, necessitating prompt diagnosis and management [2]. Ivermectin, a broad-spectrum antiparasitic medication, has emerged as a promising therapeutic option for nasal myiasis owing to its efficacy and safety profile [3, 4].
Case history
A 55-year-old Thai female patient with advanced-stage malignant melanoma of the right nasal cavity, who had previously undergone endoscopic tumor removal and completed 3 months of concurrent chemoradiation, presented a clinical manifestation characterized by nasal discharge, orbital swelling (Fig. 1), and acute visual disturbances. Upon examination, a maggot infestation within the nasal cavities was identified (Fig. 2), and imaging studies confirmed significant involvement of the paranasal sinuses with concurrent evidence of orbital cellulitis (Fig. 3). Following a definitive diagnosis of nasal myiasis and orbital cellulitis, a comprehensive treatment regimen was implemented. This regimen included endoscopic debridement and removal of the maggots (Fig. 4), followed by an extended course of antibiotic therapy utilizing ceftriaxone and clindamycin.
Fig. 1.
Right periorbital erythema and swelling (*)
Fig. 2.
A The right nasal cavity is covered with necrotic tissue and larvae at the ethmoid (*) and maxillary sinus (arrow). B Larvae were extracted manually from the right nasal cavity
Fig. 3.
Computed tomography of paranasal sinus showed a thickening of nasal cavity mucosa and paranasal sinuses (*) and right proptosis (arrow)
Fig. 4.
The right nasal cavity after debridement of necrotic tissue and removed larvae at the ethmoid (*) and maxillary sinus (arrow)
The treatment protocol consisted of oral administration of ivermectin (6-mg tablet) via tube feeding once daily, supplemented by topical application of ivermectin (6-mg tablet) dissolved in normal saline solution to irrigate both nasal cavities twice daily. This integrated approach, which employed both topical and systemic delivery methods, adhered to established academic standards and was maintained for a duration of 7 days. Upon conclusion of the 7-day treatment course, no larvae were detected. Follow-up imaging studies demonstrated no signs of infection (Fig. 5), and a nasal endoscopic examination conducted 6 months post treatment revealed recovery of the ethmoid–maxillary sinus mucosa (Fig. 6).
Fig. 5.
Magnetic resonance image of paranasal sinus after treatment revealed decreased thickening of paranasal sinuses (*) and improved right proptosis (arrow)
Fig. 6.
The right nasal cavity 6 months post treatment revealed recovery mucosa of the ethmoid (*) and maxillary sinus (arrow)
The utilization of such a homogeneous therapeutic strategy ensured consistent medication delivery and optimized the treatment’s efficacy against both nasal myiasis and orbital cellulitis, thereby significantly contributing to the successful management of this clinical case.
Discussion
In the geographical context of Southern Thailand, environmental conditions characterized by high humidity and poor sanitation practices contribute to the prevalence of nasal myiasis. Such circumstances escalate the susceptibility of individuals to fly infestations and subsequent complications. It is imperative that management strategies meticulously address these environmental factors to prevent recurrence and optimize patient outcomes.
The effective management of nasal myiasis and its associated complications necessitates a comprehensive and multidisciplinary approach. In our presented case, the timely diagnosis and intervention proved crucial to addressing the maggot infestation and subsequent orbital cellulitis. Alongside the tele-endoscopic mechanical debridement of maggots and debris followed by targeted antibiotic therapy to prevent secondary infections, a novel aspect of our treatment regimen involved the administration of ivermectin. This antiparasitic agent, delivered both orally and topically, demonstrated efficacy in eradicating maggots and preventing reinfestation, thereby playing a significant role in achieving favorable outcomes in our patient [5].
The mechanism of action of ivermectin involves its selective binding to glutamate-gated chloride ion channels in invertebrate nerve and muscle cells, consequently inducing paralysis and eventual death of the parasites [6]. Its broad-spectrum activity, coupled with anti-inflammatory and wound-healing properties [7], makes it an effective treatment option for nasal myiasis [8]. Several studies have reported successful outcomes with ivermectin therapy, underscoring its role as a valuable adjunct in the management of parasitic infestations [9–12]. Ivermectin manifests several mechanisms of action that contribute to its efficacy in treating nasal myiasis:
• Neuromuscular blockade: ivermectin selectively binds with high affinity to glutamate-gated chloride ion channels in invertebrate nerve and muscle cells, leading to increased permeability to chloride ions and subsequent hyperpolarization of the cell membrane. This sequence of events culminates in paralysis and eventual death of the larvae responsible for myiasis.
• Antiparasitic activity: ivermectin disrupts essential biological processes in parasites, including feeding, reproduction, and molting, ultimately leading to their demise. This broad spectrum activity underscores its effectiveness against various parasitic infections, including myiasis.
• Anti-inflammatory effects: ivermectin exhibits notable anti-inflammatory properties, including the inhibition of cytokine production and modulation of immune responses. In cases of myiasis characterized by tissue inflammation and damage due to larval infestation, the anti-inflammatory effects of ivermectin may mitigate tissue damage and promote healing.
• Antibacterial effects: although primarily renowned for its antiparasitic activity, studies have indicated that ivermectin may also possess antibacterial properties. In instances of myiasis complicated by secondary bacterial infections, the antibacterial effects of ivermectin may contribute to the overall therapeutic effect.
• Wound healing promotion: ivermectin facilitates wound healing processes by promoting collagen deposition, angiogenesis, and tissue remodeling. In cases of myiasis accompanied by tissue damage and ulceration, the wound-healing properties of ivermectin may expedite the resolution of lesions and restoration of tissue integrity. While the precise mechanisms underlying the effectiveness of ivermectin in treating nasal myiasis remain incompletely elucidated, its multifaceted pharmacological properties suggest that it may act through a combination of neuromuscular blockade, antiparasitic activity, anti-inflammatory effects, antibacterial effects, and wound healing promotion.
Further research is warranted to explore the specific mechanisms involved and optimize the utilization of ivermectin in the management of myiasis and other parasitic infections.
Conclusion
This case highlights the successful management of nasal myiasis and orbital cellulitis with a multidisciplinary approach and adjunctive therapy with ivermectin. Further research is warranted to elucidate the optimal dosing regimen and long-term efficacy of ivermectin in similar cases. Collaboration between otolaryngology specialists, ophthalmologists, and infectious disease experts is essential for the comprehensive management of nasal myiasis and its complications.
Acknowledgements
We acknowledge the contributions of the medical and nursing staff involved in the care of the patient in PSU hospital.
Abbreviation
- MRI
Magnetic resonance imaging
Author contributions
CP was the surgeon, reviewer, and writer; UP was the assistant surgeon; JJ and NS drafted the manuscript. All authors reviewed the manuscript.
Funding
The research was supported by a grant from the Faculty of Medicine, Prince of Songkla University, Thailand.
Availability of data and material
Database of the Faculty of Medicine, Prince of Songkla University, Thailand.
Declarations
Ethics approval and consent to participate
The Ethic Committee at the Faculty of Medicine, Prince of Songkla University, Thailand, approved the study protocol. All procedures performed in studies involving human participants were in accordance with the ethical standards of the institutional and/or national research committee and with the 1964 Declaration of Helsinki and its later amendments or comparable ethical standards.
Consent for publication
Written informed consent was obtained from the patient for publication of this case report and any accompanying images. A copy of the written consent is available for review by the Editor-in-Chief of this journal.
Competing interests
The authors declare that there are no competing interests. No author has any proprietary interest in any of the products or ideas mentioned in this article.
Footnotes
Publisher’s Note
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Data Availability Statement
Database of the Faculty of Medicine, Prince of Songkla University, Thailand.