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A 2-year-old-12 kg child, tracheostomised 1-year previously in view of subglottic stenosis was brought by his father with the complaints of foul-smelling discharge from tracheostomy site and rapid breathing. The peristomal site was severely necrosed and multiple live maggots were seen. Surgeons removed the tracheostomy tube (TT), and a large area (4 cm × 4 cm) was found necrosed and infested with maggots [Figure 1a]. The child tolerated the initial attempted removal of maggots well as they were mostly present in the already necrosed peristomal tissue. While removing the maggots using forceps, the worms started to move towards the tracheal stoma and entered the trachea. Suddenly, the child went into respiratory distress and became apnoeic. The TT was reinserted urgently and positive pressure ventilation was started. The child resumed spontaneous ventilation in 1 min, and haemodynamics remained stable. It was then decided to examine the trachea and clear maggots under general anaesthesia with the airway secured.
Pre-anaesthetic check-up revealed respiratory rate of 35/min and use of accessory muscles of respiration. Computed tomography (CT) scan showed mild subglottic stenosis. Pre-medication was given using fentanyl 12 μg intravenous. Induction of anaesthesia was done using thiopentone 60 mg and rocuronium 7.5 mg. Anaesthesia was maintained using oxygen, nitrous oxide, and sevoflurane administered through the tracheostomy tube using a Jackson–Rees modification of Ayre's T-piece. Intubation was attempted with 4, and then, 3.5-mm endotracheal tube which we failed to negotiate. A size of 3-mm tube could be inserted snugly. Surgeons evaluated the stoma and cleared nearly 50–70 live maggots and cleaned the stoma using povidione-iodine [Figure 1b]. TT 3.5-mm ID was reinserted. Subsequent perioperative period was uneventful. The surgeons decided not to explore the trachea to extract the already migrated maggots because at that time, there were no clinical signs of airway obstruction by the worms and air entry was bilaterally equal. The stomal site gradually healed, and the child was successfully decannulated after 18 days and discharged with thorough advice about home care and hygiene to the parents. Few cases of tracheostomal myiasis have been reported in the literature.[1,2,3,4]
Infants tracheostomised due to subglottic stenosis may require a long-term tracheostomy. Patients are discharged with a tracheostomy tube with advice of proper hygiene, regular tracheostomy change and scheduled hospital visits.
Maggots may infest tissue in various sites such as skin, eyes, ears and genitourinary area. Anaesthetic management of this case was challenging due to the presence of subglottic stenosis and surgeon's request to remove the tracheostomy tube. CT scan also showed mild subglottic stenosis. We only succeeded in inserting a size 3-mm tube snugly.
We suggest a few steps for the prevention of respiratory complications during the removal of worms from the tracheostomy site. First, the removal should be attempted under general anaesthesia only after insertion of an endotracheal tube. Second, the tip of endotracheal tube should be beyond the stoma site, to minimise the space available for the worms attempting to migrate inside the tracheal lumen. Third, as the worms try to move away from the light, it is very important that the migration of maggots to the trachea be prevented by avoiding direct headlight projection at the site of infestation. Fourth, turpentine oil application has been advocated for the removal of maggots from other sites, but it should be avoided in tracheostomal myiasis because spillage of turpentine oil leads to irritation of tracheal mucosa as well as the development of chemical pneumonitis. Finally, evaluation should be done of the care-givers, particularly regarding their understanding of the need for hygiene. They should be trained to prevent this complication in tracheostomised children who find it difficult to understand and are unable to communicate effectively.
There are no conflicts of interest.