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J Rhinol 16(1), 2009

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 turbinate 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 origin. The nasal cavity is a relatively rare location for pyogenic granulomas. The major causes of pyogenic granulomas have been suggested to include trauma or hormone
imbalances. Nasal packing is a common procedure for treating 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 turbinate.1-4) We present a patient with a pyogenic granuloma,
which was located on the middle turbinate, who had pituitary tumor surgery by an endoscopic sphenoid sinus approach one year ago.

CASE REPORT
A 74-year-old female was referred to the department of
Address correspondences and reprint requests to Jae Hoon Lee,
M.D., Department of Otolaryngology, Institute of Wonkwang Medical Science, Wonkwang University School of Medicine, Sinyongdong, 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

otolaryngology with a three-month history of nasal obstruction and intermittent anterior nasal bleeding. She complained of nasal obstruction becoming progressively more
severe over a three month period. Nasal endoscopy revealed 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 approach at another university hospital one year ago. She denied
having any nasal symptoms and did not have nasal problems at the time of her surgery. Coronal computed tomography of paranasal sinus showed a soft tissue mass arising
from the right middle turbinate (Fig. 2). Preoperative laboratory testing was normal and surgery was performed under general anesthesia. Using a 0telescope, the mass was
removed easily using suction cautery, unipolar electrocautery, 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 uneventful and the patient had no further complaints.

58

DISCUSSION
Pyogenic granuloma is commonly seen in the oral cavity,

LeePostoperative Pyogenic Granuloma / 59

Fig. 3. Histological examination of the pyogenic granuloma shows

lobular arrangement of larger vessels surrounded by variously
sized proliferated capillaries.
Fig. 1. A reddish mass with mild bleeding is shown in the right nasal cavity. Mmass.

Fig. 2. Coronal CT of paranasal sinus shows the soft tissue mass

from the right middle turbinate.

especially on the gingiva, but rarely in the nasal cavity. The

underlying cause of this lesion is thought to be local trauma to the skin or mucous membranes, which in turn triggers 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 commonly 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 reported 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 pituitary gland tumor surgery and/or postoperative packing.
According to Kerrs report,6) lesion formation varies between 1 week and 20 years. In the previous four cases attributed 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 Korean Literature, a case of pyogenic granuloma at the middle
turbinate was reported.7) But it may be not related to intraoperative 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 varyingsized capillaries in a lobular arrangement, often surrounded by a central caliber vessel.4) In the differential diagnosis,
Wegeners granulomatosis, hemangiosarcomas, angiosarcomas, 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. During the surgical extirpation, electrocautery instruments were
used and the mass was removed easily without any spe-

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 complication of trauma, such as intraoperative manipulation or
postoperative nasal packing. Pyogenic granulomas should
be considered in patients with epistaxis and nasal obstruction after nasal surgery.
Acknowledgments
This paper was supported by Wonkwang University in 2009.

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