Abstract
Lobular capillary hemangioma mostly occurs in the anterior portion of the nasal cavity, rarely occurring in the posterior end of the inferior turbinate, as in this case. We report a case of lobular capillary hemangioma originating from the posterior end of the right inferior turbinate, which was successfully removed via an endoscopic endonasal approach.
A 37-year-old male patient visited our outpatient clinic with right nasal obstruction and intermittent nasal bleeding that had developed 6 months previously. He had never undergone nasal surgery or nasal packing. Nasal endoscopy revealed a reddish mass in the posterior part of the right nasal cavity (Figure 1). Hemangioma was strongly suspected, and the risk of bleeding during biopsy in the outpatient clinic was considered; therefore, a biopsy was not performed. On paranasal sinus computed tomography, a soft tissue density was observed in the posterior portion of the right nasal cavity and was not accompanied by bone destruction (Figure 2).
Endoscopic view of the right nasal cavity shows a bright reddish mass located in the posterior nasal cavity.
Computed tomography of the sinuses shows a soft-density mass located in the right posterior nasal cavity without bone destruction.
A bipolar cautery and suction coagulator were prepared for bleeding when the mass was removed. Endoscopic examination was performed carefully, and it was confirmed that the mass originated from the posterior end of the right inferior turbinate. The mass was removed using an endoscopic endonasal approach under general anesthesia. No serious bleeding occurred when the mass was removed using an electrical instrument. To minimize the possibility of recurrence, a suction coagulator was used at the origin site of the mass (Figure 3A). The mass was 18 × 14 × 10 mm in size (Figure 3B).
A, Cauterization at the origin site of the mass. B, Gross finding of the mass.
Based on the histological findings, the surgically removed mass was diagnosed as lobular capillary hemangioma (LCH) due to the numerous capillary-sized vessels arranged in the lobule. He was discharged 2 days after the surgery, and he was periodically followed up as an outpatient with no signs of recurrence for 9 months after surgery.
Lobular capillary hemangioma, also known as pyogenic granuloma, is characterized by an anastomosing network of capillaries arranged in 1 or more lobules in edematous and fibroblastic stroma on histopathological examination. 1 The majority of the lesions are usually small and tend to be localized to the anterior part of the septum or head of the inferior turbinate, mainly affecting the anterior part of the nasal cavities.2-4 Proposed contributing factors for the development of LCH include trauma, hormones, viral oncogenes, arteriovenous malformations, and angiogenic growth factors. Trauma is the most likely cause of LCH in the nasal cavity, especially intranasal packing and nose picking, which can be habitual.2,5 Lobular capillary hemangioma occurs mainly in the anterior portion of the inferior turbinate or septum. It is difficult to identify the cause of trauma in this case because LCH occurred at the posterior end of the inferior turbinate, which is far from the nasal orifice, and there was no history of nasal packing.
Radiological diagnosis is not characteristic of computed tomography, which is a soft tissue density that is not accompanied by bone destruction. If the size is large, the differential diagnosis may include angiofibroma and angiosarcoma. Lobular capillary hemangioma is characterized by histologically scattered lobular hemangiomas in the fibromyxoid stroma, which are accompanied by infiltration of inflammatory cells, granulomatous tissues, and mucosal surface ulcers.
Lobular capillary hemangioma can often recur after surgical removal. 6 Therefore, it is recommended to completely remove the base of the lesion during surgery and to perform electric cautery. In this case, the base of the lesion was completely removed, and electric cautery was performed after removal. Lobular capillary hemangioma mostly occurs in the anterior portion of the nasal cavity, rarely occurring in the posterior end of the inferior turbinate, as in this case. We report a case of LCH originating from the posterior end of the right inferior turbinate, which was successfully removed via an endoscopic endonasal approach.
