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Hong Kong Journal of Emergency Medicine
Ticks in the external auditory canal
A Dalgic, T Kandogan, H Kavak, A Ari, N Erkan, MZ Ozuer
Ticks attack a wide range of vertebrates including humans, and are important vectors of numerous pathogens,
e.g. virus, rickettsia, and protozoa. We present a case of ticks found in the external auditory canal. A 12year-old girl presented to the emergency service with one-day history of right-sided earache. Otological
examination found a tick blocking the external auditory canal. The tick was removed under local anaesthesia
with a light microscope. After the tick was removed, another tick was detected in the external auditory
canal. The second tick was not adhered to the ear canal skin and was mobile. It was also removed completely.
The patient's post-procedure course was uneventful. A broad spectrum antibiotic, an analgesic, and an
antihistamine were prescribed. Both ticks were sent to the infectious disease laboratory for investigation of
Crimean-Congo haemorrhagic fever. They turned out to be Hyalomma species. (Hong Kong j.emerg.med.
2010;17:190-192)
12
Keywords: Ear canal, Hyalomma, insects, ticks
Correspondence to:
Nazif Erkan, MD
Izmir Bozyaka Training and Research Hospital, Department of
Emergency Medicine, Izmir, Turkey
Email: [email protected]
Hasan Kavak, MD
Izmir Bozyaka Training and Research Hospital, Department of
Otorhinolaryngology, Izmir, Turkey
Abdullah Dalgic, MD
Tolga Kandogan, MD
Mehmet Ziya Ozuer, MD
Izmir Bozyaka Training and Research Hospital, Department of
Infectious Diseases, Izmir, Turkey
Alpay Ari, MD
Introduction
Ticks attack a wide range of vertebrates including
humans, and are important vectors of numerous
pathogens, e.g. virus, rickettsia, and protozoa. 1 In
humans, ticks infest both hairy and non-hairy parts
of the body and have also been found in the ear
canal. 2,3 Insect and arachnid foreign bodies of the
external auditory canal can cause patients great
distress as a result of otalgia, tinnitus and hearing
loss. Rapid inactivation (killing) of the insect can
facilitate relief of symptoms, as well as insect
removal. 4
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Dalgic et al./Ticks in the external auditory canal
Case report
Discussion
A 12-year-old girl presented to the emergency
service in July 2008 with a one-day history of rightsided earache. In the otological examination, a tick
blocking the external auditory canal was detected
(Figure 1). The tympanic membrane could not be
seen since the external auditory canal was swollen
and partially blocked by the tick. During the history
taking, it was learned that she was living with a dog
in the house which might be the source of ticks.
The patient was then referred to the otolaryngology
clinic for removal of the tick. The procedure was
performed under local anaesthesia with a light
microscope. During the procedure, it was observed
that the tick was alive, its abdomen was distended,
and its mouthpart embedded into the tympanic
membrane. Complete removal of the tick was
performed with a fine cup-forceps. The tympanic
membrane was not perforated. After the tick was
removed, another tick was seen in the same external
auditory canal. The second tick was not adhered to
the ear canal skin and was mobile. This tick was
also successfully removed completely (Figure 2). The
patient's post-procedure course was uneventful.
Ticks are capable of transmitting numerous pathogens
to both humans and their pets. The risks of tick-borne
disease vary geographically and are determined by the
climate, environment, the presence of rodents and
other mammal reservoirs, and the species of ticks
parasitizing wild or domestic animals. Zoonoses such
as Lyme borreliosis, tularemia, and tick-borne
rickettsiosis can emerge in previously non-endemic
areas when circumstances favourable to their
maintenance and transmission arise. Tick-borne
zoonosis can be prevented by the implementation and
adoption of an integrated program to reduce the
likelihood of tick bites on pets and their owners.
Afterwards, a broad spectrum antibiotic, an analgesic,
and an antihistaminic were prescribed. Both ticks
were sent to the infectious disease laboratory for
investigation of Crimean-Congo haemorrhagic fever
(CCHF). It was reported that the ticks were Hyalomma
species.
Figure 1. Tick in the external auditory canal, external view.
Ticks are the second most important vector after
mosquitoes in causing viral, bacterial and protozoal
diseases such as rickettsiosis, borreliosis, babesiosis,
e h r l i c h i o s i s , t u l a re m i a , a n d Cr i m e a n - C o n g o
haemorrhagic fever in humans all over the world. Some
well-known tick-borne diseases such as rickettsiosis,
tularemia, and newly described bacterial and viral
diseases emerge in the last three decades.5,6 In Europe,
tick-borne diseases have become important,
particularly after their role in the transmission of the
agent of Lyme borreliosis was demonstrated in the
1980s. One of the tick-borne pathogens, CCHF virus,
has special importance. CCHF as an acute infectious
illness can cause multi-organ failure and death. CCHF
epidemics have been reported in Central Asia, Africa
and Eastern Europe. 7-11 Some serologic evidence
Figure 2. Second tick after removal, alive.
192
Hong Kong j. emerg. med. „ Vol. 17(2) „ Apr 2010
suggested that CCHF existed in the Anatolian region.12
Turkey introduced it in 2002,13 and CCHF has become
an emerging disease in Turkey since 2002. There were
3135 confirmed cases with 155 deaths in 2002-2008
according to the Ministry of Health of Turkey report.14
2.
As for the route of infection, ticks are thought to fall
off from their host animal and infect humans at
campsites and in open fields. Common bite sites are
the abdomen and eyelids, and bites on the external
auditory canal are extremely rare.15
5.
Many different species of insects and arachnids may
present as foreign bodies in the external auditory canal.
Ticks, which are found relatively rarely in the external
auditory canal, may transmit the widest variety of
pathogens of any blood sucking arthropod, including
bacteria, rickettsia, protozoa, and virus.15 Removal of ticks
should be attempted only by competent persons to avoid
complications because, for example, leaving the
mouthparts behind may result in infection of the wound.
Two issues are important in the removal of ticks. First,
tick removal should be accomplished as soon as possible
because the risk of transmission of infectious agents
increases significantly with the duration of attachment.
Second, tick removal must be complete and include the
mouthpart. If the tick is removed improperly, it will
probably increase the risk of transmission of disease(s).
Inappropriate removal methods may put pressure on the
tick's abdomen, causing the introduction of pathogens
from the capitulum into the host, thereby resulting in
infection.16-18 The tick should not be handled with bare
hands. During removal, sharp forceps should not be used,
as the tick's body should not be crushed, punctured or
squeezed, and twisting or jerking motions should be
avoided. Another important point is that substances such
as petroleum jelly, gasoline, lidocaine, etc, should not be
applied to the tick. The most commonly recommended
and successful tick-removal method is manual extraction
of the tick. However, a blunt, medium-tipped, angled
forceps offers the best results.19
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