Pyogenic Granuloma in the Sinonasal Cavity: A Potential 38-Year Latency Following Foreign Body Entrapment

Abstract

Background

Lobular capillary hemangioma (LCH), also known as pyogenic granuloma (PG), is a benign vascular lesion typically associated with minor trauma or irritation, predominantly occurring in the oral cavity and in females. Its sinonasal occurrence, particularly in males, is rare, and an association with remote childhood trauma remains a speculative hypothesis. Clinically, it must be differentiated from other vascular sinonasal lesions such as angiofibroma, hemangioma variants, and malignant mimics.

Case Presentation

This rare case report descripts a highly unusual case of an inflammatory nasal mass in a 43-year-old male who presented with left-sided nasal obstruction, rhinorrhea, and hyposmia for two months. Endoscopic evaluation and CT/MRI revealed a highly vascular mass attached to the left middle turbinate. Notably, the patient had a history of foreign body entrapment in the left nasal cavity at the age of 5, which was removed without immediate complications. This suggests a potential association between the initial trauma and the subsequent manifestation of the lesion after a 38-year latency period. The mass was successfully excised en bloc through endoscopic surgery.

Conclusion

This case highlights a potential, albeit rare, etiological association for sinonasal PG, raising the hypothesis that past mucosal trauma, such as a foreign body, may contribute to the delayed formation of vascular lesions decades later, particularly in a male patient at an unusual nasal site. A comprehensive diagnostic workup, including imaging and histopathology, is essential to confirm the diagnosis and ensure complete surgical management. The patient remained asymptomatic with no recurrence observed at one-year follow-up.

Introduction

Pyogenic granuloma (PG), histopathologically known as lobular capillary hemangioma (LCH), is a benign, rapidly growing vascular proliferative lesion affecting mucosal and cutaneous sites.^1,2 Although predominantly recognized in the oral cavity—accounting for approximately 75% of oral mucosal reactive lesions with a marked female predilection^3,4—PG is increasingly identified within the sinonasal cavity, representing a distinct clinical entity.^5,6

In the sinonasal tract, the most common site of origin is the anterior nasal septum (specifically Little’s area/Kiesselbach’s plexus), followed by the anterior portion of the inferior turbinate.^6,7 Occurrence on the middle turbinate or within the paranasal sinuses is exceptionally rare, frequently posing diagnostic dilemmas that mimic other benign or malignant hypervascular lesions.^7,8

The etiology of sinonasal PG remains incompletely elucidated; however, it is widely regarded as a reactive hyperplastic vascular response to chronic irritation, microtrauma, hormonal fluctuations (such as elevated estrogen and progesterone during pregnancy), or prior instrumentation.^6,9,10 Recognized local triggers in the nasal cavity include habitual digital manipulation (nose picking), repetitive nasal packing, chronic rhinosinusitis, and foreign body lodgment.^6,11,12

When induced by mechanical trauma or retained foreign bodies, vascular proliferation typically manifests within a short timeframe ranging from several weeks to a few months.^6,11 Although delayed foreign body granulomatous reactions or rhinolith-induced lesions have been reported years after exposure, bibliographic documentation of an asymptomatic latency period spanning nearly four decades (38 years) following foreign body removal is extraordinarily rare.^11,13

Here, we report a rare case of sinonasal pyogenic granuloma originating from the left middle turbinate in a 43-year-old male with a documented history of nasal foreign body entrapment at age 5. This report provides a detailed clinical, radiological, and histopathological evaluation, highlighting the diagnostic challenges and surgical management of this unusual presentation while discussing the potential association with remote mucosal trauma.

Case Report

A 43-year-old male presented with complaints of left-sided nasal congestion and rhinorrhea that had persisted for two months. The associated symptoms included a reduction in olfactory function (hyposmia) without any accompanying nasal symptoms such as epistaxis, facial pain, or pressure. There were no other illnesses documented in his medical history. According to patient and parental recollection (without surviving contemporaneous paediatric records), the patient experienced foreign body entrapment (a small plastic bead) in the left nasal cavity at age 5, which had been retained for a few days before being uneventfully extracted in an outpatient setting.

Due to the prolonged and unilateral symptoms, the patient underwent a thorough evaluation, which included imaging and endoscopy. The endoscopic examination revealed a leftward septal deviation and a haemorrhagic, crusted mass attached to the anterior medial aspect and free border of the left middle turbinate. Purulent secretions in the nasopharynx indicated either an infectious or inflammatory process (Figure 1).

Figure 1.

Preoperative endoscopy. Endoscopic view of the left nasal cavity showing a large, hemorrhagic mass originating from the middle turbinate, with concurrent septal deviation and purulent nasopharyngeal secretions.

Preoperative non-contrast CT imaging demonstrated a heterogeneous, well-defined expansile soft-tissue opacity in the left nasal cavity, extending from the anterior portion of the left middle and inferior turbinates to the posterior choana. The mass-like lesion occupied the left nasal cavity, abutting the nasal septum and the lamina papyracea, with remodeling of adjacent ethmoidal trabeculae and thinning of the lamina papyracea, but without frank osteolytic destruction or skull base erosion (Figure 2). Subsequent contrast-enhanced MRI confirmed the presence of a markedly enhancing vascular mass in the left nasal cavity, with no direct invasion into the intraorbital or intracranial compartments. Additionally, it revealed secondary retained secretions in the anterior ethmoid and maxillary sinuses due to mechanical obstruction of the ostiomeatal drainage pathway (Figure 3).

Figure 2.

Preoperative non-contrast paranasal sinus ct scans. (A) Coronal view demonstrating a well-defined, expansile soft-tissue mass within the left nasal cavity, abutting the middle turbinate. (B) Axial view showing the extent of the mass, with local remodeling of the adjacent bony structures. (C) Sagittal reconstruction illustrating the mass occupying the nasal cavity, highlighting the absence of frank osteolytic invasion or skull base erosion.

Figure 3.

Preoperative MRI findings. Axial (A) and coronal (B) sequences demonstrating the enhancing mass in the left nasal cavity, confirming no direct invasion into orbital or intracranial spaces.

Given the highly vascular characteristics of the mass, it was decided to forgo an outpatient biopsy and instead proceed directly to the operating room for a controlled surgical environment. The procedure was performed under general anaesthesia with orotracheal intubation. Endoscopic surgical management was organized based on the patient’s symptoms and imaging findings. The lateral nasal wall and septal mucosa were infiltrated with 1:100,000 epinephrine using a zero-degree endoscope. Initially, an intraoperative biopsy specimen was obtained and sent for frozen section analysis to exclude frank malignancy, which would have necessitated an alteration in the oncological surgical approach. Careful dissection was performed to separate the mass from the nasal septum and the lateral nasal wall. Once the haemorrhagic mass was fully detached from the adjacent tissues, its definitive point of attachment was confirmed at the anterior medial aspect and free border of the left middle turbinate. The mass was then meticulously mobilized towards the nasopharynx and excised en bloc. Due to its considerable size (3.2 × 3.0 × 0.8 cm), transoral delivery was executed. Bipolar diathermy and nasal packing were readily available throughout the procedure to manage potential bleeding. The feeding base of the attachment on the middle turbinate was coagulated with bipolar diathermy, and any residual oozing was controlled with epinephrine-soaked gauze; definitive haemostasis was successfully achieved without the need for a coblation device or blood transfusion.

Histopathological examination of the resected specimen revealed a respiratory mucosal lining with focal ulceration overlying a characteristic lobular proliferation of capillary-sized blood vessels lined by plump, non-atypical endothelial cells, separated by an oedematous fibrovascular stroma with mixed chronic inflammatory infiltrates. Immunohistochemical (IHC) staining demonstrated diffuse, strong endothelial positivity for CD31 and CD34, with smooth muscle actin (SMA) highlighting the surrounding pericytic layer, and a low Ki-67 proliferation index (<5%), confirming the diagnosis of lobular capillary haemangioma (pyogenic granuloma) and excluding malignant vascular neoplasms.

Regular follow-up appointments were arranged to monitor for any potential recurrence of the mass or residual sinus complications. The patient was monitored at intervals of 1 week, 1 month, and 6 months postoperatively. Post-operative nasal endoscopy revealed complete mucosal healing with no residual mass, and no signs of infection or recurrence were observed. At the most recent follow-up, the patient remained completely asymptomatic with no clinical evidence of recurrence over the past year.

Written informed consent was obtained from the patient for publication of this rare case report and any accompanying images in accordance with the Declaration of Helsinki.

Discussion

Pyogenic granuloma (PG), histopathologically designated as lobular capillary hemangioma (LCH), is a benign vascular proliferative lesion commonly affecting cutaneous surfaces and the oral cavity—particularly the gingiva.^1,2 Occurrence within the sinonasal tract is distinctly less frequent, accounting for approximately 10% of head and neck vascular lesions.^5,6 Within the nasal cavity, PG predominantly originates from the anterior cartilaginous septum (Little’s area) (55%–76%) and the anterior head of the inferior turbinate (12%–20%).^6,7 In contrast, primary origin from the middle turbinate is remarkably uncommon, frequently generating diagnostic ambiguity with other hypervascular sinonasal neoplasms.^7,8

The etiopathogenesis of sinonasal PG remains incompletely defined; it is broadly accepted to represent a reactive, non-neoplastic hyperplastic vascular proliferation triggered by chronic mucosal irritation, hormonal influences (predominantly elevated estrogen and progesterone during pregnancy/puerperium), repeated microtrauma (such as nose picking or repeated packing), or foreign body entrapment.^6,9,10 Previous literature has extensively described sinonasal PG in pregnant and postpartum women, illustrating rapid, hormone-driven vascular proliferation.^10,14 Similarly, several post-traumatic and turbinate-based PG cases have been reported in young adult males.^7,11,15 However, in nearly all previously documented post-traumatic or foreign-body-associated cases, vascular proliferation manifested within a rapid timeframe, typically spanning several weeks to a few months post-injury.^6,11

A distinctive feature of the present case is the male presentation combined with an unusual middle turbinate origin and a documented remote history of childhood nasal foreign body entrapment occurring 38 years prior. Comprehensive bibliographic searches in major biomedical databases (PubMed/MEDLINE, Scopus, Web of Science) reveal no previous reports documenting a multi-decade latent period between foreign body removal and subsequent PG development at the same anatomical site. Although delayed reactive granulomatous lesions or rhinolith-induced mucosal proliferation have been recognized years after unretrieved foreign body lodgment, an asymptomatic 38-year latency following complete foreign body removal is extraordinarily rare.

From an angiogenic perspective, molecular alterations involving vascular endothelial growth factor (VEGF), angiopoietin-1, angiopoietin-2, and Tie-2 receptor signaling pathways have been implicated in driving chronic inflammatory neovascularization in PG.^9,16 It can be hypothesized that severe childhood focal mucosal injury may induce microvascular dysregulation, microscopic subclinical scarring, or localized endothelial vulnerability, which might subsequently undergo delayed florid proliferative expansion in response to subtle, cumulative secondary adult micro-insults or chronic rhinosinusitis.

Study Limitations

It is essential to emphasize the limitations inherent to this case presentation. Most importantly, a definitive causal relationship between the childhood foreign body entrapment and the development of PG 38 years later cannot be definitively established from a single observational case. Given the extensive temporal interval, the possibility of a coincidental occurrence or an unremembered recent minor mucosal microtrauma cannot be ruled out. Furthermore, details regarding the childhood event relied on patient and parental recall rather than contemporaneous hospital records, introducing potential recall bias. Therefore, remote mucosal trauma should be regarded as a biologically plausible explanatory hypothesis rather than a confirmed causative mechanism.

Clinically, sinonasal PG requires careful differentiation from inverted papilloma, juvenile nasopharyngeal angiofibroma, hemangiopericytoma, and sinonasal malignancies.^8,17 Comprehensive radiological evaluation with contrast-enhanced CT and MRI is vital for assessing vascularity, soft tissue boundaries, and ruling out skull base or orbital erosion. Complete endoscopic surgical excision with clean mucosal margins and cauterization of the feeder base remains the standard curative approach, demonstrating exceptionally low recurrence rates.^6,11

Conclusions

In summary, this case report describes an unusual presentation of sinonasal pyogenic granuloma arising from the left middle turbinate in an adult male with a remote history of childhood nasal foreign body entrapment 38 years prior. While this multi-decade interval introduces an intriguing biological hypothesis regarding long-term mucosal susceptibility, it should be interpreted as a potential association rather than definitive delayed causation. Pyogenic granuloma should remain an important consideration in the differential diagnosis of unilateral vascular sinonasal masses. Complete endoscopic surgical excision combined with comprehensive radiological and histopathologically evaluations ensures definitive diagnosis, rules out underlying malignancy, and provides curative outcomes.

Data Sharing Statements

The data supporting the findings of this study are included within the article. Any further details regarding the clinical data are available from the corresponding author upon reasonable request.

Ethics and Consent to Participate

Institutional review board (IRB)/ethics committee approval is not required for single-case reports of de-identified patient data under the institutional research governance policies of Iran University of Medical Sciences (IUMS), as this work involved standard clinical management and non-experimental diagnostic and therapeutic procedures. The study was conducted in strict accordance with the ethical principles outlined in the Declaration of Helsinki. Written informed consent was explicitly obtained from the patient for the publication of this case report and any accompanying clinical and radiological images. A copy of the written consent is available for review by the Editor-in-Chief upon request.

Consent to Publish

Written informed consent was obtained from the patient for publication of this case report and any accompanying images. A copy of the written consent is available for review by the Editor-in-Chief of this journal.

Authors’ Contributions

All authors made a significant contribution to the work reported, whether that is in the conception, study design, execution, acquisition of data, analysis and interpretation, or in all these areas; took part in drafting, revising or critically reviewing the article; gave final approval of the version to be published; have agreed on the journal to which the article has been submitted; and agree to be accountable for all aspects of the work.

Funding Statement

This study received no specific grant from any funding agency in the public, commercial, or not-for-profit sectors.

Disclosure

The authors declare that they have no competing interests.