Myiasis of Peristomal Sinuses Around Tracheostomy Wound: Case Report of 2 Cases

Abstract

“Myiasis” is considered in Hindu mythology as “God’s punishment for sinners”. Literature abounds with reports of myiasis affecting the nasal cavity, ear, non healing ulcers, exophytic malignant growth and cutaneous tissue. But case report of myiasis of the tracheostomy wound is relatively rare and that also peristomally is seen first time. We are reporting two cases whose tracheostomy was done, one for laryngeal cancer and other for laryngocoele. We are discussing the need for the proper care of tracheostomy wound myiasis because the site of such an infestation is close to vital organs in the neck and avoiding complications.

Introduction

The term myiasis was derived from the Greek term muia (fly). Myiasis is caused by dipterous larvae (maggots) which feed on the living or necrotic tissue of vertebrate animals or humans[1]. Human myiasis is common parasitic infestation in the tropics and subtropics like India, Southeast Asian and African countries. Myiasis is mainly seen in people with poor hygiene and living in rural areas and less common in urban areas and developed countries.

Flies causing myiasis can be classified into two groups, based on the relationship with their hosts: Obligate parasites, specifically producers of myiasis, can develop only on live hosts; Facultative parasites, their larvae feed primarily on cadavers or vegetables, but can sporadically infest human or animal tissues. Removal of maggots by applying turpentine oil locally on the tissue and careful removal is the best treatment of choice. Myiasis of natural orifices like ear, nose and oral cavity are more common, but myiasis of tracheostomy wound site is relatively rare entity. These case reports discuss the importance of proper health education to the patient regarding the tracheostomy wound care and to prevent maggots infestation, also the various causes for it and the overway eradication plans (Figs. 1, 2, 3).

Fig. 1.

Maggots seen around tracheostoma forming peristomal sinuses

Fig. 2.

Maggots retrieved after keeping turpentine oil soaked gauze around stoma

Fig. 3.

Wound after complete removal of maggots and change of tracheostomy tube

Case reports

First case was of a 64 years old man who presented to our ENT outpatient department for evaluation of a foul-smelling, blood-stained discharge and frequent itching and severe episodic pain at the site of tracheostomy tube. This patient was tracheostomised in emergency for laryngocoele 1 year back at our Bundelkhand Medical College, Sagar. But now we can see maggots scrawling around tracheostoma forming peristomal sinuses and not coming from tube. Patient was admitted in isolation in ENT ward. Maggots were removed manually 2–3 times a day. Patient was given intravenous antibiotics and dressing (betadiene soaked gauze) around stoma was done daily. We removed around 54 maggots in 4 days and changed tracheostomy tube. The patient was kept under mosquito net and patient as well as his relatives were explained to maintain hygiene and tracheostomy tube care. Then patient was discharged on 5^th day with no maggots and in stable condition and advised for regular follow up.

Second case was of a 63 years old man who presented to our ENT OPD with sharp neck and chest pain around tracheostoma, itching and something scrawling around tracheostomy tube. This patient was tracheostomised for carcinoma larynx 1 month back at other hospital and now came here for further management. Similar care was given as in previous patient. By continuous meticulous effort in 3 days around 149 maggots were taken out from peristomal sinuses formed around tracheostoma and double lumen tracheostomy tube was placed so that better self care possible. Patient and his relatives were educated about tracheostomy care and then patient discharged on 4^th day, symptomatically improved and maggots free, with regular follow up advise.

The isolated parasite in both cases was identified as coming from the species Musca Domestica.

Discussion

Myiasis was considered, by Hindu mythology, as “God’s punishment of sinners”. [2]

According to the tropism of the tissue, dipterous larvae are divided into: [3]

• Cutaneous myiasis: these invading dermo-epidermal layers of the host

• Myiasis of natural orifices: nose, ear, oral, pharyngeal myiasis;

• Myiasis with inner migration: larvae migrate inside the body before emerging at skin level.

In our case the predisposing factors for such infestation could be.

1. Odour of decomposition that can attract flies;

2. Poor hygiene, habit of keeping the area uncovered and irregular cleaning of tracheostomy tube.

3. Smaller dimension of the surgical tracheostomy.

Clearing the maggots with turpentine oil and antiseptic dressing is very important. In our patients, we couldn’t directly apply locally turpentine oil to prevent aspiration pneumonitis, so we used turpentine oil soaked gauze and kept around tracheostoma for a few minutes and then removed maggots which came out and got asphyxiated.

Hospital admission may be useful to avoid spreading of the tissue lesions or broncho-pulmonary complications, since larvae in the bronchial tree, can behave as a living foreign body. With proper care, use of topical and systemic antibiotics, intermittent removal of maggots and regular dressing chances of recurrence are quite less.

The larvae can damage the vital tissues which sometime be fatal if they cause life threatening hemorrhage [4]. The severity of the lesion depends on the time interval from the onset of infection and the diagnosis of the lesion. If the lesion is diagnosed early, less number of larvae will be present with minimal tissue damage. But if the lesion is presented at later stage or delayed, it will result in greater number of larvae with extensive tissue necrosis. Therefore early diagnosis is crucial to limit tissue damage. Depending on the number of viable eggs that are actually deposited by the female fly, the same number of larvae hatches and grow in any lesion.

Mechanical removal of the larvae is the traditional treatment of myiasis [5]. Anti-larval measures includes use of turpentine oil or mixture of turpentine oil and aqua chloroformis followed by removal of the larvae [6]. But also use of topical and systemic antibiotic as coadjuvants in the treatment improves the favorability of prognosis in severe cases.

Tracheostomy wound myiasis can actually be benign if a secondary species (e.g., Musca domestica) confines its activities to diseased and dead tissue. On the other hand, it can turn serious if an obligate species (e.g., Chrysoma bezziana) infests living tissue. Breeding season for flies runs from August through November in India, and thus the risk of maggots is greatest during these months [7].

In our cases, emergency tracheostomy, early discharge and irregular follow up visits lead to myiasis around tracheostoma and this is first time that maggots were seen peristomally and not coming from stoma of the tracheostomy wound. Regular sterile dressing, proper nutrition, and thorough understanding of the importance of wound management by the patient and patient party could have avoided this condition. Until now, case reports were from tracheostomy wound myiasis only, but our cases are totally new, different and unique.

Life cycle of fly

Conclusion

Maggots infestation in tracheostomy wound is relatively rare even in tropical country like India. Although this is not a lethal disorder, knowledge of this disease is necessary from preventive, diagnostic and curative standpoints. The prognosis is better when there are no associated complications, hospital admission and proper care is very essential. Clearing the maggots with turpentine oil meticulously, tracheostomy care and treatment of underlying disease is very vital. It is also important to send the larvae for culture to classify the generic group.

Myiasis can be prevented by practicing good personal hygiene, primary care of wound, controlling fly population and maintenance of sanitation of the surroundings. Apart from these, patient’s relatives should be educated about the post-operative care, by teaching them the dressing and wound care and the importance of it, so that such manifestation of larvae could be prevented. Close observation and examination of the tracheostomy wound should be done for a week after their returning to home. Any symptoms relating to infestation should be reported to the hospital as the earliest, so that the lesion can be treated with minimal tissue damage rather than extensive necrosis when presenting at later stage. These cases are described to keep in mind that with proper care, such complications of tracheostomy can be prevented, as “prevention is better than cure”.

Funding

None.

Compliance with ethical standards

Highly compliance with ethical standards.

Conflict of interest

Dr. Lavi Ukawat declares that there is no conflict of interest. Dr. S. K. Pippal declares that there is no conflict of interest. Dr. Ankur Gupta declares that there is no conflict of interest.

Consent

Proper consents are there.