Otolaryngology Case Reports 13 (2019) 100132

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Otolaryngology Case Reports

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Intra-aural tick induced facial palsy T

∗
Assaye Nibret , Nardos Bulfeta
Addis Ababa University, College of Health Sciences, School of Medicine, Tikur Anbessa Specialized Hospital, Department of Otorhinolaryngology, Head & Neck Surgery,
Addis Ababa, Ethiopia

A B S T R A C T

Facial palsy is a common case encountered in ENT clinics, Bell's palsy as the most common universally reported diagnosis. Here, we present a case of unilateral
infranuclear facial palsy following intra-aural tick infestation in a 7-year-old male child from a rural part of Oromia Region, Ethiopia who came to our ENT OPD at
Tikur Anbessa Specialized Hospital with a one-week history of facial weakness.

Introduction facial swelling, ear pain and facial weakness compared to the initial. On
further inquiry, there was no history of fever, body rash, mental status
Ticks are ectoparasites which thrive by feeding on their hosts’ blood change, any other body weakness. On physical examination, vital signs
and are known to affect a wide range of mammals including humans were within normal range for his age. There was left side House-
[6]. There are over 900 identified species worldwide [13], with a broad Brackmann Grade IV infra-nuclear facial palsy. Other neurological ex-
classification into two: Hard tick (Ixodidae) and Soft tick (Argasidae). aminations were normal.
Ticks are most commonly found in tropical & subtropical regions of the
world.
Human tick infestation is a common problem in rural areas where
there is close human contact with livestock and domestic animals. It is
also common to have this problem in those who hike in dense brush-
hood. Tick infestation of the ear also known as otoacariasis is reported
to be the most common cause of foreign body in the ear in some areas
[8,13].
Ticks, which carry different protozoa, rickettsia and bacteria, are
believed to be the second most important vectors relevant to human
health [4] and tick-borne diseases are well covered in literatures. Ticks
can also cause neuro-toxicosis called tick paralysis: a generalized as-
cending flaccid motor paralysis that has been discussed as a differential
diagnosis of GBS, Botulism and Myasthenia Gravis. Localized mono-
neuropathy such as isolated facial palsy following otoacariasis is a
much less frequently encountered event and has caught our attention in
the unique presentation of the following patient.

Case presentation

A 7-year-old male child from rural side of Ethiopia presented with a

one-week history of left ear pain, left sided facial swelling, facial pain
and weakness following a witnessed tick infestation of the left ear.
There were no attempts to remove or kill the tick at the time. His
parents are farmers and they share similar shelter with their cattle's. On
presentation to our ENT OPD there was subjective improvement to his
On Otoscopic examination, an immobile tick was identified attached
to the postero-inferior wall of the left ear canal. There was no active
bleeding from canal wall. Tympanic membrane was intact with good

∗
Corresponding author.
E-mail addresses: assayen@gmail.com (A. Nibret), ngbulfeta@gmail.com (N. Bulfeta).

https://doi.org/10.1016/j.xocr.2019.100132
Received 10 August 2019; Received in revised form 25 August 2019; Accepted 21 October 2019
Available online 04 November 2019
2468-5488/ © 2019 Elsevier Inc. This is an open access article under the CC BY-NC-ND license (http://creativecommons.org/licenses/BY-NC-ND/4.0/).
A. Nibret and N. Bulfeta
light reflex. Using microscope and micro ear forceps, the tick was
grasped and detached from canal skin without the need for anesthesia.
There was minimal edema at the attachment site otherwise otoscopy
was unremarkable after the procedure. Laboratory tests likeCBC, LFT,
RFT were within the normal range. Serology for Lyme Disease was not
available and therefore not done. The removed dead tick was identified
as an Ixodidae; further species identification was based on epidemio-
logical significance, with Rhipicephalus as a primary suspect.
The patient was sent home after advised on eye care and given ar-
tificial teardrops with an appointment to return in four weeks. Upon
follow-up, parents stated that the child had attained full function two
weeks after their first visit. CNVII examination showed no abnormality.
Otoscopic examination was unremarkable at 4 weeks.
Discussion
Tick paralysis has been defined as “an acute, progressive, ascending
motor paralysis caused by salivary neurotoxin(s) produced by certain
species of ticks”. This toxin concentrates during the feeding process on a
host and its release into the host's body is believed to inhibit
Acetylcholine release from pre-synaptic neurons at neuromuscular
junctions causing generalized flaccid motor paralysis [1]. About 69
species of ticks worldwide have been identified capable of causing tick
paralysis, the most toxic being Ixodus Holocyclus [4] known as the
“paralysis tick” endemic to Australia. The most important species in
Ethiopia are Rhipicephalus evertsi evertsi and Argas Walkerae [11,14].
Isolated facial nerve palsy is not so straightforward but there are
different theories that attempt to explain the pathophysiology. One
such theory proposes that, with local attachment of a tick, either in the
ear canal or behind the ear, it is likely that a presence of perforation in
the tympanic membrane enabled the tick saliva (with toxin) to enter the
middle ear and reach the facial nerve probably through a natural de-
hiscence of the fallopian canal causing paralysis [5]. In cases where the
tympanic membrane is intact, direct extension of the inflammatory
process to the fallopian canal is via persistent dehiscence or direct in-
vasion of the infectious organisms into the facial canal through the
middle ear results in edema of the inflamed nerve within the canal [9]
and presents as palsy.
Lyme disease must be considered in patients with otoacariasis who
present with neurologic manifestations. Typically, cranial nerve in-
volvement occurs in the second stage of lyme disease. This stage known
as ‘Early disseminated disease’ occurs weeks to months after the first
stage; and patients can have secondary skin lesions, lymphadenopathy,
migratory joint and muscle pain plus meningitis. However there has
been a case report of an unusual presentation of lyme disease with early
neurologic manifestation preceding an atypical skin rash [16].
The most common clinical presentation of patients with otoacariasis
is ear pain (90%) [13]. Patients have also presented with dizziness,
tinnitus, reduced hearing and even bleeding from the ears [8,13].
Foreign body sensation is not as such common because of the local
chemicals the ticks release that numbs the attachment site enabling
them evade detection and inflammatory response by the host. Facial
pain & swelling are seen in patients who present with facial palsy.
Behind the ear, scalp, and neck attachments are reported as regions of
high risk for development of palsy [13]. There is an unexplained female
Otolaryngology Case Reports 13 (2019) 100132
predilection for otoacariasis [13] and associated facial palsy [8]. Ages
ranging from 13months to 78yrs have been reported [3,12,15,17].
The principal management of otoacariasis is removal of all portions
of the tick using forceps. Anesthesia may be required in some difficult
cases. Use of short course systemic steroids with or without antibiotics
[13] remain experimental with insufficient data available to neither
recommend nor reject their added benefit, unless there is an established
infectious process such as otitis externa, otitis media [12,13] or tick-
borne diseases. The average time of recovery in patients is 4 weeks after
tick removal, even in patients with tympanic perforation [12], although
incomplete recovery has been reported [8].
Conclusion
There are lots of predisposers for tick infestation. One of them is
sharing the similar shelter with livestock which is a common scenario in
third world countries. Also hiking in dense brush hood or being around
deer are potential predisposing activities. So we deem it is necessary to
be aware of such unusual presentation of tick infestation. Tick-borne
disease causing facial nerve palsy is an important item on the differ-
ential diagnosis to keep in mind for the otolaryngologist especially in
those individuals with obvious predisposition. Physicians should also
actively elicit and rule out presence of facial palsy in all cases of
otoacariasis.
Ethical clearance
Ethical clearance to write this case as well as to publish the child's
photograph was taken from the father of the child verbally.
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