Recurrent rhinosporidiosis is a chronic granulomatous disease with a known tendency to reoccur. Coblation EVAC 70 is a novel surgical tool which seems to provide excellent option in management of this notorious disease. We present an interesting case and the innovative approach in its management, using Coblation system.
Rhinosporidiosis is a rare chronic granulomatous disease of mucocutaneous tissue. This disease is widely endemic in Indian subcontinent and some parts of Africa. The etiological agent rhinosporidiosis seeberi is an aquatic protistan parasite [
A 65-year-old male presented to us with difficulty in breathing, change in voice, and nasal obstruction. Patient was a Hindu priest by profession, was a resident of Jharkhand, and had a positive family history of rhinosporidiosis in a paternal cousin and maternal uncle. Patient had been operated on 11 times earlier; first surgery was done when he was 16 years of age. The last procedure was done about 1 year back with KTP laser when he had to undergo a tracheostomy because of the extensive nature of the disease. On examination, a fleshy mass was seen filling both nasal cavities with yellowish pinhead sized spots on surface. Note was also made of the presence of septal perforation in the cartilaginous part of the septum. The mass was extending in the oropharynx behind the soft palate. On laryngoscopy, growth was seen involving bilateral vallecula, bilateral glossoepiglottic fold, and lingual surface of epiglottis pushing the epiglottis over the laryngeal inlet. Vocal cords could not be visualized. A contrast enhanced computed tomographic scan was done, which revealed a homogenous mass filling bilateral nasal cavity without any bony invasion, although thinning of bilateral lamina papyracea was noted. Also mass was filling nasopharynx and oropharynx involving the lingual surface of epiglottis, obscuring laryngeal inlet (Figure
An elective tracheostomy was done taking into view the difficult airway. Patient was put under general anesthesia. The nasal extension of the mass was first addressed under endoscopic vision. Using Coblation wand EVAC 70, the nasal mass was ablated but there was no attachment in the nasal cavity and mass appeared to arise from the nasopharynx attached to the posterior wall. The patient was then put in tonsillectomy position and mouth gag was applied and then mass was removed from the nasopharynx using Coblation wand at a setting of 8 in ablation mode, and the wand had to be bent to approach the choanal region. Following this the mass was removed from the oropharynx including vallecula and lingual surface of epiglottis and lateral glossoepiglottic folds (Figure
Fleshy papillary mass filling nasal cavity and oropharynx.
CT scan coronal and sagittal section views showing extension of the tumor in nasopharynx and oropharynx.
On gross pathology, fleshy mass with white pinhead sized spots on the surface was noted. Microscopic evaluation identified sporangia and endospores demonstrating a granulomatous reaction with eosinophilia. Final diagnosis was consistent with rhinosporidiosis with chronic inflammation and giant cell reaction. Patient was started also on dapsone after assessing the G6PD level on 100 mg twice daily.
Postoperatively patient was followed up for 1 year, during which patient was subjected to endoscopic examination twice, with no evidence of reoccurrence at 1 year of follow-up.
Rhinosporidiosis is a rare disease which has been known for hundred years since its first description in 1900 by Seeber, an individual from Argentina [
Rhinosporidiosis seeberi, the causative organism, has a debatable taxonomy as the microorganism is intractable to isolation and microbiological culture, and the morphological features resemble both fungi and protozoa. But recently a study has classified
Diagnosis is made by biopsy and histological examination of the section. The tumor is covered with columnar epithelium, along with many spores and sporangia in various stages of development. Also there is cellular infiltrate with lymphocytes, plasma cells, polymorphs, and eosinophils [
The treatment of choice is wide local excision with cauterization of the base. In addition, systemic dapsone is given for a period of 1 year and is known to prevent reoccurrence which arrests the maturation of sporangia and promotes fibrosis [
In a case report of recurrent rhinosporidiosis by Nichlani, in which they excised the lesion using diode laser, they followed up the case for 1 year, in which no recurrence was reported [
Coblation has recently been used to treat various otolaryngological conditions: obstructive sleep apnea, tonsillectomy, turbinate reduction, and benign tumors of head and neck [
With the use of Coblation system, we could achieve complete resection of the lesion, with minimum bleeding and less blood contamination, also preserving the integrity of local tissue. Patient is under follow-up for last 1 year and there is no evidence of occurrence (Figure
Post-op follow-up picture after 1 year shows no signs of reoccurrence.
Coblation system can be a promising new tool in the surgical resection of recurrent rhinosporidiosis. This system enables the surgeon to obtain better resection of the disease due to constant suctioning, with minimum lateral thermal damage. This also decreases the chances of reoccurrence due to very little contamination of the surrounding areas by preventing autoinoculation. The novel design of the wand can help to resect “the difficult to reach areas.”
Written informed consent was obtained from the patient for publication of this case report and the accompanying images. A copy of the written consent is available for review.
The authors declare that they have no competing interests.
Dr. Iram Khan and Dr. Shweta Gogia were major contributors in collecting the data and writing the case report.
The authors are grateful to the patient and his family, who agreed to the publication of this case report and provided all the needed information.