Myiasis, derived from the ancient Greek word “myia” (meaning fly), is defined as the infestation of live humans or animals by fly larvae (1). Due to improved living standards, human myiasis has become less prevalent. Within otorhinolaryngology, aural myiasis remains a rare clinical entity (2). Predisposing factors include chronic ear infections, poor personal hygiene, exposure to contaminated water, immunocompromised states, neglected children, advanced age, and intellectual disability (3). Diagnosis is mostly made by history and clinical examination, though further investigations are warranted if middle ear extension is suspected (4). While most cases respond well to topical treatment (5), some may require surgical intervention (6). This article presents a case of aural myiasis in a long-term bedridden elderly patient, emphasizing the critical need for vigilance in vulnerable populations.

An 89-year-old female patient was admitted to the hospital on September 22, 2025, following the discovery of maggots in her right external auditory canal seven hours prior. The patient's family members noticed maggots wriggling at the external auditory meatus of the patient's right ear. No definite otalgia or aural pruritus was reported, and the infestation was first observed by family members. The patient had been bedridden at home for the past year. Before becoming bedridden, the patient was largely independent in daily activities. During the bedridden period, the patient's daily care and personal hygiene were primarily provided by family members. The right external auditory canal orifice is occluded by multiple living white maggots (Figure 1), and impacted oily cerumen is present in the left external auditory canal. High-resolution temporal bone computed tomography (CT) demonstrated soft tissue density in the right external auditory canal, bilateral cholesteatoma, and absence of the right ossicles. Hearing tests indicated profound deafness in the right ear. According to the patient's family, there was no known history of chronic otitis media, persistent otorrhea, or previously diagnosed tympanic membrane perforation prior to the current presentation. The patient had no known history of diabetes, vascular disease, malignancy, or chronic immunosuppression. The patient had not been receiving any long-term medications and was not taking antiparkinsonian drugs prior to admission.

During hospitalization, the patient presented with lethargy, unresponsiveness, slowed reactions, and increased muscle tone in all four limbs. A neurological evaluation subsequently established a first-time diagnosis of Parkinson's syndrome. Under otoscopic examination, multiple maggots were observed crawling within the ear canal (Figure 2). After removal of six maggots, swelling of the right external auditory canal and perforation of the right tympanic membrane were identified. The external auditory canal was repeatedly irrigated with iodine brine and normal saline. The patient subsequently received combined topical and systemic antibiotic therapy, including Levofloxacin ear drops and intravenous Cefuroxime (0.75 g every 8 hours for 5 days). Following irrigation and antibiotic therapy, the patient showed partial clinical improvement, with a reduction in visible inflammation and cessation of further maggot emergence. However, swelling of the external auditory canal and signs of tympanic membrane perforation persisted, and imaging continued to show soft-tissue density in the middle ear and mastoid region, raising concern for residual disease. Unfortunately, the patient's family declined morphological identification of the maggots, thus precluding species determination.

The patient presented with a tympanic membrane perforation complicated by middle ear cholesteatoma. Given the suspicion of residual lesions in the middle ear, a right mastoid exploration was performed on September 24, 2025, to prevent potential intracranial and extracranial complications associated with these residual lesions, after carefully ruling out any surgical contraindications. During the operation, a right tympanic membrane perforation was found, and no maggots were detected. The tympanic membrane was lifted, and exploration revealed the absence of the incus and malleus; only the stapes remained in the tympanic cavity, with edema of the middle ear mucosa. Postoperative pathological examination of the specimen revealed inflammatory tissue. The patient was followed for 2 months after surgery. Follow-up otoscopic examinations showed complete epithelialization of the tympanic membrane and a well-healed mastoid cavity. No residual larvae, recurrent otorrhea, or secondary infections were observed during the follow-up period. The patient's hearing in the right ear remained at the preoperative level of profound loss, with no further deterioration. No postoperative complications were recorded.

Flies can deposit eggs and/or live larvae in and around natural body orifices (7). Myiasis is classified based on the affected anatomy, including cutaneous myiasis, myiasis of external orifices (nose, paranasal sinuses, and external ear), or internal organs, and myiasis invading head cavities (8). In mammals, including humans, dipteran larvae can feed on living or necrotic tissues, bodily fluids, or ingested food, potentially causing extensive infestations (9). The extent of infection depends on the fly species, host, the site of infestation, and the host's immune response (2). Infestation of the external and/or middle ear by maggots/larvae is termed aural myiasis (4).

Middle ear cholesteatoma is characterized by a mass of keratinized squamous epithelial cells within the tympanic and mastoid cavities, accompanied by subepithelial connective tissue and accumulated keratin debris, often with an inflammatory response (10). The resulting otitis media can lead to chronic purulent ear discharge, frequently associated with a foul odor. Persistent discharge may also cause local skin necrosis and tympanic membrane perforation. Although no clear otorrhea had been noted before admission, the underlying cholesteatoma likely contributed to retention of secretions and odor formation, which in turn facilitated fly attraction and aural myiasis. A review suggests that the unpleasant odor emanating from the ear canal can attract female flies, prompting them to deposit larvae, thereby leading to aural myiasis. Thus, chronic otitis media and other ear pathologies are significant predisposing factors (11).

Patients mostly present themselves with sensation of foreign substance in the ear, aural itching, pain, bleeding, tinnitus, hearing loss, and vertigo (12). In our case, the patient had otitis media but did not complain of any symptoms, most likely due to cognitive impairment caused by Parkinson's disease, which delayed diagnosis and treatment. Otoscopic examination may reveal maggots, inflammation, and swelling of the ear canal, and sometimes tympanic membrane perforation (13). Documented complications include ossicular destruction leading to hearing loss (14), deafness, and intracranial penetration causing potentially fatal meningitis (15).

Diagnosis of myiasis is typically straightforward, based on clinical findings alone. Currently, there are no established clinical practice guidelines for treating this condition. Directly killing maggots in the ear can make them difficult to locate, and retained dead maggots may provoke a foreign body reaction. Initial treatment primarily involves maggot removal via simple aural suction, supplemented with topical and/or oral antibiotic coverage (8). Various agents, including 70% ethanol, chloroform, normal saline, urea, oil drops, dextrose, creatine, iodine saline, and topical ivermectin, have been used for ear canal irrigation to eliminate residual larvae (16).

For aural myiasis accompanied by otorrhea extending to the middle ear, or in cases of residual disease, extensive surgical debridement, including mastoidectomy followed by reconstruction, is recommended, along with systemic antibiotic therapy.

In this case, the patient presented with concomitant middle ear cholesteatoma and bilateral oily cerumen secretions. The combination of cholesteatoma discharge and oily cerumen created a retention effect, impeding normal drainage. The accumulated secretions emitted odors that attracted flies, leading to larval deposition and subsequent aural myiasis. The patient's delayed symptom reporting was likely due to cognitive impairment associated with Parkinson's syndrome, which postponed diagnosis and treatment. Although the patient was not immunocompromised in a medical sense, advanced age and prolonged bedridden status may have contributed to reduced local defense mechanisms of the external auditory canal.

The presence of tympanic membrane perforation, coupled with middle ear cholesteatoma, necessitated mastoid surgery for thorough debridement and removal of maggots from the sinus opening and mastoid cavity, thereby preventing potential intracranial and extracranial complications from residual lesions.

Compared with previously reported cases of aural myiasis, this case presents several distinctive features. A systematic review and multiple case reports have shown that chronic suppurative otitis media with overt, foul-smelling otorrhea and poor hygiene are among the most frequent predisposing conditions for aural myiasis (11, 17, 18). In particular, many patients described in the literature had long-standing ear discharge and neglected chronic ear disease in association with low socioeconomic status or suboptimal living conditions (17, 18). Furthermore, several authors have emphasized that aural myiasis often occurs in debilitated or cognitively impaired individuals—including patients with Alzheimer's disease or other mental deficits—who depend on caregivers for daily hygiene and medical care (18, 19). In contrast, our patient was an extremely elderly, bedridden individual receiving home-based care by family members rather than institutional care, highlighting that aural myiasis can also arise in the context of home long-term care when regular ear inspection and hygiene are insufficient. Another distinctive aspect of this case is that Parkinson's syndrome with cognitive slowing was newly diagnosed during this admission, and, although the patient was not classically immunocompromised, her neurocognitive impairment likely contributed to delayed symptom recognition and reporting. Finally, while most published cases are managed conservatively, some reports describe middle-ear or mastoid extension requiring surgical intervention (20). In our case, mastoid exploration allowed simultaneous management of underlying cholesteatoma, exclusion of residual disease, and resulted in good anatomic healing without recurrence during follow-up.

Beyond its clinical implications, aural myiasis in a dependent, bedridden elderly patient also raises concerns regarding the possibility of neglect or suboptimal caregiving. Myiasis has been recognized in the forensic and medicolegal literature as a potential indicator of inadequate hygiene, insufficient supervision, or delayed recognition of symptoms in vulnerable individuals who rely on others for daily care. Bugelli et al. emphasized that myiasis may serve as a marker of neglect in living or deceased individuals, particularly when occurring in patients with limited autonomy or cognitive impairment (21). Although our case is purely clinical and not forensic in nature, the occurrence of aural myiasis in this patient highlights the importance of optimizing caregiving practices, maintaining adequate hygiene, and ensuring regular inspection of vulnerable patients to prevent such complications.

Another important limitation of this case is the absence of morphological identification of the larvae. Because the patient's family declined specimen collection, the species of fly responsible for the infestation could not be determined. This lack of entomological characterization restricts the ecological and epidemiological inferences that can be drawn from the case, as different fly species vary in their habitat preferences, life cycles, and medical relevance. Future similar cases would benefit from proper collection, preservation, and morphological—and when feasible, molecular—identification of larvae to enable accurate species determination and enhance understanding of local epidemiological patterns.

Poor hygiene is likely the most significant risk factor for human myiasis (22). Management of myiasis should prioritize prevention through maintaining proper hygiene, improving living conditions, and actively treating external auditory canal or middle ear diseases. For bedridden or cognitively impaired individuals, additional preventive measures are recommended. These include regular inspection and cleaning of the external auditory canal, maintaining scalp and ear hygiene, timely management of cerumen impaction, and ensuring adequate environmental sanitation to minimize fly exposure. Caregivers should be educated to recognize early changes such as new-onset ear discharge, foul odor, or unexplained irritability, particularly in patients with impaired ability to report symptoms. These measures can significantly reduce or eliminate opportunities for flies to enter and lay eggs.