Lobular Capillary Hemangioma on The Anterior Part of the Right Inferior Turbinate
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Nosebleed (epistaxis) is one of the most common emergencies encountered in ear, nose and throat clinics. Sometimes, the cause is a simple vascular area injury or mucosal damage in patients; sometimes, a cause such as pyogenic granuloma may occur, as in the patient I shared with you here.
What is Pyogenic Granuloma?
Pyogenic granuloma is a rapidly growing, benign, vascular-originated lesion with a slight error in naming. Histopathologically, it is called lobular capillary hemangioma and tends to occur more in areas with mechanical trauma. It is usually seen in the oral mucosa, gingiva and skin, but rarely in the nasal cavity. Nasal localization is more frequently detected in areas vulnerable to trauma, especially the inferior turbinate and septum.
Synonyms of Pyogenic Granuloma
- Lobular Capillary Hemangioma
- Granuloma Telangiectaticum
- Eruptive Hemangioma
- Pregnancy Tumor
- Granuloma Gravidarum
Clinical Case Summary
Patient: 17-year-old male patient
Complaint: Recurrent right nosebleed and nasal congestion
History: It was learned that the patient had been bleeding from the right nose intermittently for 3 months and the amount of bleeding had increased in recent days. The patient had a history of constantly picking his nose and nosebleeds usually started after picking his nose.
Examination Findings: A bright red, pedunculated, easily bleeding mass approximately 1 cm in diameter was observed in the anterior part of the right inferior turbinate during endoscopic nasal examination. There was mucosal edema and slight exudate around the lesion. Other nasal structures were normal. The patient did not use blood thinners or have hypertension as an etiology.
Diagnosis: Clinical appearance and endoscopic findings suggested pyogenic granuloma. The definitive diagnosis was made by histopathological examination after excision. The patient underwent cauterization after excision of the lesion with radiofrequency.
Etiology and Pathogenesis
Nasal pyogenic granulomas are usually associated with the following factors:
- Mechanical Trauma: Nose picking, nasal foreign bodies, piercings (local mechanical trauma was the most common cause in this patient)
- Hormonal Changes: Common during pregnancy (our patient was a male)
- Infections: Chronic inflammation and bacterial infections
- Topical Medication Use: Nasal steroids, decongestants
In this case, nose picking and possible microtrauma may have played a role in the etiology.
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Diagnostic Methods
Nasal endoscopy is the most important tool for diagnosis. The lesion usually has the following characteristics:
- Pediculated, lobulated, reddish-purple in color
- Easily bleeding
- Clearly raised from the mucosal surface
Imaging (especially CT or MRI) is preferred for large, deeply invaded or rapidly growing masses. However, direct endoscopic examination is sufficient in most cases.
Differential Diagnosis
- The following lesions should be considered in the differential diagnosis of nasal pyogenic granuloma:
- Hemangioma
- Nasal polyp
- Inverted papilloma
- Juvenile angiofibroma (especially in male adolescent patients)
- Nasal malignancies (e.g. nasal melanoma, SCC)
- Granulomatous diseases (Wegener, sarcoidosis)
Therefore, histopathological examination must be performed.
Treatment
The first choice in the treatment of nasal pyogenic granuloma is usually surgical excision. Excision performed endoscopically provides both diagnosis and treatment. Points to consider during surgery:
Complete excision of the lesion
If necessary, cauterization of the base with bipolar cautery (reduces recurrence)
Control of bleeding
Alternative treatments:
- Silver nitrate cauterization (in small lesions)
- Laser applications (CO2 or KTP laser)
- Topical medical agents such as timolol (especially tried in pediatric patients)
Recurrence and Follow-up
The recurrence rate of pyogenic granulomas is approximately 10–15%. Recurrence is usually seen in cases of:
- Incomplete excision
- Inadequate cauterization of the base
- Continued trauma.
Patients should be followed up endoscopically in the 1st, 4th and 12th weeks.
Nosebleeds may not always be due to a superficial cause. Rare lesions such as pyogenic granuloma seen in the anterior part of the right inferior turbinate can be recognized with careful endoscopic examination. Recognition and appropriate treatment of such cases is important both for rapid control of symptoms and prevention of possible recurrences. In this patient, a pyogenic granuloma was detected rather than a simple anterior septal hemorrhage. After surgical excision and cauterization, the patient did not experience a recurrence of the lesion. No nasal wedge was detected during the patient's follow-up examinations.
Search result link where you can find articles prepared by Dr. Murat Enöz about pyogenic granuloma and published on this website (you can also reach previous articles by clicking "more posts" at the end of the page) >> https://www.ent-istanbul.com/search?q=pyogenic+granuloma
Sources:
- Pagliai KA, Cohen BA. Pyogenic granuloma in children. Pediatr Dermatol. 2004;21(1):10–13. https://doi.org/10.1111/j.0736-8046.2004.21103.x
- Jafarzadeh H, Sanatkhani M, Mohtasham N. Oral pyogenic granuloma: a review. J Oral Sci. 2006;48(4):167–175. https://doi.org/10.2334/josnusd.48.167
- El Sayed Y, Al-Serhani AM. Lobular capillary hemangioma (pyogenic granuloma) of the nose. J Otolaryngol. 2001;30(5):304–307. https://pubmed.ncbi.nlm.nih.gov/11603767
- Lee CH, Chen MK. Lobular capillary hemangioma of the nasal cavity: a retrospective study of 15 cases. Am J Otolaryngol. 2006;27(5):343–346. https://doi.org/10.1016/j.amjoto.2005.11.008
Murat Enoz, MD, Otorhinolaryngology, Head and Neck Surgeon
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