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J Rhinol 16(1), 2009 www.ksrhino.or.kr

A Case of Postoperative Pyogenic Granuloma at the Middle Turbinate

Jae Hoon Lee, MD

Department of Otolaryngology, Institute of Wonkwang Medical Science, Wonkwang University School of Medicine, Iksan, Korea

ABSTRACT Pyogenic granuloma is a benign, vascular lesion of unknown etiology that occurs uncommonly in the nose. Trauma and hormonal

factors are considered major causes of pyogenic granuloma. Nasal packing is a very common procedure in rhinology and this procedure might be related to the development of pyogenic granulomas. The most frequent symptoms of pyogenic granulomas are epistaxis and nasal obstruction. This report represents the second case of pyogenic granuloma occurring at the middle tur-binate in the English literature and it may have arisen secondary to postoperative nasal packing or intraoperative trauma. KEY WORDSPyogenic granulomaMiddle turbinateEpistatxisNasal obstruction.

INTRODUCTION

Pyogenic granuloma, also known as lobular capillary hemangioma, is a benign vascular lesion of unknown ori-gin. The nasal cavity is a relatively rare location for pyo-genic granulomas. The major causes of pyogenic granulo-mas have been suggested to include trauma or hormone imbalances. Nasal packing is a common procedure for tre-ating epistaxis or postoperative hemostasis, and four cases of pyogenic granulomas have been reported in the English literature as complications of nasal packing. Among the four lesions, the inferior turbinate was the location of three lesions and one lesion was located on the middle turbi-nate.1-4) We present a patient with a pyogenic granuloma, which was located on the middle turbinate, who had pitu-itary tumor surgery by an endoscopic sphenoid sinus ap-proach one year ago.

CASE REPORT

A 74-year-old female was referred to the department of

otolaryngology with a three-month history of nasal ob-struction and intermittent anterior nasal bleeding. She com-plained of nasal obstruction becoming progressively more severe over a three month period. Nasal endoscopy reveal-ed a lobulated, fragile, and reddish mass filling the right nasal cavity (Fig. 1). Her otolaryngologic examination was otherwise normal. She had undergone pituitary gland tumor surgery by a right endoscopic sphenoid sinus appro-ach at another university hospital one year ago. She denied having any nasal symptoms and did not have nasal prob-lems at the time of her surgery. Coronal computed tomog-raphy of paranasal sinus showed a soft tissue mass arising from the right middle turbinate (Fig. 2). Preoperative lab-oratory testing was normal and surgery was performed un-der general anesthesia. Using a 0telescope, the mass was removed easily using suction cautery, unipolar electrocau-tery, and various nasal forceps. The bleeding from the mass was minimal. The 201515 mm mass originated from the posterior portion of the right middle turbinate. After the mass was removed, a right widened sphenoid sinus ostium was visible. Pathologic examination confirmed a pyogenic granuloma with proliferating blood vessels of various sizes (Fig. 3). The postoperative course was une-ventful and the patient had no further complaints.

DISCUSSION

Pyogenic granuloma is commonly seen in the oral cavity,

Address correspondences and reprint requests to Jae Hoon Lee, M.D., Department of Otolaryngology, Institute of Wonkwang Med-ical Science, Wonkwang University School of Medicine, Sinyong-dong, Iksan 570-749, Korea Tel82-63-859-1441, Fax82-63-841-6556 E-mailnose-1023@hanmail.net Received for publication on August 27, 2008 Accepted for publication on October 2, 2008

LeePostoperative Pyogenic Granuloma / 59

especially on the gingiva, but rarely in the nasal cavity. The underlying cause of this lesion is thought to be local trau-ma to the skin or mucous membranes, which in turn trig-gers an inflammatory response. Trauma induced by picking at the nasal mucosa is the most common cause of pyogenic granulomas. Nasal packing is a very common procedure for nasal bleeding and postoperative hemostasis and some publications have reported this lesion as a complication of nasal packing.1-4) Within the nasal cavity, this lesion com-monly occurs in the anterior portion of the nasal septum (Littles area), and less frequently on the anterior portion of the inferior turbinate.5) These areas are apt to be dam-

aged by trauma induced by picking or nasal procedures, such as nasal packing or electrocautery. In the case report-ed herein, the lesion originated from the posterior aspect of the middle turbinate. The cause of this case is presumed to have resulted from iatrogenic damage during the pitui-tary gland tumor surgery and/or postoperative packing. According to Kerrs report,6) lesion formation varies be-tween 1 week and 20 years. In the previous four cases at-tributed to nasal packing, these lesions developed between 2 weeks and 3 months.1-4) In the patient reported herein, the lesion was detected one year after surgery. In the Ko-rean Literature, a case of pyogenic granuloma at the middle turbinate was reported.7) But it may be not related to in-traoperative trauma and/or nasal packing. Sometimes, it might be difficult to find out the predisposing factor of the pyogenic granuloma.

The most common presenting symptom associated with nasal pyogenic granuloma is epistaxis. Nasal obstruction, nasal discharge, and epiphora are other symptoms. In our case, the major symptom was nasal obstruction, which could be related to the increase in the size of the mass.

Pathologically, the lesion is characterized by varying-sized capillaries in a lobular arrangement, often surround-ed by a central caliber vessel.4) In the differential diagnosis, Wegeners granulomatosis, hemangiosarcomas, angiosar-comas, Kaposis sarcomas, and hemangiosarcomas should be considered.3)

The treatment is surgical excision and recurrences are rare. In the case reported herein, a preoperative biopsy was not done because of the vascular nature of the mass. Dur-ing the surgical extirpation, electrocautery instruments were used and the mass was removed easily without any spe-

Fig. 1. A reddish mass with mild bleeding is shown in the right na-sal cavity. Mmass.

Fig. 2. Coronal CT of paranasal sinus shows the soft tissue massfrom the right middle turbinate.

Fig. 3. Histological examination of the pyogenic granuloma showslobular arrangement of larger vessels surrounded by variously sized proliferated capillaries.

60 / J Rhinol 16(1), 2009

cific problems, such as significant bleeding. This is the case of pyogenic granuloma on the middle

turbinate. This lesion can arise in the nasal cavity as a com-plication of trauma, such as intraoperative manipulation or postoperative nasal packing. Pyogenic granulomas should be considered in patients with epistaxis and nasal obstruc-tion after nasal surgery. Acknowledgments This paper was supported by Wonkwang University in 2009.

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2) Sheen TS, Ko JY, Hsu YH. Pyogenic granuloma-an uncommon com-plication of nasal packing. Am J Rhinol 1997;11:225-7.

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4) Kurtaran H, Uraldi C, Ark N, Aktas D. Lobular capillary haemanigio-ma of the middle turbinate. Acta otolaryngologica 2006;126:442-4.

5) El-Sayed Y, Al-Serhani A. Lobular capillary haemanigioma (pyogen-ic granuloma) of the nose. J Laryngol Otol 1997;111:941-5.

6) Kerr DA. Granuloma pyogenicum. Oral Surg Oral Med Oral Pathol 1951;4:158-76.

7) Heo KW, Kwon CH, Lee SR, Chang HJ. A case of concurrent oste-oma and lobular hemangioma of the middle turbinate. Korean J Oto-laryngol 2006;49:339-42.