Uncommon complication: maggot infestation around tracheostomy tube wound

INTRODUCTION

Myiasis, a parasitic infestation caused by fly larvae (maggots), was first reported in 1587 by Soares “d” Souza as cutaneous myiasis.¹ In 1840, Rev. F. W. Hope coined the term "myiasis" (formerly scholechiasis), and in 1919, Castellani and Chalmer described nasal myiasis caused by Chrysomya, known as Peenash in India.1 Our case is significant as only a few cases of myiasis in this context have been reported.²

True myiasis occurs when flies deliberately lay their eggs in or on a host’s tissues. It has two primary forms: obligate and facultative. Obligate myiasis involves maggots that must feed on living tissue to complete their life cycle. These parasites are restricted to specific fly species that require living hosts.³ Facultative myiasis occurs when flies exploit wounds or decaying flesh to incubate their larvae. Unlike obligate myiasis, facultative myiasis can affect both living and dead tissues. The majority of human myiasis cases are facultative, often occurring in areas with poor hygiene or in individuals with compromised immune systems.⁴

The main fly families that cause myiasis are Calliphoridae (blowflies) and Muscidae (houseflies). Blowflies contribute significantly to both obligate and facultative myiasis as their larvae can develop in both living tissue and decaying matter. Houseflies, primarily associated with decaying organic matter, can also cause facultative myiasis in certain conditions.⁵

While many species of flies causing facultative myiasis are relatively benign and not inherently pathogenic, some, such as Lucilia sericata (green bottle fly), are used in larval therapy. This therapy utilizes maggots to clean wounds by digesting necrotic tissue without harming healthy tissue, aiding in the healing of chronic wounds and ulcers.⁶

In contrast, obligate parasites like Cochliomyia hominivorax (New World screw-worm) can cause severe, often fatal infections if untreated, as the larvae invade healthy tissue, causing extensive damage.⁷

Epidemiologically, myiasis is more common in tropical and subtropical regions, where flies are more active and conditions like poor sanitation, open wounds, and inadequate medical care are prevalent. It poses a particular threat to vulnerable populations, such as the elderly, immunocompromised individuals, and those with chronic conditions like diabetes or cancer.⁸

CASE REPORT

Herein we represent to you a case of 62 years old man with Myiasis around tracheostomy tube. Patient came to us with complaint of discharge, and feeling of something moving around the tube since, 2 weeks. He gave history of trauma 1 year back with chest injury for which he had gone through tracheostomy. He had history of seizure also. He was under medication from government hospital.

The dressing of tracheostomy tube was usually done by his relatives who was a nurse. Since, two weeks he was in discomfort from the wound around tube so he came to us. Physical examination shown, there were severely necrosed with multiple live maggots around the tracheostomy tube.

Initial management

Maggots were removed with the help of toothed forceps and curved artery, removal of unhealthy tissue was done. Thorough NS wash given and dressing was done

Wound care

Daily dressing for few days were done as there was reoccurrence. After few days of dressing maggots were completely gone.

Then after patient was asked to after 5 days. The wound completely healed after 3 weeks.

Additional treatments

Antibiotics and pain killer were also prescribed for few days.

DISCUSSION

Maggot infestation around tracheostomy tubes is uncommon, but can arise due to several contributing factors: the smaller size of percutaneous tracheostomies compared to surgical tracheostomies, the patient’s vegetative state, inadequate cleanliness of the inner and outer tubes, the smell of decaying tissue that draws flies, and living in rural areas.⁹ Other common risk factors for myiasis are advanced age, poor hygiene, malnourishment, social isolation, diabetes, cancer, and peripheral artery disease.¹⁰

Most reported cases of myiasis involve obligatory parasites at various wound sites, with only a few instances around tracheostomy tubes. In our case, the contributing factors were poor socio-economic conditions, lack of proper hygiene, the foul odour of decomposition, and delayed cleaning of the tube. The tracheostomy tube had not been replaced for a prolonged period, and dressing changes were done at home without antiseptic precautions.¹¹

Treatment included the periodic removal of larvae and consistent dressing changes, which significantly reduced the risk of recurrence. Possible complications during larval removal included the danger of aspiration and the presence of live foreign bodies in the airway.¹¹

CONCLUSION

Myiasis is a rare but serious condition that requires early detection and intervention, particularly in immunocompromised patients or those with chronic illnesses. Prompt removal of maggots, debridement of necrotic tissue, and, if necessary, antibiotics to prevent secondary infections are crucial for managing the condition. In severe cases, surgery may be needed to remove deeply embedded larvae and repair tissue damage.

Treatment involves the careful mechanical removal of larvae, with local anesthesia if necessary. In cutaneous myiasis, organic phosphorus insecticides can effectively destroy the insects on the skin.

Myiasis is largely preventable with good hygiene, proper wound care, and timely medical attention. Understanding the differences between obligate and facultative myiasis, along with the role of different fly species, is essential for prevention and effective treatment. Patient education on tracheostomy care, regular cleaning, and maintaining cleanliness in the area is vital to avoid this issue, with prompt, knowledgeable intervention being key to successful treatment.

Funding: No funding sources

Conflict of interest: None declared

Ethical approval: Not required

REFERENCES

1. 1. Arora S, Sharma JK, Pippal SK, Sethi Y, Yadav A. Clinical etiology of myiasis in ENT: a reterograde period-interval study. Braz J Otorhinolaryngol. 2009;75:356-61.
2. 2. Hope FW. On insect and their larvae occacionally found in human body. Trans R Ent Soc. 1840;2:256-71.
3. 3. Sykes JE, Merkel L, Little SE. Myiasis. InGreene's Infectious Diseases of the Dog and Cat. WB Saunders. 2021: 1347-1358.
4. 4. Amandeep Singh AS, Zorawar Singh ZS. Incidence of myiasis among humans-a review.
5. 5. Sukontason KL, Narongchai P, Sripakdee D, Boonchu N, Chaiwong T, Ngern-Klun R, et al. First report of human myiasis caused by Chrysomya megacephala and Chrysomya rufifacies (Diptera: Calliphoridae) in Thailand, and its implication in forensic entomology. J Med Entomol. 2005;42(4):702-4.
6. 6. Whitaker IS, Twine C, Whitaker MJ, Welck M, Brown CS, Shandall A. Larval therapy from antiquity to the present day: mechanisms of action, clinical applications and future potential. Postgrad Med J. 2007;83(980):409-13.
7. 7. Hall MJ. Screwworm flies as agents of wound myiasis. World Animal Rev. 1991;19:8-17.
8. 8. Neto A. Myiasis. Available at: Radiopaedia.org. Accessed on 03 December 2024.
9. 9. Franza R, Leo L, Minerva T, Sanapo F. Myiasis of the tracheostomy wound: case report. Acta Otorhinolaryngologica Italica. 2006;26(4):222.
10. 10. Ajmal H, Ahmad SA, Naeem A, Tabassum S, Nashwan AJ. Facultative para-tracheostomy myiasis with a housefly (Musca Domestica): A case report. Otolaryngol Case Reports. 2024;30:100565.
11. 11. Sutasir MN, Memioglu M, Ece M, Altınbilek E, Coskun A. Tracheostomal Myiasis: A Case Report. J BioMed Res Rep. 2024;4(3):78.