Introduction
Nasal rhinosporidiosis refers to a chronic granulomatous disease of the nose that is caused by Rhinosporidium seeberi.1-4 The disease affects both human beings and animals and is reported more commonly in hot tropical climates even though it is endemic in India and Sri Lanka.1,5-8 On the other hand, sporadicity has been reported elsewhere such as Brazil, Africa and Argentina.6,7,9,10 Despite the disease being very rare in Tanzania, there are some countries that have reported an appreciable number of cases.8
Regarding race and sex predilection of rhinosporidiosis, there is no racial predominance reported and in terms of sex of predominance, males are more affected than females with the male to female ratio being 4:1.1,9-11 The disease also affects those individuals aged 15-40 years.1,2,12
The mode of transmission of rhinosporidiosis may be by direct contact with spores and this can be through dust, infected clothing and swimming in stagnant water.1,8,12-14
The diagnosis of nasal rhinosporidiosis is usually established by observing the characteristics of the implicated etiological agent in nasal tissue biopsies like sporangia. The sporangia when examined in nasal tissue biopsies may be visible at variable stages of maturation. On the other hand, rhinosporidiosis has a tendency of mimicking other nasal masses as it presents like a polypoidal mass.1,7,15-17 Therefore a high index of suspicion by clinicians is of paramount importance in instituting the management of patients with nasal masses particularly in this era where the disease is on surge.
The variable clinical presentation of nasal rhinosporidiosis includes an indolent nasal growth, nasal obstruction, intermittent epistaxis, nasal itching and sneezing and yellowish foul smelling nasal discharge accompanied with blood-stained purulent nasal discharge.1,9,10
The recommended treatment of choice for nasal rhinosporidiosis remains to be surgical excision of the nasal mass despite the reported high recurrence rate.3,16,18 Despite being amenable to surgery, there are reported deaths in patients who are not immunocompetent.19 Whenever accessible electro cauterization of the base of the excised site should be done though cryosurgery can also be used.20 Systemic therapy with dapsone serves as an important adjuvant therapy.1,20,21
To the best of our knowledge, this is perhaps the second reported case of nasal rhinosporidiosis in Central Tanzania and the first case of its unique nature due to synchronicity with inverted papilloma.
Being a rare benign tumor, inverted papilloma was described initially in 1854 by Ward and in 1855 by Billroth.20,22 This tumor accounts for 0.5-4% of all nasal tumors.20,23 The disease tends to peak in the 5th to 6th decade 23 with male to female ratio being between 3:1 and 10:1.20 It is exceptional in the pediatric population by being very rare as only very few cases have been reported.24 Though inverted papilloma is known to be a benign tumor, yet it is characterized by its possibility of undergoing malignant transformation to carcinoma, local aggressiveness, high risk of synchronous or metachronous malignancy and has the propensity of local recurrence especially if incomplete surgical excision is entertained.22-24
The commonest location for inverted papilloma is the lateral nasal wall and the paranasal sinuses. There are other rare anatomical sites being involved by inverted papillomas outside the sinonasal tract such as skull base 25, nasolacrimal duct 26, oropharynx 27.28 and nasopharynx.29,30
The exact etiology of inverted papilloma is still debated to date thus unknown. There is a laid hypothesis that Human papillomavirus may be implicated in the development of inverted papillomas; particularly type 11.31-35 There are other proposed aetiological agents like chronic inflammation, allergy and occupational exposures.23,33 The treatment of choice remains to be surgical excision of the nasal mass which can be done endoscopically whenever equipment permits. 23,26 Despite adequate treatment of an inverted papilloma, recurrence rate may be as high as 30 – 60 % of cases.20
We are therefore reporting a paediatric patient who presented with a synchronous nasal rhinosporidiosis and inverted papilloma and was managed by endoscopic surgical excision of the nasal mass and kept on oral dapsone for 6 months postoperatively.