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A Case of Giant Nasal Pyogenic
Granuloma Gravidarum
Sunil Choudhary, MBBS, MS, FRCSEd,*
Craig A. MacKinnon, MBChB, FRACS,*
Graham P. Morrissey, MBChB, FRACS,*
†
Swee T. Tan, MBBS, FRACS, PhD*
Wellington, New Zealand
Abstract: Pyogenic granuloma gravidarum occurs as oral or nasal
lesions in approximately 5% of pregnant women. Nasal mucosa is
an unusual site for this lesion with few cases reported in the lit-
erature. A case of giant nasal pyogenic granuloma gravidarum
that required radical excision through an open rhinotomy after
superselective embolization is described. The patient had a good
cosmetic result and a satisfactory airway when she was seen for
follow-up 1 year after surgery. Giant pyogenic granuloma gravi-
darum is best managed with a multidisciplinary approach involv-
ing radical excision after preoperative superselective embolization
for safe and complete removal of the lesion.
Key Words: Embolization, nasal, pregnancy, pyogenic
granuloma gravidarum, treatment
Pyogenic granuloma gravidarum (pregnancy tu-
mor) is a benign fibrovascular lesion with exten-
sive endothelial proliferation occurring in pregnant
women. It involves the oral gingiva most commonly,
although it is also known to occur on the lips, tongue,
buccal mucosa, and palate. Although nasal mucosa is
not an uncommon site for this lesion, it is quite rare
for them to reach giant proportions, with only two
such cases reported in the literature.
1,2
Most of these lesions are small, and they nor-
mally involute spontaneously after childbirth. Sur-
gery usually is deferred until after delivery and is
reserved for cases that fail to regress completely. In-
complete excision of these lesions is associated with
a high rate of recurrence.
3
Most lesions are small and
can be simply excised. To our knowledge there is
only one report in the literature of a large lesion that
warranted preoperative selective embolization.
4
We
describe an unusual case of a giant pyogenic granu-
loma gravidarum occurring in the nasal fossa that
required preoperative superselective embolization
and removal via an external rhinotomy approach.
CASE REPORT
A 34-year-old woman was referred to our service
immediately after delivery with a large exophytic le-
sion in her left nasal cavity associated with nasal
obstruction and episodes of severe epistaxis. The le-
sion had slowly enlarged during her pregnancy and
had reduced slightly in size after delivery.
Endoscopic examination showed that the lesion
was occupying the whole of the left nasal cavity,
displacing the nasal septum markedly to the oppo-
site side with bilateral nasal obstruction. Histologic
findings of a biopsy of the lesion showed features of
a fibrous nasal polyp, although the lesion bled pro-
fusely after biopsy. A computed tomography scan
and a magnetic resonance imaging (MRI) scan with
gadolinium enhancement revealed a 4- ×5-cm hy-
pervascular lesion arising from the inferior turbinate
and occupying the whole of the left nasal cavity (Fig
1). The lesion was well circumscribed with no evi-
dence of bony erosion, suggesting a benign nature.
A superselective angiogram confirmed the hy-
pervascularity of the lesion, which was supplied by
branches of the left internal maxillary artery (Fig 2).
The lesion was excised via a lateral rhinotomy ap-
proach 6 weeks after deliver, following superselec-
tive embolization 2 days before surgery. The embo-
lization resulted in marked reduction of the size of
the lesion to approximately half of its original dimen-
sion. Intraoperatively, a partially involuted polypoid
lesion measuring 2.5 ×2.5 cm arising from the ante-
rior two thirds of the inferior turbinate was noted.
There was marked deviation of the entire nasal sep-
tum caused by a mass effect of the lesion, which was
excised with part of the inferior turbinate (Fig 3) with
From the *Head & Neck and Skull Base Surgery/Oncology Pro-
gramme, Wellington Regional Plastic, Maxillofacial & Burns
Unit,
†
Department of Otolaryngology, Hutt Hospital, Wellington,
New Zealand.
Address correspondence and reprint requests to Dr. Tan, Wellington
Regional Plastic, Maxillofacial & Burns Unit, Hutt Hospital, PO
Box 91 907, Lower Hutt, New Zealand; e-mail: sweetan@plastsurg.
co.nz.
GIANT NASAL PYOGENIC GRANULOMA GRAVIDARUM / Choudhary et al
319
minimal bleeding. A standard septoplasty was also
performed.
RESULTS
The histologic analysis of the lesion showed surface
hemorrhage, stromal sclerosis, relatively acellular
stroma, and thin walled ectatic blood vessels in a
lobular arrangement, and there was no evidence of
mitotic activity. These features were those of a pyo-
genic granuloma gravidarum (Fig 4). Both estrogen
and progesterone receptor assays were negative.
The postoperative course was uneventful. The
patient had a satisfactory airway and good cosmetic
result when she was reviewed 1 year after surgery.
DISCUSSION
Pyogenic granuloma gravidarum occurs as oral or
nasal lesions in approximately 5% of pregnant
women.
5
It is histologically indistinguishable from
pyogenic granulomas that occur in males and non-
pregnant females. A variety of etiologic factors have
been proposed, but most authors believe in a multi-
factorial etiology,
3,5
including poor oral hygiene, lo-
cal irritation by plaque/calculus, and hormonal
changes during pregnancy.
Pyogenic granuloma gravidarum has been at-
tributed to an exaggerated response to local recur-
rent irritants brought about by elevated levels of cir-
culating sex hormones.
5
The levels of estrogen or
progesterone receptors in such lesions have been
shown to be similar to the lesions occurring in males
or nonpregnant females, as was our case.
6
However,
the levels of estrogen and progesterone are markedly
elevated during pregnancy and thus could stimulate
the endothelial proliferation of mucosal surfaces in
the oral and nasal cavities.
Surgical treatment of pyogenic granuloma
gravidarum usually is deferred until after childbirth
and is reserved for lesions that fail to regress com-
pletely.
3,4
Most of these lesions are small and can be
Fig 2 A superselective angiogram showing the pyogenic
granuloma gravidarum being supplied by branches of the
left internal maxillary artery (A) before and (B) after em-
bolization.
Fig 1 Contrast enhanced T
1
-weighted MRI axial scan
showing a large lesion occupying the left nasal fossa and
causing marked deviation of the nasal septum and bilateral
nasal obstruction. The lesion shows high signal intensity
with flow voids indicating hypervascularity and also an
area of low enhancement anteriorly corresponding to an
area of partial involution (arrow) seen at operation.
THE JOURNAL OF CRANIOFACIAL SURGERY / VOLUME 16, NUMBER 2 March 2005
320
treated by simple intranasal excision. There are very
few reports of giant nasal pyogenic granuloma gravi-
darum.
1,2
To our knowledge, the case presented here
has the largest dimension. Such gigantic lesions can
be confused with malignancies, and an incomplete
excision is associated with a high recurrence rate. A
multidisciplinary approach is needed for such gigan-
tic lesions. This involves preoperative superselective
embolization and excision by an open rhinotomy ap-
proach for safe and complete removal.
Acknowledgment: The authors thank their colleagues Dr. Trevor
FitzJohn, consultant interventional radiologist, and Dr. Judith
Wishart, consultant histopathologist, for their assistance in man-
aging this case.
REFERENCES
1. Lance E, Schatz C, Nach R, et al. Pyogenic granuloma gravi-
darum of the nasal fossa: CT features. J Comput Assist To-
mogr 1992;16:663–664
2. Lim IJ, Singh K, Prasad RN, et al. ‘Pregnancy tumor’of the
nasal septum. Aust NZ J Obstet Gynaecol 1994;34:109–110
3. Ong MA, Chai WL, Ngeow WC. Recurrent gigantic pyogenic
granuloma disturbing speech and mastication: a case report
and literature review. Ann Acad Med Singapore 1998;27:258–
261
4. Forman D, Goldberg HI. Microembolization and resection of a
highly vascular pyogenic granuloma. J Oral Maxillofac Surg
1990;48:415–418
5. Mussalli NG, Hopps RM, Johnson NW. Oral pyogenic granu-
loma as a complication of pregnancy and the use of hormonal
contraceptives. Int J Gynaecol Obstet 1976;14:187–191
6. Whitaker SB, Bouquot JE, Alimario AE, et al. Identification
and semiquantification of estrogen and progesterone recep-
tors in pyogenic granulomas of pregnancy. Oral Surg Oral
Med Oral Pathol 1994;78:755–760
Treatment of Recalcitrant
Idiopathic Muscular Torticollis
in Infants with Botulinum Toxin
Type A
Michelle B. Joyce, MBChB,* Tristan M. B. de
Chalain, Msc, MBChB, FRCSC, FRACS
†
Auckland, New Zealand
Congenital muscular torticollis (CMT) is the most common form
of torticollis in children, significantly outnumbering orthopedic,
neurologic, and ocular causes. CMT may present as a palpable
sternomastoid tumor (SMT) or a simple tightness of the sterno-
cleidomastoid muscle (SCM), designated as idiopathic muscular
torticollis (IMT). Muscular torticollis has been associated with po-
sitional plagiocephaly in neonates who slept in the supine posi-
tion. We have had difficulty in treating some of these combined
cases by traditional methods such as physiotherapy, stretching
exercises, and molding helmets. In November 2000, we began in-
jecting botulinum toxin type A in cases in which there was per-
sistent IMT, despite significant physical therapy input. The 15
patients included in this retrospective study all presented with
IMT and positional plagiocephaly; all had responded poorly to
conservative treatment, including physiotherapy, stretching exer-
From the *Department of Plastic and Reconstructive Surgery,
Middlemore and Kidz First Hospitals, Auckland, New Zealand,
and the
†
Regional Center for Plastic Surgery, Middlemore Hospi-
tal and The University of Auckland, Auckland, New Zealand.
Address correspondence to Mr. Tristan de Chalain, Regional
Center for Plastic Surgery, Middlemore Hospital, Private Bag
93311, Otahuhu, Auckland, New Zealand. E-mail: dechalain@
middlemore.co.nz
Fig 3 The operative specimen, including a partial inferior
turbinectomy. Note the area of partial involution (arrow).
Fig 4 Hematoxylin and eosin stain (original magnifica-
tion, ×10) of the lesion showing stromal sclerosis and thin-
walled ectatic blood vessels in a lobular arrangement, all of
which are typical features of a pyogenic granuloma gravi-
darum.
TREATMENT OF IDIOPATHIC MUSCULAR TORTICOLLIS / Joyce and de Chalain
321
