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Pyogenic Granuloma of Nasal Septum

Authors:
Anuja Kulkarni at Jagjivan Ram Railway Hospital Mumbai
Anuja Kulkarni
  • Jagjivan Ram Railway Hospital Mumbai
Bachi T Hathiram at Topiwala National Medical College & B. Y. L. Nair Charitable Hospital
Bachi T Hathiram
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Abstract and Figures

Pyogenic granuloma also known as lobular capillary hemangioma is although rare but well-documented clinical entity. However, it is more commonly reported in cases pertaining to lesions of oral cavity and especially in female patients during pregnancy usually in third decade of life. But, here we report a very uncommon presentation of pyogenic granuloma arising from nasal septum in a 52-year-old male patient who presented to us with history of epistaxis and left-sided nasal obstruction since 4 months.
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Pyogenic Granuloma of Nasal Septum
Clinical Rhinology: An International Journal, September-December 2011;4(3):163-165 163
AIJCR
Pyogenic Granuloma of Nasal Septum
1Anuja Santosh Kulkarni, 2Bachi T Hathiram
1Assistant Divisional Medical Officer and Consultant, Department of ENT and Head and Neck Surgery, Jagjivan Ram Hospital
Mumbai, Maharashtra, India
2Professor and Head, Department of ENT and Head and Neck Surgery, BYL Nair Charitable Hospital and Topiwala National Medical College
Mumbai, Maharashtra, India
Correspondence: Anuja Santosh Kulkarni, Assistant Divisional Medical Officer and Consultant, c/o Santosh J Kulkarni, H. No. 809
Shri Yashwant Maharaj Mandir, Nashik-400001, Maharashtra, India, Phone: 9004490547, e-mail: dr.anujakulkarni@gmail.com
CASE REPORT
CASE REPORT
A 52-year-old male patient came with chief complaints of
history of epistaxis from left nostril since last 4 months
which was spontaneous in onset, moderate in amount, four
to five episodes per week stopped on conservative treatment.
This was associated with left-sided nasal blockage. There
was also history of mucoid, bloodstained discharge from
the left nostril as well as history of anosmia. There was
neither history suggestive of atrophic rhinitis nor that of
sinusitis. There was neither any history suggestive of
bleeding tendency nor that of jaundice. There was no history
of prolonged used of painkillers or any antiplatelet drugs in
the past. There was no history of major medical or surgical
illness in past.
On examination of nose, there was no external nasal
deformity. There was deviation of nasal septum toward right.
There was left middle turbinate hypertrophy. A pinkish
polypoidal pedunculated mass was present attached to
posterior aspect of nasal septum, insensitive to touch and
did not bleed on touch. Air blast was reduced on left side.
There was no paranasal sinus tenderness. On posterior
rhinoscopy, there was no abnormality detected. Ear and
throat examination did not reveal any abnormality.
Patient was investigated subsequently. Diagnostic nasal
endoscopy performed with zero degree endoscope which
revealed 2.4 × 0.5 × 2.5 cm sized pinkish, polypoidal, fleshy,
pedunculated mass attached to posterior aspect of nasal
septum; extended posteriorly up to nasopharynx; insensitive
to and did not bleed on touch (Fig. 1). Endoscopic excision
of mass with cauterization of base done; hemostasis achieved.
Mass was sent for histopathology and immunohistochemistry.
Pyogenic granuloma also known as lobular capillary hemangioma is although rare but well-documented clinical entity. However, it is more
commonly reported in cases pertaining to lesions of oral cavity and especially in female patients during pregnancy usually in third decade of
life. But, here we report a very uncommon presentation of pyogenic granuloma arising from nasal septum in a 52-year-old male patient who
presented to us with history of epistaxis and left-sided nasal obstruction since 4 months.
Keywords: Pyogenic granuloma, Lobular capillary hemangioma, Epistaxis.
ABSTRACT
Histology revealed lobular mass closed by stratified
squamous epithelium with focal bridging and ulceration.
Stroma showed fibroconnective tissue with plenty of
capillaries lined by flattened endothelial cells containing
RBCs. This was suggestive of lobular capillary hemangioma
also called as pyogenic granuloma (Figs 2 and 3).
On immunohistochemistry, the tissue was positive for
CD31 and CD34 markers both highlighting the endothelial
cell linings suggesting strong angiogenetic potential of mass
(Figs 4 and 5).
DISCUSSION
Pyogenic granuloma arising from the nasal septum is a very
rare clinical entity.1 Pyogenic granuloma also known as
lobular capillary hemangioma is more commonly reported
entity in cases of oral cavity lesions. It is predominantly
Fig. 1: Endoscopic appearance of pyogenic granuloma
10.5005/jp-journals-10013-1102
Anuja Santosh Kulkarni, Bachi T Hathiram
164 JAYPEE
Pyogenic granuloma is a misnomer as previously this
entity was thought to be caused due to bacterial infection
but it is not so. It is neither a true neoplasm too. It is caused
due to abnormal proliferation of capillaries in lobular
pattern.3-5 It is also one of the mimickers of Kaposis
sarcoma. Immunostaining for human herpesvirus 8 latent
nuclear antigen-1 helps to distinguish Kaposi sarcoma from
its mimickers.6 Among the various immunochemical
markers tried, this lesion is consistently positive for CD31
and CD34 markers as these markers selectively highlight
vascular endothelial cells.6-8 Local trauma or trauma due to
intubation is considered as one of the etiological factors.9
Presence of pyogenic granuloma causes recurrent unilateral
epistaxix and nasal obstruction. Differential diagnosis
includes hamartomas, venous hemangioma, arteriovenous
malformation, nasal polyp.
Conclusively, pyogenic granuloma should be considered
as one of the important clinical entity as a differential
diagnosis in a patient presenting with history of recurrent
nasal bleed.
REFERENCES
1. Yousry El-Sayeda1 CL, Al-Serhania Awad. Lobular capillary
haemangioma (pyogenic granuloma) of the nose. Journal of
Laryngology & Otology 1997;111:941-45.
2. Cengiz Ozcan, Düsmez Apa Duygu, Kemal Görür. Pediatric
lobular capillary hemangioma of the nasal cavity. Eur Arch
Otorhinolaryngol 2004;261(8):449-51.Epub 2003.
3. Yuan K, Wing LY, Lin MT. Pathogenetic roles of angiogenic
factors in pyogenic granulomas in pregnancy are modulated by
female sex hormones. J Periodontol 2002;73(7):701-08.
4. Sampurna Roy. Pathological case of the month: Diagnosis and
discussion; pyogenic granuloma of the tongue. Arch Pediatr
Adolesc Med 2001;155,1065-66.
5. Nair Lt Col S, Bahal Maj A, Bhadauria Col RS. Lobular capillary
haemangioma of the nasal cavity: Observation of three specific
cases. Acta Otorhinolaryngol Belg 2001;55(3):241-46.
6. Cheuk W, Wong KO, Wong CS, Dinkel JE, Ben-Dor D.
Immunostaining for human herpesvirus & latent nuclear antigen-1
Fig. 2: Photomicrograph of histological appearance of pyogenic
granuloma (lobular capillary hemangioma) of nasal septum H & E
staining (magnification 10×)
Fig. 3: Histological appearance of pyogenic granuloma of nasal
septum on higher magnification H & E staining (magnification 40×)
Fig. 4: Immunohistochemistry showing lesion positive for CD31
marker highlighting the endothelial linings
Fig. 5: Immunohistochemistry study showing lesion strongly
positive for CD34 marker highlighting endothelial cell linings
seen in female patients, usually in their third decade of life,
especially during pregnancy;2-4 hence, it is also known as
pyogenic granuloma gravidarum.
Pyogenic Granuloma of Nasal Septum
Clinical Rhinology: An International Journal, September-December 2011;4(3):163-165 165
AIJCR
helps distinguish kaposi sarcoma from its mimickers. Am J Clin
Pathol 2004;121(3):335-42.
7. Yuan K, Jin YT, Lin MT. The detection and comparison of
angiogenesis-associated factors in pyogenic granuloma by
immunohistochemistry. J Periodontol 2000;71(5):701-09.
8. Epivatianos A, Antoniades D, Zaraboukas T, Zairi E,
Poulopoulos A, Kiziridou A, et al. Pyogenic granuloma of the
oral cavity: Comparative study of its clinicopathological and
immunohistochemical features. Pathol Int 2005;55(7):
391-97.
9. Neves-Pinto RM, Carvalho A, Araujo E, Alberto C, Basilio-
De-Oliveira GA. Nasal septum giant pyogenic granuloma after
a long lasting nasal intubation: Case report. Rhinology Mar 2005;
43(1):66-69.
... The occurrence of TB and LEP granulomatous nasal disorders was the least among patients in this study with incidence rate between~1-2% only (Table 1, Figure 1A), mostly reported in females of lowsocioeconomic background, similar to that of RSC cases. Such a low prevalence of TB and LEP granulomatous nasal disorder have been reported previously in different Asian and Caucasian populations and therefore we have not subsequently focussed on these forms of granulomas (Foxen, 1979;Hassan and Goh, 2012;Kim et al., 2021;Kulkarni, 2011). Lastly, frequent occurrence of RSC, TB and LEP cases in middle-aged females (in comparison with age-matched males) suggest that the responsible pathogen for these cases is likely to be widely present in home or local community spaces in rural areas and lack of social and female hygiene could also play an important role (Cabral et al., 2022;Guarner, 2012;Pagan and Ramakrishnan, 2014;Ploemacher et al., 2020). ...
Systematic identification and characterization of clinical and socio-economical correlates of granulomatous nasal and para-nasal sinuses: A large-scale study among patients of Odisha, India
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Granulomatous formation in the nose and paranasal sinuses still presents an unmet clinical challenge as it affects both the physical health and personality of patients, and the lack of a systematic diagnostic and disease management approach has further complicated the scenario. Occurrence of granulomatous nasal disorder in the rural Indian population is associated with several factors such as lack of proper medical care, lack of hygienic and clean working and living conditions, and limited financial abilities to access the already overburdened primary healthcare system. This study aims to understand the correlation disease incidence, manifestation of signs and symptoms and associated socio-epidemiological parameters for 104,000 patients over a period of 23 months in Odisha. Primarily the study used socio-epidemiological surveys collected, annotated, and curated independently for granulomatous nasal disorder patients and compared this with their clinical records for signs & symptoms and performed several statistical analyses to better understand the disease incidence correlation with age, socio-economic and gender based parameters. Overall results suggest that males from low socio-economic background living in rural areas are the most vulnerable population and commonly affected with granulomatous nasal disorder (commonly Rhinosporidiosis sub-type) with common origin of the disease reported at the nasal septum and floor. We also highlight that change in the mass of nose followed by bleeds on touch, nasal discharge and hanging mass in throat are the most common manifestations presented by patients with granulomatous nasal disorders. Together, this research work identifies and characterise clinical and socio-economic factors that lead to and exacerbate the incidence of granulomatous nasal disorders.
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... The histologic features of lobular capillary hemangioma were quite similar to those of rapidly involuting infantile hemangioma in that both lesions were composed of lobules of capillaries and surrounding fibrous tissue, but were different from those of venous vascular malformation (also known as cavernous hemangioma), which were composed of dilated blood-filled spaces lined by flattened endothelium. 7,10,11 For atypical lesions, along with HPE, immunohistological markers such as CD31 and CD34 markers can be used to highlight the endothelial cell linings suggesting strong angiogenetic potential of mass, thus narrowing down the diagnosis to PG. 12 Magnetic resonance imaging and computed tomography (CT) were additional investigation of choice to see if there was any bony involvement and to rule out malignancies. CT features of LCH consisted of an intensely enhancing mass, whereas on a contrastenhanced CT, an iso or hypoattenuating cap of variable thickness around the intensely enhancing mass noted. ...
Septal pyogenic granuloma: a continuing riddle
Article
Full-text available
  • Nov 2021
p class="abstract">Pyogenic granuloma (PG) is a benign vascular lesion of the skin and mucous membranes commonly affecting the head and neck but less common in the nasal septum. Septal PG and can present with epistaxis and nasal obstruction. It is also called a lobular capillary hemangiomas (LCH) as histologically, pyogenic granuloma consists of circumscribed aggregates of capillaries arranged in lobules. Granulomatous lesions like Wegners granulomatosis, sarcoidosis and also tumours like squamous cell carcinoma, malignant melanoma can all mimic a septal PG. Surgical excision is the treatment of choice and diagnosis can be confirmed by histopathological examination. Complete resection can decrease the rates of recurrence. Here we reported a case of pyogenic granuloma of the nasal septum in a young female patient.</p
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The Detection and Comparison of Angiogenesis-Associated Factors in Pyogenic Granuloma by Immunohistochemistry
Article
Full-text available
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Pyogenic granuloma is a benign inflammatory lesion demonstrating obvious activity of angiogenesis. Female steroid hormones are believed to play important roles in the etiology because the lesion is frequently found in females with high levels of sex hormones. Few molecular mechanisms of the pathogenesis have been proposed and proven. The purpose of this study was to detect and compare the expression of angiogenesis-associated factors among healthy gingiva, gingiva from periodontitis, and pyogenic granuloma to clarify the pathogenesis of pyogenic granuloma. Fifteen specimens were collected from each of 3 groups of gingiva (healthy gingiva, periodontitis, and pyogenic granuloma). The subjects were age and gender matched. The specimens were processed for immunohistochemistry to detect and compare the expression of 2 angiogenesis enhancers, i.e., vascular endothelial growth factor (VEGF) and basic fibroblast growth factor (bFGF), 2 angiogenesis inhibitors, i.e., angiostatin and thrombospondin-1 (TSP-1), and estrogen receptor (ER). Using the subject as the unit of statistical analysis, either analysis of variance or chi-square analysis was employed to show the statistically significant difference at a level P <0.05. The pyogenic granuloma group expressed significantly more VEGF and bFGF than healthy gingiva and periodontitis. The positive staining of VEGF was mostly localized in the cytoplasm of macrophages and fibroblasts while that of bFGF was in the extracellular matrix of lamina propria. Angiostatin was expressed significantly less in pyogenic granuloma than the other 2 groups and was mostly localized in the nuclei of endothelial cells and epithelial cells. There was no significant difference in the expression of TSP-1 and ER among the 3 groups. The results of this research suggest that the etiology of pyogenic granuloma is due to the imbalance between angiogenesis enhancers and inhibitors. Whether and how the angiogenesis-associated factors are regulated by female steroid hormones remain to be answered.
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Lobular capillary haemangioma (pyogenic granuloma) of the nose
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To present a number of cases with lobular capillary haemangioma (pyogenic granuloma) of the nose; and to discuss the clinical and histopathological diagnosis of this disorder. A clinicopathological study of patients diagnosed with nasal lobular capillary haemangioma who were treated at King Abdel Aziz University Hospital, Riyadh from 1986 to 1995. The study group consisted of 12 patients (four males and eight females ranging in age from 17 to 65 years; mean 30.1 years). Clinically, most patients presented with epistaxis and a rapidly growing unilateral haemorrhagic mass. Most lesions were located on the septal mucosa. The clinical impression was misleading in some cases. The histological diagnosis was based on the lobular arrangement of capillaries. One case was initially misdiagnosed as angiofibroma. Excisional biopsy was the mainstay of treatment. One instance of recurrence was recorded. This uncommon lesion should be considered in the differential diagnosis of a rapidly growing haemorrhagic lesion within the nasal fossa. Clinical and histological diagnostic pitfalls occur frequently.
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Lobular capillary haemangioma of the nasal cavity: Observation of three specific cases
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Lobular Capillary Haemangioma of the nasal cavity: Observation of three specific cases. Lobular Capillary Haemangioma, unproperly called "Pyogenic granuloma", is a benign vascular tumour pedunculated on the skin and on mucous membranes of the oral and nasal cavities. Microtrauma and pregnancy are the most often evocated aetiologic factors. Epistaxis and nasal obstruction are the most marked symptoms of this irregular and friable mass. We report three cases (two adult and one paediatric) of this pathology. Two have as trigger factor a nasal microtrauma, the third an oestro-progestative impregnation. A clinical, radiological and histological description allows us to expose the characteristics of this lesion that remains obscure to many rhinologists. Lobular Capillary Haemangioma has to be evocated in the differential diagnosis of each haemorrhagic endonasal mass.
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Pathogenetic Roles of Angiogenic Factors in Pyogenic Granulornas in Pregnancy Are Modulated by Female Sex Hormones
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Nasal septum giant pyogenic granuloma after a long lasting nasal intubation: Case report
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