Primary nasal rhinosporidiosis - a ten year multicentre experience: what we know?

INTRODUCTION

Rhinosporidiosis is chronic granulomatous inflammatory disease caused by Rhinosporidium seeberi. It has been recently classified as an aquatic protistan parasite. Tamil Nadu is endemic region for this condition. In this state southern districts like Kanyakumari, Ramanathapuram, Madurai, Sivagangai and Tiruvarur district is considered hyperendemic.¹ The authors have worked in various institutions across the state of Tamil Nadu like Thiruvarur, Thiruvannamalai, Vellore and Chennai, have vast experience in treating rhinosporidiosis. Various studies have mentioned the inferior meatus, inferior turbinate, nasal floor, nasal septum as the primary site of attachment of rhinosporidiosis.²

The aim of the study was to describe the demographic distribution, clinical presentation and site of attachment of primary nasal rhinosporidiosis in various districts of Tamil Nadu over the period of ten years.

METHODS

This is a prospective study of seventy-eight cases of primary rhinosporidiosis over a period of ten years (February 2009 to December 2019) in various tertiary care centres in Tamil Nadu (Tiruvarur, Thiruvannamalai, Vellore and Chennai). Recurrent cases were excluded. Ten patients who did not come for follow up after one year were not included when deriving the final results. Patients who were operated under local anesthesia were not included in this study. All the patients (45 patients) were subjected to endoscopic surgery for excision of the rhinosporidiosis under general anesthesia after informed written consent. Correct size Endo tracheal tube with appropriate cuff pressure inflation was done by anesthetist. Under direct visualization the throat was packed with saline soaked ribbon gauze pack by the surgeon. With 0 degree nasal telescope the nose was decongested with one in thousand dilution adrenaline pack, taking care not to create microabrasion and trauma. After two minutes of decongestant packing, the inferior meatus was packed with adrenaline soaked ribbon gauze following gentle push of the inferior turbinate towards the nasal septum taking care not to injure the mucosa. The region of valve of Hasner was visualised and the site of attachment on the posterior lip of valve of Hasner was cauterised with bipolar diathermy in low voltage setting to prevent charring and block to the valve. Once the procedure is complete the inferior meatus is again decongested and visualized for any remanant, inferior canaliculus was flushed with saline and the patency of nasolacrimal duct was confirmed. In patients with very large rhinosporidiosis Mass cutter- shaver device was used to morselize the rhinosporidiosis, taking diligence not to create mucosal damage. This maneuver is important to remove the rhinosporidiosis through the involved nose and not remove through the oral cavity. This prevents uninvolved areas from getting into contact with rhinosporidiosis. Brief demographic and clinical data of patients were collected for this study.

RESULTS

In the forty-five cases thirty-nine were males and six females. Most of the patients belongs to Tiruvarur and Thiruvannamalai districts (Figure 1). All patients gave history of bathing in ponds in which animals like bullocks and buffalo too had access. Males in the age group of twenty-five to fifty were the commonest to get infected (Figure 2). Unilateral nasal obstruction being the most common clinical presentation (Figure 3). Posterior lip of valve of Hasner in the inferior meatus (Figure 4) and (Figure 5) was the site of attachment in primary nasal rhinosporidiosis in our study. During the dry season in Tiruvarur and Tiruvannamalai district when all ponds have dried, the incidence was reduced (Figure 6). Most commonly O+ve blood group individuals were affected (Figure 7). Histopathologically presence of sporangia and numerous endospores seen with hematoxylin-eosin stains confirms the diagnosis (Figure 8). Rhinospordiosis is aquatic protistan parasite and cannot cultured in vitro.

DISCUSSION

Rhinospordiosis is a chronic granulomatous disease of the upper respiratory tract and it is characterized by formation of polypoid masses. This disease is endemic in india and Sri Lanka. In Tamil Nadu particulary some districts like Tiruvarur and Ramanathapuram are hyperendemic.

Total 45 cases were studied over the period of ten years. Most common age group being 25 to 50 years with male preponderance. Study by Arseculeratne et al, and Kutty et al, also found the maximum number of cases in the age-group 21 to 30 years with male preponderence.^2,3

Most of the affected individuals shared common thing is bathing in the ponds in which buffalos, cows and other farm animals had acesss. Study by Karthikeyan et al, found the same.⁴

Most of the patients presented with unilateral nasal obstruction followed by nasal bleeding.⁴ Similar results found in studies conducted by Guru et al, and Bandyopadhyay et al.^5,6

The most common site involved is nasal mucosa followed by nasopharynx, oropharynx, tracheobronchial tree, esophagus, conjunctiva and ears.⁷ Cutaneous and visceral involvement occurs following disseminated disease. For the first time the posterior lip of valve of Hasner has been found to be the most common site of attachment in primary nasal rhinosporidiosis followed by nasal septum, nasopharynx and floor of nose.

Most common blood group involved in our study is O+ve. Similar results found in Sinha et al.⁸

CONCLUSION

Rhinospordiosis is hyperendemic in Tiruvarur and Thiruvannamalai. Rhinospordiosis affect individuals who take bath in ponds in which farm animals have access. Rhinospordiosis is more common when migratory birds roost in the ponds. For the first time the posterior lip of valve of Hasner has been found to be the most common site of attachment in primary nasal rhinosporidiosis. Correct identification of the site of attatchment and surgical excision with cauterisation prevents its recurrence. Postoperative medical therapy with dapsone has limited role. Some precautions like avoidance of bathing in ponds and domestic purposes helps to reduce the incidence.

Funding: No funding sources

Conflict of interest: None declared

Ethical approval: Not required

REFERENCES

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