Management of Palatal Perforation Secondary to Nasal Myiasis in Chronic Atrophic Rhinitis: A Case Report

Suhas SS¹, Priya Badkar²https://orcid.org/0000-0003-1887-4753

^1,2Department of Otorhinolaryngology, Mysore Medical College and Research Institute, Mysuru, Karnataka, India

Corresponding Author: Priya Badkar, Department of Otorhinolaryngology, Mysore Medical College and Research Institute, Mysuru, Karnataka, India, Phone: +91 9036251734, e-mail: priyabadkar@gmail.com

How to cite this article: Suhas SS, Badkar P. Management of Palatal Perforation Secondary to Nasal Myiasis in Chronic Atrophic Rhinitis: A Case Report. Clin Rhinol 2024;15(1):37–40.

Source of support: Nil

Conflict of interest: None

Patient consent statement: The author(s) have obtained written informed consent from the patient for publication of the case report details and related images.

Received on: 10 December 2019; Accepted on: 06 June 2023; Published on: 16 November 2024

ABSTRACT

Atrophic rhinitis is a chronic inflammation of nose characterized by roomy nasal cavities with atrophy of nasal mucosa and turbinates. Loss of sensation predisposes to nasal myiasis which causes the destruction of surrounding soft tissue and bony structure. Here, we report one such case where a middle-aged female patient presented with bilateral progressive nasal obstruction, anosmia and recurrent episodic epistaxis. A detailed investigation revealed atrophic rhinitis characterized by palate erosion due to localized destruction caused by maggots. Treatment involved the manual extraction of maggots, surgical cleaning, modified Young’s operation, and the use of a palatal obturator. The patient fully recovered, demonstrating the effectiveness of this combined approach, rendering surgical repair of the palatal perforation unnecessary.

Keywords: Atrophic rhinitis, Case report, Nasal myiasis, Oronasal fistula, Palatal erosion.

INTRODUCTION

Nasal myiasis, a disturbing condition of the nose, commonly occurs in individuals with atrophic rhinitis, particularly among those in low socioeconomic groups due to inadequate nasal hygiene.¹ It is characterized by foul-smelling discharge and decomposed nasal debris, which attract flies of the genus Chrysomya. These flies lay eggs which might develop into maggots, leading to tissue damage in various areas such as nose, sinuses, nasopharynx, pharyngeal walls, orbital tissues, lacrimal apparatus, facial tissues, and skull base. This can result in nasal dorsal and facial deformities, septal and palatal perforations, and in severe cases, may lead to meningitis and death.^2,3

Case Presentation

A 50-year-old female presented to the Otorhinolaryngology Department with bilateral progressive nasal obstruction, foul-smelling yellowish mucopurulent nasal discharge for the past 6 months, anosmia for 3 months, and several episodes of mild epistaxis for the past month. The patient had no other underlying health conditions.

Upon examination of the nose, the skin and osteocartilaginous framework appeared normal. The vestibule was widened. Anterior rhinoscopic examination shows spacious bilateral nasal cavities filled with yellowish-green crusts and maggots. Intraoral examination indicated poor oral hygiene with significant halitosis, partially missing teeth, and a few teeth affected by caries. A palatal perforation measuring 1 × 1 cm, encompassing the entire soft palate and extending to the posterior part of the hard palate, covered with crusts, was observed (Fig. 1).

Fig. 1: Palatal perforation with crusts

Diagnostic nasal endoscopy showed greenish crusts and numerous maggots present in both nasal cavities, along with turbinates exhibiting atrophy (Fig. 2).

Fig. 2: Endoscopic visualization of right nasal cavity showing numerous maggots

A computed tomography of nose and paranasal sinuses revealed a heterogeneously enhancing lesion in the region of soft palate measuring 4.6 × 2.5 × 3.5 cm with oronasal fistula measuring 1.1 × 1.1 cm noted in the anterior aspect of soft palate. Soft tissue density in bilateral inferior meatus and erosion of bilateral inferior and middle turbinates noted (Fig. 3). Biopsy from the soft palate showed necrotic tissue with bacterial colonies and dense collection of neutrophils. Based of clinical and radiological findings diagnosis of nasal myiasis secondary to atrophic rhinitis with palatal perforation was made.

Fig. 3: Computed tomographic images showing palatal perforation and destruction of right middle turbinate

Further management includes medical, surgical and preventive measures. Preventive measures include use of mosquito nets. Patient was started on injection ceftriaxone 1 gm iv twice daily, inj metronidazole 100 mL iv thrice daily and removal of maggots by instillation of drops of turpentine oil was done daily. Alkaline saline douching was continued up to 6 weeks.

Surgical debridement was done to remove the crusts and necrotic tissue in the nasal cavity and palatal perforation. Ryles tube feeding was done up to 2 weeks after which oral feeding was encouraged. Palatal obturator was used to prevent nasal regurgitation. Patient also underwent modified Young’s procedure after 6 weeks. Regular follow-up was done every week which showed the reduction in size of the defect (Fig. 4). Complete closure was seen after 2 months (Figs 5 and 6).

Fig. 4: Post debridement

Fig. 5: After 2 weeks follow-up

Fig. 6: Complete closure of perforation after 2 months

DISCUSSION

Atrophic rhinitis is chronic inflammation of the nose in which the nasal mucosa gradually changes from a functional, ciliated respiratory epithelium to a nonfunctional lining of nonciliated squamous metaplasia, with a loss of mucociliary clearance and neurologic regulation. Crusting, fetor, atrophied nasal mucosa, and widely patent nasal cavities are seen in patients who complain of nasal obstruction. The normal pattern of airflow is changed, which likely contributes to the sensation of congestion and obstruction in addition to decreased olfactory function.⁴

Palatal perforation is a defect in the hard palate or soft palate resulting in the communication of oral and nasal cavity. Etiology of palatal perforation are numerous. These includes developmental defects, traumatic, drug abuse (cocaine and heroin), infections (syphilis, tuberculosis, leprosy, atrophic rhinitis, and mucormycosis), autoimmune (Wegener’s granulomatosis, sarcoidosis, and lupus erythematosus), iatrogenic, and neoplasm.⁵

Palatal fistulas are often symptomatic due to their size and location. Symptoms include hypernasality in the phonation related to nasal air escape during speech, nasal cavity fluid leakage, and infection due to food accumulation. Depending on the degree of functional impairment, the presence of a palatal fistula can lead to psychological, social, and developmental challenges and, therefore, may necessitate repair.⁶ Several treatment options have been explored in the literature, including prosthetic obturators, silicone buttons,⁷ and surgical procedures such as closure using local or distant flaps.⁸ Prosthetic obturators help in preventing nasal reflux, enabling proper swallowing and adequate speech production. The placement of a silicone button to seal the perforation aims to enhance nasal airflow and minimize the advancement of local tissue necrosis.⁹ For smaller defects, nasal septal flaps, tongue flaps, buccal mucosal flaps, and pharyngeal flaps have been used. For larger defects, the temporalis flap, forehead flap, and the deltopectoral flap have also been reported.¹⁰

CONCLUSION

The implementation of a palatal obturator significantly enhances the patient’s quality of life by preventing nasal food regurgitation and nasal tone alteration in the voice. In this instance, our patient required a modified Young’s operation to address atrophic rhinitis, with the palatal obturator aiding in perforation healing. Complete closure of the perforation was observed after 2 months, underscoring the effectiveness of utilizing a palatal obturator and obviating the necessity for surgical repair of the palatal perforation.

ORCID

Priya Badkar https://orcid.org/0000-0003-1887-4753

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