Middle ear and mastoid cavity myiasis is a rare parasitic infestation characterized by the invasion of the middle ear by fly larvae. Although myiasis more commonly affects the external ear, involvement of the middle ear can lead to severe complications, including tympanic membrane perforation, bone destruction, hearing loss, and, intratemporal and intracranial extensions [1]. This infestation is most frequently observed in individuals with poor hygiene, low socioeconomic status, discharging ear due to chronic otitis media, or underlying medical or mental disabilities, but cases have also been reported in otherwise healthy individuals and neonates [2].

Clinical presentation includes otalgia, otorrhea, bleeding, and in some cases visible larvae and the diagnosis is confirmed by direct visualization and identification of the larvae species [3]. The most commonly implicated fly species include Sarcophaga, Lucilia, Wohlfartia magnifica, and Musca domestica, with regional and environmental factors influencing the distribution of causative agents [4].

Prompt recognition and mechanical removal of larvae and appropriate antimicrobial therapy are essential to prevent serious complications [5]. Given the potential for significant morbidity, increased awareness among clinicians is crucial, especially in endemic regions and among at-risk populations.

A 52-year-old male patient presented with a 3-day history of progressive right otalgia, aural fullness, vertigo, and tinnitus. The patient's history was significant for a right canal wall down tympanomastoidectomy (CWDT) performed 15 years prior for right ear cholesteatoma, and a 3-year history of chronic otorrhea. He also reported a brief episode of a fly entering his right ear one week earlier, which he initially ignored. The patient was otherwise healthy with no other significant medical comorbidities. Physical examination revealed inflammation of the external auditory canal (EAC), the presence of a CWDT cavity, and a perforated tympanic membrane. Live insect larvae were observed filling the middle ear, epitympanum, and mastoid cavity (Figure 1). Initial attempts to remove the larvae in the clinic setting were limited due to patient discomfort and the provocation of vertigo. Computed tomography (CT) scan confirmed the previously performed CWDT and demonstrated soft tissue density extending through the EAC, mesotympanum, hypotympanum, epitympanum, and mastoid cavity (Figure 2). The patient was subsequently scheduled for debridement and endoscopic explorative tympanotomy under general anesthesia. Endoscopic visualization was utilized to perform thorough debridement, effectively cleaning the middle ear, epitympanum, and mastoid cavity. Middle ear exploration was also performed, including the removal of larvae from the round window niche. Following larval removal, the cavity was meticulously irrigated with normal saline. Post-debridement, the entire cavity was inspected using 0-degree and 45-degree endoscopes to ensure complete removal and confirm no residual larvae remained. Systemic ivermectin and ciprofloxacin as well as topical ciprofloxacin drops were initiated postoperatively. Otological examination was repeated on postoperative first and seventh day and no larvae was seen on external auditory canal, middle ear, epitympanium and mastoid cavity. Microbiological analysis confirmed the diagnosis as ‘Wohlfahratia Magnifica’ (Figure 3). Informed consent was obtained from the patient for the publication of this case report.

Figure 1: Otoscopic examination. Living larvae were noted in middle ear and mastoid cavity.

Figure 2: Soft tissue density was noted in middle ear on CT scan.

Figure 3: Macroscopic examination of larvae.

Figure 4: Microscopic examination of larvae on x40 amplification.

Myiasis is the infestation of living vertebrate tissue by the larvae of flies, is a rare but clinically significant presentation, particularly when it affects the middle ear and the mastoid cavity [6]. Myiasis may affect various body sites but aural myiasis is uncommon, and its involvement of deep ear structures elevates the risk of severe morbidity and mortality due to rapid tissue destruction and potential intracranial extension [7].

Parasitic diseases of the ear are primarily caused by arthropods, including ticks, mites, and fly larvae, with myiasis being the most aggressive form caused by the latter [4]. Aural myiasis is typically observed in vulnerable populations. Recent case series and reviews consistently identify Chronic Suppurative Otitis Media (CSOM), poor personal hygiene, low socioeconomic status, advanced age, mental retardation, and other debilitating conditions as significant predisposing factor [8]. The presence of a chronic, often foul-smelling, aural discharge provides an attractant for the gravid female fly, leading to the deposition of eggs or larvae, most commonly from the Sarcophagidae or Calliphoridae families [9]. In this study, our patient underwent CWDT surgery for cholesteatoma and has actively recurrent discharging ear with perforated tympanic membrane which provided the convenient enviroment for the fly to deposition of eggs. Our case was infested by Wohlfahratia Magnifica which belongs to Sarcophagidae family.

The larvae may gain access to the deeper structures the such as middle ear and mastoid air cell system via a perforated tympanic membrane [10]. Their relentless burrowing and feeding activity causes significant tissue damage, characterized by severe otalgia, bleeding, and the characteristic sensation of movement, which may be muted in cognitively impaired patients, thus delaying diagnosis [11]. The involvement of the mastoid, especially in patients with a history of chronic ear disease, transforms a localized infestation into a life-threatening situation by bringing the larvae into direct proximity with the bony structures of the temporal bone and the central nervous system (CNS) [11].

The destructive nature of the larvae poses a threat to the integrity of the temporal bone. Deeply localised aural myiasis may lead to ossicular destruction, resulting in permanent conductive hearing loss and more critically, the infestation can progress to severe intratemporal and intracranial complications [1]. The larvae's ability to destroy bone can lead to mastoiditis, and subsequent spread may result in potentially fatal outcomes such as meningitis, intracranial abscess and sigmoid sinus thrombosis [12].

Although the diagnosis of myiasis is primarily clinical, made by direct visualization of larvae, High-Resolution Computed Tomography (HRCT) of the temporal bone is mandatory in cases of deep-seated or suspected middle ear and mastoid involvement. HRCT helps to precisely delineate the extent of soft tissue inflammation, bone erosion, or mastoiditis caused by the larvae, providing a surgical roadmap [9]. If there is any clinical or radiological suspicion of intracranial involvement (e.g., headache, fever, neurological signs), Magnetic Resonance Imaging (MRI) with contrast is necessary to detect subtle changes such as subdural empyema or cerebral venous sinus thrombosis [13]. In our study, we performed HRCT before the surgery and analysed the extent of the disease and also the situation of the middle ear and mastoid cavity anatomy beceause of the previous CWDT surgery.

The management of deep aural myiasis is an otologic emergency. The treatment cornerstone is the complete mechanical removal of every larva. The initial step involves immobilizing the larvae using topical agents like 2% lidocaine solution, mineral oil, or specific antiparasitic drops [6]. Caution must be exercised with agents such as alcohol or chloroform, which are ototoxic and strictly contraindicated when a tympanic membrane perforation is present; in such cases, only physiological saline should be used for irrigation [14]. In our study, we only used physiological saline for irrigation in order to avoid ototoxic effects of the other solutions.

For middle ear and mastoid cavity involvement, simple irrigation and mechanical removal from the external auditory canal are often inadequate, necessitating a surgical approach. Otoendoscopic management has been shown to be superior to conventional methods, as it allows for better visualization and precise removal of larvae from deep and inaccessible areas within the middle ear cleft, often reducing the number of sittings required for complete clearance [13]. In cases with extensive tissue damage or when endoscopic removal is incomplete, surgical exploration (e.g., mastoidectomy) is required to meticulously debride the infected and necrotic tissue and ensure all larvae are eradicated from the mastoid air cells [7]. In our study, we preferred endoscopic removal of larvae which allow us to remove all larvae under direct vision.

Systemic antibiotics are crucial to treat or prevent secondary bacterial infections, which are almost invariably associated with this condition [7]. The antibiotic regimen should be broad-spectrum, covering common pathogens associated with chronic otitis media and deep neck/CNS infections. In our study, systemic ciprofloxacin was administered. Following eradication, a robust follow-up protocol is critical. This includes repeated otoscopic examinations to monitor the healing of the tympanic membrane and ear canal, along with a formal audiometric assessment to document any residual hearing loss [11]. Long-term prevention strategies must focus on improving hygiene, prompt treatment of CSOM, and controlling fly exposure, especially for patients in endemic regions or those with predisposing factors [3].

Aural myiasis, particularly when associated with middle ear and mastoid involvement, constitutes a rare yet high-morbidity otologic emergency. This case underscores the paramount necessity of maintaining a high index of suspicion, especially in vulnerable populations afflicted by predisposing factors such as Chronic Suppurative Otitis Media (CSOM) and diminished hygiene standards. Definitive management mandates the complete mechanical eradication of larvae. Successful outcomes rely not only on parasitic clearance but also on the aggressive management of secondary bacterial infections with systemic antibiotics.

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