Nasal Myiasis - A Rare Nasal Infestation

What Are Fly Larvae?

Maggots, also known as fly larvae, represent the immature stages of flies, particularly those belonging to the genus Chrysomia, including C. Bezzaiana, C. Megacephala, and C. Phaonis. These flies are attracted to the malodorous nasal discharge emanating from individuals with atrophic rhinitis. A fly can lay approximately 200 eggs, hatching into larvae within 24 hours. The peak occurrence of these larvae is typically observed between September and November.

Larvae are cylindrical, tapering at both ends, and possess a creamy-white coloration. During the larval stage, they exhibit voracious feeding behavior, as this stage is followed by the pupal stage, during which they do not feed. The larvae are equipped with backwardly directed hooks that assist them in anchoring themselves in position. These hooks are highly developed in the initial stages, rendering their extraction challenging. However, as the larvae mature, the hooks become less pronounced, allowing easier removal.

What Is Nasal Myiasis?

Nasal myiasis is a highly distressing condition that primarily affects individuals suffering from atrophic rhinitis and having suboptimal nasal hygiene. This condition is frequently observed within lower socioeconomic demographics. Atrophic rhinitis represents a chronic nasal ailment characterized by the gradual deterioration of the nasal mucosa and the underlying bone structure of the turbinates. This degeneration results in viscous secretions that quickly dry up, forming crusts that emit a distinct foul odor, commonly referred to as ozaena or an unpleasant stench.

In cases of atrophic rhinitis, individuals may experience reduced sensory perception, rendering them unaware of flies landing on the nasal crusts or discharge. When maggots infest the nasal passages under such circumstances, this condition is termed nasal myiasis, peenash, or scholechiasis. Although nasal myiasis is a rare occurrence on a global scale, it is more prevalent in tropical regions characterized by hot and humid climates. This condition is commonly observed among elderly individuals, especially females, and is notably more frequent in lower socioeconomic strata due to limited access to adequate nasal hygiene practices.

What Are the Symptoms of Nasal Myiasis?

The affected person’s clinical symptoms exhibit variations over time. During the initial three to four days, maggots can lead to pronounced irritation, triggering symptoms such as sneezing, excessive tearing, and headaches. Additionally, blood-tinged discharge may emanate from the nostrils.

In the later stages, more severe symptoms emerge, including active nosebleeds accompanied by the visible presence of maggots exiting the nasal passages. The presence of maggots results in extensive tissue damage within the nose, sinuses, and soft facial tissues, including the palate and orbit. In some cases, it can even lead to the formation of palatal fistulas, and in severe instances, it may culminate in meningitis, potentially resulting in fatality.

How Is Nasal Myiasis Diagnosed?

For the diagnosis of nasal myiasis, an ear, nose, and throat (ENT) specialist will perform a thorough clinical examination. The specialist doctor may utilize an otoscope to visualize the nasal passages to verify the presence of larvae. In several cases, imaging studies such as X-rays or CT (computed tomography) scans may be necessary to estimate the extent of tissue damage.

How Is Nasal Myiasis Managed and Treated?

Treatment Plan for Nasal Myiasis in Affected Individuals:

• Active Intervention by the Doctor: The doctor will perform manual maggot removal at least twice daily, focusing on nighttime when maggots are more active and emerge from their burrows in darkness.

• Maggot Disposal: The maggots will be carefully extracted using nasal dressing forceps and immediately placed in a bowl of boiling water to ensure their instant termination and prevent their crawling elsewhere.

• Nasal Drops: All affected individuals will receive nasal drops containing turpentine oil and liquid paraffin to aid in maggot expulsion and alleviate symptoms.

• Endoscopy: Endoscopic procedures will be conducted in each case to remove crusts, clear suction blockages, and access and eliminate maggots located in deep or hard-to-reach areas of the nasal passages.

• Prompt Resolution: The treatment will lead to maggot-free status within two to three days.

• Antibiotics: Injectable antibiotics such as crystalline Penicillin and Gentamicin will be administered as anti-meningitis prophylaxis, supplemented by oral Trimoxazole to reduce soft tissue edema.

• Secondary Atrophic Rhinitis: Specific treatments tailored to this condition will be initiated alongside the standard nasal myiasis treatment for individuals with secondary atrophic rhinitis.

• Alkaline Nasal Douching: After ensuring complete maggot removal, alkaline nasal douching will be introduced to maintain nasal hygiene and minimize re-infestation risk.

• Preventative Measures: Mosquito nets will continuously be placed around the affected individual’s bed to prevent fly reinfestation.

• Modified Young's Operation: In cases where at least two weeks of maggot-free status is confirmed, the doctor may perform the modified Young's operation. This surgical procedure completely closes one nostril at the vestibule using a double-breast technique at the mucocutaneous junction, leaving a two-millimeter hole in the center. The same procedure will be repeated on the other side after patient adaptation, typically after 15 to 20 days. Special care will be taken to ensure the shape of the ala (nostril wing) remains unchanged by using tension-free sutures.

This comprehensive treatment plan aims to effectively manage nasal myiasis in affected individuals, providing both immediate relief and long-term solutions to prevent recurrence.

What Are the Complications of Nasal Myiasis?

Complications of nasal myiasis were minimal, and they include the following:

• Septal perforation.

• Nasal saddle deformity

• Palatal perforation.

• Mild periorbital swelling without double vision.

Conclusion:

Nasal myiasis, though rare, can be a distressing condition. Maintaining good personal and environmental hygiene is essential to reduce the risk of fly infestation. Nasal myiasis, found in various contexts, including low socio-economic settings, travelers, and immunocompromised individuals, is treated primarily through manual or endoscopic maggot removal. Young larvae pose challenges due to strong anchoring, while mature larvae are easier to extract. Turpentine oil and liquid paraffin nasal drops aid in maggot expulsion and suffocation. Antiozaena nasal drops maintain nasal health alongside glucose and glycerin nasal drops for bacterial control and mucosal moisture. Prevention strategies include nasal hygiene, mosquito nets, and nostril closure options like Young's or modified Young's operation, preserving speech but affecting manual labor and deep kissing. Permanent nasal cavity closure can alleviate social stigma linked to malodor in atrophic rhinitis, with some achieving recurrence-free outcomes.