Pyogenic granuloma is a rapidly growing hyperplastic, vascular proliferation of the skin or mucous membrane. A benign lesion of unknown aetiology commonly associated with pregnancy, oral contraceptives and trauma. While lesions occur frequently in oral cavity, occurrence in the nasal septum is rarely reported. We report a case of 38-year-old male (known case of active pulmonary tuberculosis on anti-tubercular therapy) who presented with unilateral pyogenic granuloma of the anterior nasal septum with unilateral nasal obstruction. We emphasize that the rarely seen lobular capillary hemangioma (pyogenic granuloma) must be kept in mind in the differential diagnosis of a rapidly growing mass of the nasal cavity, even without history of epistaxis. Here we report an uncommon case and review current literature regarding aetiology, site and role of rifampicin in pyogenic granuloma.
Pyogenic granuloma of nasal cavity is also known as lobular capillary hemangioma, epulis gravidarum, eruptive hemangioma, granulation tissue-type hemangioma, granuloma gravidarum, pregnancy tumour, botryomycome [
A 38-year-old male presented with nasal obstruction and a visible mass in the left nasal cavity of two weeks duration. He complained of nasal obstruction due to the increasing size of mass becoming progressively severe over a week period. There was no history of trauma, nasal packing and/or irritation. The patient was on anti-tubercular therapy (ATT) for pulmonary tuberculosis as per RNTCP (Revised National Tuberculosis Control Program) guidelines of a “new case”. He had completed a 2 months intensive phase of ATT which included- Isoniazid (300 mg), Rifampicin (450 mg), Pyrazinamide (1500 mg) and Ethambutol (1200 mg) thrice-weekly. This was to be followed by a continuation phase of Rifampicin (450 mg), and Pyrazinamide (1500 mg) for a period of 6 months thrice-weekly. The patient at the time of presentation was on the 3rd month of continuation phase. Physical examination revealed a large, dark reddish polypoid mass in the left nasal cavity, insensitive to touch and this did not bleed on manipulation. It originated from the anterior portion of the septal mucosa about 3 mm posterior to the left vestibule, extended to the nasal vestibule completely obstructing the nasal orifice (Fig- ure 1). Complete removal of nasal mass was done under local anesthesia by cauterization of the base with a unipolar electro-cautery with minimal blood loss. The mucosal defect thus created was 2 mm × 1 mm in size; thedefect was left for free epithelialization. On gross examination, a smooth-surfaced, grayish-pink polypoid mass was approximately 10 × 15 × 5 mm in size (
Pyogenic granuloma was first described as “human botryomycosis” by Poncet and Dor in 1897, and later in 1974 Haetzell coined the term “pyogenic granuloma” [
Arrow showing dark reddish polypoid mass in the left nasal cavity
A smooth-surfaced, greyish-pink polypoid mass meas- uring approximately 10 × 15 × 5 mm
Histology showing lobules of dilated and congested capillaries with profound inflammatory cell infiltration (H & E) in 40× and 100× respectively
178 patients, reported that the head and neck area, particularly the oral cavity accounted for the most common sites involved (62.4%) [
The pathogenesis of pyogenic granuloma still remains unclear [
Pyogenic granuloma occurs at all ages, but more often in the third decade, and is more common in females. In the paediatric age group, pyogenic granuloma commonly affects males [
Symptomatic manifestations of pyogenic granuloma include unilateral epistaxis (95%), nasal blockage (35%), rhinorrhoea (10%), facial pain (7.5%), headache and hyposmia (4%) [
Complications of pyogenic granuloma are cosmetic and functional. They depend on the location, size or rapid proliferating phase of the neoplasm. Some type of complication is found in 40% of lesions, the commonest being bleeding (75%) and ulceration (21%) [
The differential diagnosis of tubercular intranasal pyogenic granuloma which includes nasal polyp, sarcoidosis, Wegener’s granulomatosis, simple granulation tissue, papilloma, Kaposi’s sarcoma, squamous cell carcinoma, mucosal malignant melanoma and lymphoma.
Radiological evaluation (computed tomography or magnetic resonance imaging) is only indicated has as complementary test to nasal endoscopic examination in large lesions especially those involving the skull base, or rapidly enlarging mass with evidence of bony erosion to exclude malignancy [
Total excision of the lesion by either classical or endoscopic surgery techniques has been recommended [
Michel Noubom et al. [
We have reviewed the literature of pyogenic granuloma of nasal septum and reported a rare case of nasal septum pyogenic granuloma in an adult male with active pulmonary tuberculosis on anti-tubercular treatment. Failure to recognize the clinical features and histopathological characteristics can lead to confusion with other forms of hemangioma or granulating lesions. Complete excision can be curative. The role of rifampicin and its dosage still requires further study before establishing it as a recognized treatment option. Therefore, pyogenic granuloma should be considered in the differential diagnosis of any anterior nasal septum mass even without associated epistaxis.