Giant nasal granuloma gravidarum
- 1 Surgery, New York Hospital Queens, New York, New York, USA
- 2 Pathology, Acupath Laboratories Inc, Plainview, New York, USA
- Correspondence to Professor Larry Shemen; lshemen@gmail.com
Abstract
Nasal granuloma gravidarum usually presents as a small vascular lesion on the septum or turbinates during pregnancy. We present a case of a giant nasal granuloma gravidarum and its management.
Background
The hyper-hormonal state of pregnancy causes engorgement of tissues naturally endowed with a rich vascular supply. An untoward occurrence during pregnancy is the development of a nasal granuloma gravidarum which can cause epistaxis, nasal irritation or nasal obstruction.
The nomenclature of ‘granuloma’ is inaccurate as it truly represents a lobular capillary hemangioma and is a proliferation rather than a neoplasm. Nevertheless, the literature continues to use the misnomer.
During the COVID-19 pandemic, many patients have either avoided physician visits or their physician’s offices were shuttered or not offering services. As a result, many common conditions, which are usually detected when small and easily treated, during the pandemic, have presented in much more advanced stages.
Herein, a case of an unusually large granuloma gravidarum is presented.
Case presentation
A 30-year-old 38-week pregnant G0P0 (gravida 0, para 0) woman presented with a 2-month history of a right nasal sill lesion which was causing profuse epistaxis and nasal obstruction. She had contacted several physicians regarding both the pregnancy and the mass, but they either declined to remove the lesion or their offices were closed during the pandemic. When she ultimately presented to this office, examination disclosed a 2.5 cm friable, exophytic mass emanating from the right nasal sill (figures 1 and 2). This was excised without incident under local anaesthesia (figure 3). The pathological examination confirmed granuloma gravidarum. She healed without incident.
Anteroposterior view of lesion emanating from right nose.
Tilted view of lesion emanating from right nose.
Specimen.
Investigations
Microscopic examination disclosed an exophytic growth of capillaries and venules, some in lobules, separated by fibrous trabeculae associated with stromal oedema and a mixed inflammatory cell infiltrate (figures 4–6).
Histologic view 10×.
Histologic view 20×.
Histologic view 40×.
Differential diagnosis
The differential diagnosis for this tumour includes non-neoplastic masses such as polyps, rhinoscleroma, sarcoidosis, mycobacterium or other granulomatous processes; benign neoplastic masses such as hemangioma, angiofibroma, inverting papilloma or mucocele; malignant masses such as hemangiopericytoma, squamous cell carcinoma, esthesioneuroblastoma, nasal lymphoma, rhabdomyosarcoma, melanoma or adenocarcinoma.1
Treatment
Complete surgical excision is the treatment of choice.
Outcome and follow-up
The patient recovered uneventfully and delivered a healthy baby girl several weeks later.
Discussion
Granuloma gravidarum is a benign, fibrovascular lesion otherwise classified as hemangioma, which enlarges under the effect of the hyper-hormonal milieu of pregnancy. The head and neck lesions can arise anywhere in the oral or nasal cavities with the presenting symptoms of bleeding or mass with irritation or obstruction.2 3 The prevalence has been reported as .5%–5% of all pregnancies.4 Most patients present later in their pregnancy.5
Some authors suggested that pre-existing nasal trauma (such as forceful blowing or picking) or cold weather may stimulate the development of the granuloma.6
Imaging studies are usually unnecessary unless the lesion is situated deep in the nasal cavity or nasopharynx. CT features are a well-defined mass while MRI shows the lesions to be hyperintense on T2 and hypointense on T1.7 When advanced, the lesions may cause bone erosion.8
The clinical findings are usually a small (<1 cm), smooth, spherical, erythematous, friable mass. These lesions should be excised, if feasible, under local anaesthesia so as to rectify the bleeding or obstruction. On the other hand, if the patient prefers to wait, the lesion may spontaneously regress following delivery.
During the COVID-19 pandemic, with lockdowns prohibiting travel, many patients have avoided or were unable to visit their physicians. As a result, many patients are now presenting with advanced or enlarged lesions that would otherwise be detected at a far earlier stage. In this case, the patient had tried to have the lesion removed earlier, when smaller, but either the medical offices were closed or the physicians declined to remove the lesion. As a result, she presented with an unusually large lesion.
Histologically, granuloma gravidarum or lobular capillary hemangioma is a common vascular proliferation, probably non-neoplastic, which appears as an elevated dark red lesion. The pathological features include numerous neoformed vessels separated from each other by an inflamed and edematous stroma. They may also contain foamy histiocytes. The lesion is usually partially ulcerated. These features, in fact, closely resemble those of a pyogenic granuloma.
Patient’s perspective
This lesion was causing me much trouble. I am glad that it was removed.
Learning points
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Granuloma gravidarum is a nasal lesion seen commonly during late gestation.
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It may cause epistaxis, irritation or nasal obstruction.
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These lesions may spontaneously involute after delivery. However, if symptomatic, the lesion should be excised under local anaesthetic.
Footnotes
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Contributors LS have treated the patient, wrote and researched the paper and took the clinical photographs. OF read the pathology and wrote the pathological description and made the photomicrographs.
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Funding The authors have not declared a specific grant for this research from any funding agency in the public, commercial or not-for-profit sectors.
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Competing interests None declared.
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Patient consent for publication Obtained.
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Provenance and peer review Not commissioned; externally peer reviewed.
- © BMJ Publishing Group Limited 2020. No commercial re-use. See rights and permissions. Published by BMJ.
References
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