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 Table of Contents  
CASE REPORT
Year : 2021  |  Volume : 14  |  Issue : 3  |  Page : 392-395

Palatine tonsil: An unusual location of rhinosporidiosis


Department of Otorhinolaryngology and Head and Neck Surgery, IMS and SUM Hospital, Siksha “O” Anusandhan University, Bhubaneswar, Odisha, India

Date of Submission27-Jun-2021
Date of Acceptance26-Jul-2021
Date of Web Publication30-Sep-2021

Correspondence Address:
Dr. Santosh Kumar Swain
Department of Otorhinolaryngology and Head and Neck Surgery, IMS and SUM Hospital, Siksha “O” Anusandhan University, K8, Kalinga Nagar, Bhubaneswar - 751 003, Odisha
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/kleuhsj.kleuhsj_176_21

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  Abstract 

Rhinosporidiosis is a granulomatous disease caused by Rhinosporidium seeberi which belongs to class Mesomycetozoea. It mainly affects mucous membranes of the nose, nasopharynx, and oropharynx. It can also involve uncommon sites of the human body to disseminated types. Water and soil act as a reservoir for this organism. Isolated involvement of the palatine tonsil by rhinosporidiosis is extremely uncommon. Extra-nasal manifestations of rhinosporidiosis are relatively uncommon in clinical practice. Tonsillar rhinosporidiosis is extremely rare and often confused with oropharyngeal tumors. The mainstay of treatment of rhinosporidiosis is surgical excision by coblation, laser, or electric diathermy. Here, we report a 32-year-old man presented with a red, polypoidal mass of the palatine tonsil and bleeding occasionally and the diagnosis of rhinosporidiosis was confirmed by histopathological examination. The mass was completely removed along with the tonsil by coblation technique and the base was coagulated under general anesthesia. Hence, the possibility of this atypical site of rhinosporidiosis should be included in the clinical differential diagnosis of any pinkish mass originating from the palatine tonsil, particularly in the endemic area.

Keywords: Coblation, oropharynx, palatine tonsil, rhinosporidiosis, tonsillectomy


How to cite this article:
Swain SK. Palatine tonsil: An unusual location of rhinosporidiosis. Indian J Health Sci Biomed Res 2021;14:392-5

How to cite this URL:
Swain SK. Palatine tonsil: An unusual location of rhinosporidiosis. Indian J Health Sci Biomed Res [serial online] 2021 [cited 2021 Dec 8];14:392-5. Available from: https://www.ijournalhs.org/text.asp?2021/14/3/392/327249


  Introduction Top


Rhinosporidiosis is a chronic granulomatous disease caused by Rhinosporidium seeberi, an aquatic protistan parasite which belongs to the class of Mesomycetozoea.[1] The class Mesomycetozoea comprises uncultivated aquatic microbes of animal-fungal boundary.[1] The phylogenetic analysis of R. seeberi 18S rRNA gene revealed that this group of pathogens was part of the DRIP clade (acronym derived from Dermocystidium, rosette agent, Ichthyophonus, and Psorospermium).[2] The first documentation of R. seeberi was given by Malbran in 1892 and later reported from cattle in India in 1894.[3] The first human case of rhinosporidiosis was reported by Guillemo Seeber in 1900 in a 19-year-old boy of an agricultural laborer from Buenos Aires, Argentina.[3] The most common site of involvement by rhinosporidiosis in human is the nose. Other sites affected by rhinosporidiosis are nasopharynx, oropharynx, larynx, conjunctiva, lacrimal sac, and external genital mucosa.[4] Primary involvement of the tonsil is extremely rare. We report the case of a 32-year-old male with reddish polypoidal mass in the right tonsil which subsequently revealed the presence of R. seeberi in histopathological examination. The objective of this article is to report an extremely rare location of the rhinosporidiosis with unusual presentation.


  Case Report Top


A 32-year-old man attended the outpatient department of otorhinolaryngology with complaint of foreign-body sensation in the throat for 1 month. He had two episodes of mild bleeding from the mouth during the last 1 month. He had no history of nasal obstruction and nasal bleeding. He had a habit of pond bathing. On examination, there was a polypoidal pinkish mass in the right tonsil [Figure 1]. The mass was partially obstructing the oropharyngeal airway. We suspected a nasopharyngeal pathology hanging to the oropharynx. However, diagnostic nasal endoscopy revealed normal nasal cavity and nasopharynx. Oropharyngeal examination confirmed the origin of the mass which attached to the right tonsil. Computed tomography (CT) scan of the neck showed a hyperdense mass originating from the right tonsil and extending toward the oropharyngeal airway. CT scan showed no growth in other places of the head and neck region. Systemic and hematological examinations were within normal limits. The serum biochemistry report was normal. A small piece of tissue was taken from the right tonsillar mass and sent for histopathological examination which confirmed the rhinosporidiosis. The histopathological picture showed thick-walled sporangia containing numerous endospores in a background of fibrovascular stroma [Figure 2]. By coblation technique, the patient underwent complete excision of the right tonsil along with mass and coagulation was done of the tonsillar fossa for preventing any recurrence. He was followed up for 1 year and showed no evidence of bleeding from the tonsillar region and no evidence of recurrence.
Figure 1: Oral cavity examination showing isolated right side tonsillar rhinosporidiosis

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Figure 2: Histopathological picture showing a large sporangium containing multiple pink-colored spores and capsule (PAS stains, ×1000)

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  Discussion Top


Rhinosporidiosis is a tropical granulomatous disease affecting mucous membrane, more commonly nose and nasopharynx. The common sites of the body affected by rhinosporidiosis are nose, nasopharynx, oropharynx, conjunctiva, rectum, and external genitalia.[2] It rarely affects skin and internal organs of the body. In this case, rhinosporidiosis was found in the palatine tonsil The palatine tonsil is an extremely rare site for rhinosporidiosis. Rhinosporidiosis is caused by R. seeberi, an enigmatic microorganism with disputed taxonomy. Originally R. seeberi was considered as a protozoan and subsequently a fungus and currently as an aquatic Mesomycetozoea (between fungi and animals) on the basis of the phylogenetic analysis of 18S r DNA.[5]

Rhinosporidiosis is presumably a waterborne zoonotic disease and is often seen after swimming in stagnate freshwater ponds, lakes, or rivers but also thought to occur from dust or air.[6] The route of the transmission of infection to human being is not clearly defined. However, most of the clinicians believe that direct contact with the spores via water, dust, or soil are potential risk factors for contracting the infections.[7],[8] The natural hosts of this aquatic parasite are amphibians and fish.[9] In 1923, Ashworth has described first the life cycle of R. seeberi.[10] It is most prevalent in India and Sri Lanka, followed by South America and Africa.[11] The mode of transmission of rhinosporidiosis is usually through water or dust, from which the endospores penetrate the mucosal lining of the nasal cavity, mature into sporangium within the submucosal compartment, and after maturation burst with release of sporangia into adjacent tissues.[12] Pond bathing habit of our case may be responsible for transmission of the infection to the patient.

Patients with rhinosporidiosis are usually present with polypoidal reddish mass which bleeds profusely with minor trauma. Rhinosporidiosis is often found in the anterior part of the nasal septum and nasal vestibule.[12] Oropharynx, larynx, trachea, and skin are less commonly affected. In this case, the rhinosporidiosis was found in the palatine tonsil and presented with foreign-body sensation in the throat. If the lesion compromises, the oropharyngeal or laryngeal airway may result in breathing difficulty. In some cases, osteolytic bone infiltration is also a clinical presentation.[13] Tonsillar rhinosporidiosis is an uncommon disease in routine clinical practice which may mimic to neoplasm of the tonsil. Hence, it is imperative for clinicians to consider rhinosporidiosis as a differential diagnosis of the oropharyngeal mass in an endemic region like India.

The diagnosis is confirmed by excision biopsy where histopathological examination shows sporangia in the tissue. There may be distinctive sporangia and spores at different stages of maturation are found in the histopathological picture. Histologically, the infected tissue shows granulomatous reaction (mixed cell granuloma), pseudocystic abscess, and fibrosis around the organism.[13] R. seeberi can be seen with fungal stains such as Gomori methenamine silver and periodic Acid–Schiff as well as H and E staining.[14] This organism is difficult to culture and diagnosis of rhinosporidiosis is usually based on microscopy and histopathological examination. In our case, a histopathological study confirmed the diagnosis.

The treatment of choice is meticulous, complete, and wide surgical excision of the rhinosporidiosis. Complete excision with electrocoagulation of the lesions is recommended for rhinosporidiosis. Electrocauterization at the base of the rhinosporidiosis may abate recurrence due to spillage of endospores on the adjacent mucosa.[15] The treatment options of the rhinosporidiosis are excision followed by cauterization of the base for preventing recurrence, coblation, and laser. The ablation technique like coblation is an important tool in the current scenario for surgical resection of the rhinosporidiosis.[16] In our case, coblation technique was used for surgical excision and coagulation of the base. The ablation technique also helps to decrease the chance of contamination of the adjacent tissue and prevents auto-inoculation.[17] Laser is also a useful technique for complete excision of the mass with good hemostasis and reduces the chance of complications and recurrence. CO2 laser is often used to excise the rhinosporidiosis and cauterize the base of the attachment.[2] Dapsone can be tried to reduce the recurrence rate. Dapsone is often prescribed after surgery for preventing the recurrence of rhinosporidiosis. Many cases of rhinosporidiosis need multiple surgeries as the rate of recurrence is high.[18] Recurrence is known to occur by spillage of endospores to the adjacent tissue or due to incomplete excision.[4] Antifungal medications such as griseofulvin and amphotericin B are tried but without much success. Dapsone (4,4-diaminodiphenyl sulfone) is thought to arrest the maturation of the sporangia and to promote fibrosis in the stroma, which is often used as an adjunct to surgery.[19] Tablet dapsone is usually given for 1–2 years for avoiding the recurrence and dissemination of the disease. In this case, the patient had taken tablet dapsone for avoiding recurrence. However, the medical treatment for rhinosporidiosis has limited efficacy.


  Conclusion Top


Rhinosporidiosis is a chronic granulomatous disease, mostly affects the nasal cavity and nasopharynx. It is caused by R. seeberi and is endemic in India and Sri Lanka. The diagnosis is usually done by clinical observation and histopathological examination. Although rhinosporidiosis is commonly found in the nasal cavity, nasopharynx, and ocular structures, it has from time to time been reported in different uncommon sites of the body. In an endemic area like India where the history of pond bathing often considered as aggravating factor towards development of rhinosporidiosis at the unusual site like palatine tonsil. Routine cytological stains along with histopathological examination provide a definitive diagnosis of rhinosporidiosis. Isolated tonsillar rhinosporidiosis is extremely uncommon which may mimic neoplasm of the oropharynx.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form, the legal guardian has given his consent for images and other clinical information to be reported in the journal. The guardian understands that names and initials will not be published and due efforts will be made to conceal identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

 
  References Top

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SaqulainG, Jailisi M. Rhinosporidiosis: Presenting as a mass in the oral cavity. Pak J Otolaryngol 1996;12:218-20.  Back to cited text no. 13
    
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Morelli L, Polce M, Piscioli F, Del Nonno F, Covello R, Brenna A, et al. Human nasal rhinosporidiosis: An Italian case report. Diagn Pathol 2006;1:1-4.  Back to cited text no. 14
    
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Echejoh GO, Manasseh AN, Tanko MN, OgalaEchejoh SE, Silas OA, Nimikur TL, et al. Nasal rhinosporidiosis. J Natl Med Assoc 2008;6:713-5.  Back to cited text no. 15
    
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Swain SK, Ghosh TK, Das A. Microscope-assisted coblation tonsillectomy: Our experiences at a tertiary care teaching hospital of eastern India. Ann Indian Acad Otorhinolaryngol Head Neck Surg 2020;4:35-8.  Back to cited text no. 16
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