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Main Article

KTP-532 LASER IN THE MANAGEMENT OF RHINOSPORIDIOSIS

Mohan Kameswaran, R. S. Anand Kumar, Sathiya Murali, S. Raghunandhan, Jeeth Jacob*

ABSTRACT: Rhinosporidiosis, a difficult granulomatous disease of the nose is notorious for its high
rate of recurrence and vascularity. Potassium Titanyl Phosphate (KTP) laserization of the mass seems to
have provided an optimal solution in the management of this disease. We present our experience with the
use of KTP-532 laser for this challenging disease.

Key Words: Rhinosporidiosis, KTP/532 laser

Rhinosporidiosis is a chronic infestation by the fungus
Rhinosporidium seeberi. Rhinosporidiosis is a granuloma
prevalent in the tropics.[1] The disease manifests with vascular
polypoidal granulomata primarily affecting the nose,
nasopharynx and occasionally other rare sites. Osteolytic[2]
lesions of the bone have also been reported.
The disease, which is chronic and characterized by the formation
of papillomatous and polypoid lesions tends to affect younger
males and is endemic in many regions of India and Sri Lanka.[3]
The characteristic lesion is a bleeding polyp and histologically
the polyp has a vascular fibromyxomatous structure.
The granulomata are traditionally managed by endonasal wide
excision with diathermy and cautery to the base. However
recurrence is a common feature with this treatment modality.
Diamino-diphenyl sulfone (Dapsone), an anti-leprosy drug
was recommended in the belief that this reduces the vascularity
of the granulomata, although this optimism has not been
shared by many, in practice.
Thus the present management of Rhinosporidiosis is far from
satisfactory. Local recurrence and further dissemination pose
a constant challenge to the management of this disease.
This study evaluates the use of Potassium Titanyl Phosphate
KTP/532 laser in the management of Rhinosporidiosis.
MATERIALS AND METHODS
This is a prospective study of 22 patients treated for
Rhinosporidiosis at Madras ENT Research Foundation, a
referral E.N.T. hospital at Chennai. The study period extended
for a period of 30 months from April 2001 to September 2003.
The study was designed to find out the Efficacy of the KTP-
532 laser vs conventional diathermy excision. The study
looked at three main criteria, which included:
1. Clearance of the disease.
2. Effect on Post Laser Recurrence of Rhinosporidial mass at:
 Same site.
 Different sites.
3. Effect on blood loss.
The disease was diagnosed by taking a detailed history, clinical
examination, and a battery of investigations including X-ray
PNS, CT-PNS, Diagnostic nasal endoscopy and biopsy. All
patients with confirmed Rhinosporidiosis uncomplicated by
other co-existing disease were included in the study. The
patients were divided into two groups – a study group A where
KTP-532 laser was used to treat the disease and a control
group B where conventional mode of treatment viz. Diathermy
excision was used.
The Rhinosporidial mass was laserized using KTP/532 laser.
The laser was passed through a hand-held probe under direct
vision. For lesions where direct vision was not possible then
Laserisation of the Rhinosporidial mass was carried out by
passing the laser through a flexible bronchoscope or alongside
a 0* nasal endoscope.
The KTP-532 laser comes with a variety of hand-held probes
of various lengths and depending on the depth of the lesion
different sized probes were used. Using the near contact mode
(avoiding direct contact of the lesion with the probe) and with
the help of a suction tip to remove the plume, the mass was
vaporized. Laserization of the base of the Rhinosporidial mass
was also done as a routine.

Consultant ENT Surgeons, MERF, *Senior Registrar, MERF, Madras ENT Research Foundation, Mylapore, Chennai, Tamil Nadu, India

Indian Journal of Otolaryngology and Head and Neck Surgery Vol. 57, No. 4, October-December 2005
 KTP-532 laser in the management of rhinosporidiosis 299

The procedure was performed using intravenous Propofol

(6 mg/kg/h) supplemented with topical Lidocaine 2% so that
the patient could be woken up soon after the procedure. Once
the mass was excised, the entire nasal cavity and nasopharynx
were examined for hidden lesions. A follow up was done at
2 weeks, 3, 6, 9 months, and at the end of 1 year to look for
any recurrence of the disease or appearance of fresh lesions.
A series of 22 cases of recurrent nasal/nasopharyngeal
Rhinosporidiosis formed the basis of this study.

The study period was for 30 months (April 2001–October

2003). The study group was entirely male and their age ranged
from 24 to 52 years. Patients with involvement of sites other
than the nose and nasopharynx were excluded from the study. Figure 1: Photograph of rhinosporidial mass in right nasal cavity
The 22 patients were divided into two groups of 11 each in a
random fashion.

All the patients in-group A were left without postoperative

nasal packing. The first author operated on all 22 patients.
Postoperatively another surgeon who was not informed
regarding the type of treatment administered to the patient,
followed up the patients.

All the 22 patients were followed up for a period of

12 months and were subjected to clinical examination and
diagnostic nasal endoscopy at regular intervals as specified
above. The results were recorded in a computerised proforma
and any recurrences noted.
Figure 2: Photograph of laserisation of mass with KTP-532 Laser
RESULTS
This is a prospective study of 22 patients with
Rhinosporidiosis between April 1st 2001 and September 30th
2003. Half of the 22 cases (group A) were treated by
Laserization of the Rhinosporidial mass using KTP/532 Laser,
the remaining (group B) were treated by conventional surgery
with cautery to the base. Laserization was done using a hand-
held probe in the near-contact mode. All the patients (100%)
in the study were males. The peak age incidence in group A
was between 20 and 30 years (36%) and group B was between
30 and 40 years (27%).

In Group A there was a near equal incidence between nasal

(55%) and nasopharyngeal (45%) lesions. In group B the most
common site of occurrence was seen to be in the nasal cavity
(72.7%). The rate of recurrence of the Rhinosporidium was
also calculated and it was found out that in group B recurrence
was about 63% while that in group A was 27%. In three
patients of group A recurrence occurred, of which interestingly
in two patients (18%) it was seen that the new Rhinosporidial
mass did not arise from the exact same site of initial
presentation but rather from a different site. One patient had
recurrence in the same site.
Figure 3: Photograph of lasered area with resultant mucosal defect
Due to the bleeding caused by disease blood transfusion was
required in many patients. It was seen that in group B, six
patients (54%) required whole blood transfusion but in the
case of group A, where the cases were treated with the KTP-
532 Laser it was seen that only two patients (18%) required
whole blood transfusion.

Indian Journal of Otolaryngology and Head and Neck Surgery Vol. 57, No. 4, October-December 2005
300 KTP-532 laser in the management of rhinosporidiosis
DISCUSSION
Rhinosporidiosis is a predominantly tropical fungal disease
characterized by the occurrence of fungal granulomata in the
upper airway.[1] The fungus Rhinosporidium seeberi causes
the disease.[2] Recently, doubts have been cast on the exact
taxonomic position of the causative organism. [3] The
predominant sites of occurrence are the nose and nasopharynx.
Rarer sites include the lacrimal sac, oropharynx, larynx, skin,
and occasionally a disseminated form.[4] Treatment is at present
far from satisfactory, as recurrence is the rule rather than the
exception. Bleeding during surgery is profuse and can be life
threatening. Till recently the accepted management involves
excision with cautery to the base.[5] The advent of the sinus
endoscope has facilitated the clearance of smaller granulomata
but bleeding from the larger granulomata can impair vision
and pose difficulties when using the endoscope. The
introduction of the surgical laser for fulguration and
vaporization of these granulomata would be a logical step, as
one would expect this to reduce bleeding and also improve
vision with the endoscope.
The KTP-532 laser is a surgical laser, which is gaining
increasing popularity in the field of Otorhinolaryngology. The
KTP-532 laser is a Nd – YAG laser that is frequency doubled
by passage through a KTP crystal.[6] This endows the laser with
excellent cutting and coagulating properties. The wave length
of KTP laser approximates to the absorption spectrum of
Oxyhaemoglobin. Hence this laser selectively concentrates in
areas of haemorrhage, providing excellent haemostasis. Further
more, the laser can be passed through optical fibers and can be
used in Rhinology alongside the nasal endoscopes. Specially
designed probes for Rhinological use ensure that the laser can
be applied at ‘difficult to reach’ areas and around corners. By
varying the distance of the laser tip to the incident site, the
fluence can be varied; thus varying the function of the laser.
Thus when the laser is applied in the near contact mode, it cuts.
When the probe is withdrawn slightly and the laser is applied
in the contact mode, it vaporizes and when the laser is applied
from still further away in the noncontact mode it acts a
coagulator. It stands to reason that the best method of
laserization of a vascular granuloma like Rhinosporidiosis
would be in the near contact and noncontact modes.
An additional theoretical advantage would be that since there
is minimum physical contact with the fungal granulomata,
tissue seedling should be minimal. This would explain the
lower incidence of recurrence. However the biggest benefit
from the laser seems to be the dramatic reduction in bleeding.
This not only helps the surgeon avoid unnecessary blood
transfusion but also improves vision when working with the
endoscope.[6] Most patients who underwent laserization could
be discharged home the same evening or the following day
greatly reducing the period of hospital stay. Although our study
Indian Journal of Otolaryngology and Head and Neck Surgery Vol. 57, No. 4, October-December 2005
number is admittedly small our study has conclusively shown
that the KTP-532 laser is a superior tool than conventional
cautery for treatment of this difficult tropical disease. Based
on the data collected from all the 22 patients it was also seen
that the extent of the disease was also proportionate to the
duration of the disease.
Complications that arose out of the laser procedure were very
minimal. One of the patients developed nasal synechiae and
this was corrected during his subsequent follow up.
CONCLUSION
This double blind randomized study shows that the KTP-532
Laser has numerous advantages over the conventional
treatment modality of Rhinosporidiosis.
The KTP-532 laser is a superior tool as compared to diathermy
excision. It enables the surgeon to obtain a better clearance
margin with improved visiblity and also significantly
decreases the total amount of blood loss.
Rhinosporidiosis is a disease, which is very troublesome, and
the KTP-532 laser promises to be the main stream treatment
in the future. At present, the main limiting factors for using
the KTP-532 laser is the high cost.
In the study, it was seen that the KTP-532 laser helped in
reducing the chances of recurrence. This could also be
attributed to the fact that treatment with laser can be achieved
without direct contact of the infected granulomata thus
avoiding tissue contamination. Thus it can be concluded that
the KTP-532 laser is a valuable tool in the surgical
management of Rhinosporidiosis. Such recent advances in
laser science have revolutionized the current management of
this disease”.
REFERENCES
1. Kameswaran S. Surgery in Rhinosporidiosis. Int Surg 1966;46:602.
2. Sathyanarayana C. Rhinosporidiosis. Acta Otolaryngologica
1960;51:348-66.
3. Lakshmanan M, Kameswaran S, Jayapal JI. Histochemistry of
Rhinosporidium Seeberi. Proceedings of the International Symposium
of Taxonomy of Fungi: Chennai, India; 1973.
4. Belou P. Quoted by Ashworth. Tr. Royal Soc. Edinburgh 1903: 1923.
p. 53-301.
5. Fain A, Herin V. Systemic mycoses. Ciba Foundation, Wolstenholme,
GEW and Ruthporter EDJ and A Churchill Ltd: London; 1968.
6. Kameswaran S, Kameswaran M. ENT disorders in tropical
environment. 1999. p. 19-24
Address for Correspondance
Dr. Mohan Kameswaran
Madras ENT Research Foundation, Mylapore, Chennai,
Tamil Nadu, India