Management of Rhinosporidiosis: by Coblation

Abstract

Rhinosporidiosis is a granulomatous disease commonly affecting the mucous membrane. It is caused by Rhinosporidium seeberi, an aquatic parasite & seen affecting the nose, paranasal sinuses most commonly. A retrospective study was conducted at a tertiary care hospital situated in Indian peninsula and five patients who were diagnosed and treated for rhinosporidiosis were analysed. Surgical excision by coblator along with medical management using Dapsone 100 mg once daily for 6 months given promising results in view of reducing recurrence. Combined approach of management including surgical excision using coblator and medical therapy with dapsone is effective in managing the rhinosporidiosis with no recurrence.

Introduction

Rhinosporidiosis, a chronic granulomatous disease caused by Rhinosporidium seeberi. The organism was once thought to be a fungus but is now believed to be a rare aquatic protistan parasite of fish [1]. It mainly occurs in southern India and Sri Lanka, but sporadic cases from other parts of the world have also been reported [2]. Infection generally occurs after swimming in stagnant freshwater ponds or lakes but is also suspected to occur from dust or air [2, 3]. The mainstay of treatment is surgical excision using coblator followed by dapsone therapy to reduce recurrence rates [4]. We describe a case series of 5 cases with their varying presentations & treatment employed to reduce recurrence.

Case Details

Among the 5 patients reported, all were males (100%) between the age range of 22–67 years. 3 of them belonged to Kerala, one patient was from Maharastra and other one was from Karnataka. All patients had the history of swimming in stagnant water (100%). Nasal obstruction with nasal mass was the presenting complaint in 3 patients, one patient presented with recurrent epistaxis. One presented with (R) ear fullness. (L) nostril was seen affected in 3 of the 4 patients who presented with nasal complaints & one patient presented with (R) nasal mass compromising nasal airway. In patient with (R) ear fullness, the diagnostic nasal endoscopy shown a mass with classical strawberry appearance extending to choana.

Off the 5 patients, four patients had the previous history of surgery and the indications for the surgery were suggestive of rhinosporidiosis even though they were not diagnosed histologically & no documents were carried by the patients pertaining to previous surgery. None of the patients were started on Dapsone after previous surgeries. The patient who presented with (R) aural fullness and later diagnosed as (R) nasal mass had no previous history of surgery (Table 1).

Table 1.

Showing clinical details of the patients

S. No	Age (yrs)	Sex	Side presented	Location of lesion	Primary presentation	Recurrence	Swimming habits	Past surgical history
Case 01	35	M	Left	Nose	Recurrent epistaxis	Yes	+	+
Case 02	37	M	Left	Nose	Nasal obstruction, Nasal mass	Yes	+	+
Case 03	29	M	Left	Nose	Nasal obstruction, Nasal mass	Yes	+	+
Case 04	67	M	Right	Nose	Nasal mass, Nasal obstruction	Yes	+	+
Case 05	25	M	Right	Nose	(R) Ear blockage	No	+	−

All the patients undergone excision of the mass using nasal wand EVac 70 coblator. After histopathological confirmation of rhinosporidiosis all patients were started on tablet Dapsone 100 mg once daily for 6 months. The contraindications for Dapsone like Glucose 6 phosphate dehydrogenase deficiency and other hemolytic anemias were ruled out before starting the chemotherapy. All patients were on regular monthly follow up during the period of dapsone therapy and were screened for hemolytic anemias with peripheral blood smear examination. All 5 patients completed the Dapsone therapy for 6 months (100%). None of them showed recurrence (Figs. 1, 2, 3, 4) .

Fig. 1.

Reddish mass in arising from floor of (L) nasal cavity

Fig. 2.

Reddish mass hinging into oropharynx pushing the soft palate anteriorly

Fig. 3.

Mass removed in piecemeal by coblator

Fig. 4.

HPE-cysts of variable sizes (sporangium) with numerous spores

Discussion

Professor Malbren, of Buenos Aires, first identified Rhinosporidiosis in 1892 but it was not until 1900 that Guillermo Seeber comprehensively described it. The first case recognized in India was by O’Kinealyi in 1894. In 1923, Ashworth after a study of Rhinosporidium, proved that it was not a sporozoa but a fungus due to the similarity of its life cycle with other typical fungi and called it Rhinosporidium seeberi [5]. Fredrick and colleagues showed that R. seeberi is a protist from a novel clade of parasites that infect fish and amphibians and not a classic fungus [6]. It is currently included in a new class, the Mesomycetozoea.

R. seeberi has a worldwide distribution with a proclivity for warm, tropical environments. It is most prevalent in southern India & Sri Lanka [7]. This study was done in a tertiary care hospital located in southern India.

Frequency of distribution of various anatomical regions for Rhinosporidiosis is around 70–85% of Naso-pharyngeal Rhinosporidiosis, which is the commonest location followed by Occulosporidiosis which has a frequency range up to 15%. Less common sites (10%) include skin, paranasal sinuses, palate, tonsil, larynx, vocal cords, trachea, bronchus, parotid gland, and genitalia [6, 8–11].

Natural habitat for R seeberi is stagnant freshwater ponds, lakes, or rivers, but is also suspected to occur from dust or air. High incidence is found among rural populations. The most common site of implantation by the parasite is nasal mucosa [4].

Modes of spread documented in literature include (i) autoinoculation by spillage of endospores due to trauma or surgery (ii) haematogenous dissemination to distant sites (iii) lymphatic routes and (iv) sexual [11].

Epistaxis and nasal obstruction are the most common findings. It may be unilateral or bilateral. The enlargement of these lesions occurs slowly over months or years.

The characteristic lesion is a painless friable polypoid sessile or pedunculated vascular mass [12], the surface is studded with tiny white dots from spores beneath the epithelium, giving it a “strawberry-like” appearance. They arise primarily from the nasal cavity and can spread posteriorly to the nasopharynx and oropharynx [11].

The diagnosis is established by detailed history, clinical examination, Nasal endoscopy to rule out other possible differentials like antrochoanal polyp, inverted papilloma. Observation of ‘strawberry-like’ nasal mass with histopathology suggestive of Multiple sporangia at variable stages of maturity surrounded by inflammatory cells confirms the diagnosis.

Coblation is a better technique for the excision of rhinosporidiosis owing to its lower temperature which decreases the chances of thermal damage to the nasal mucosa. Since the intra operative bleeding by coblation is minimal it enhances its effectiveness by minimizing the contamination and hence the recurrence [11]. Coblation system has added advantage of low temperature dissection along with clear surgical field due to constant suctioning. A 10% chance of recurrence after the excision of nasal rhinosporidiosis was documented [12]. Dapsone has shown promising results when used in the postoperative period to prevent recurrence [13].

Conclusion

Rhinosporidiosis can have high recurrence rates following incomplete or improper excision. Coblator assisted excision of the lesion with medical management using Dapsone 100 mg once daily for 6 months following histopathological confirmation of the diagnosis reduces the risk of recurrence.

Funding

No funding was received to assist with the preparation of this manuscript.

Declarations

Conflict of interest

The authors have no relevant financial or non-financial interests to disclose.

Informed Consent

Informed consent was taken from the patient for the case report.