Printer Friendly

Two cases of pyogenic granuloma in pregnancy.


A 29-year-old pregnant woman presented with a history of recurrent epistaxis treated elsewhere by cauterization. She had also required packing, and she presented to our office for packing removal. After removal of packing, nasal endoscopy was performed, demonstrating a right-sided pedunculated mass arising from Little's area (figure). This appeared to be the source of the recurrent epistaxis. Based on this finding and the recurrent, profuse epistaxis, the recommendation was made to remove the source lesion.

The patient was very anxious and elected for an examination under general anesthesia with subsequent removal of the intranasal mass. Given the patient's pregnant state, the plan was discussed extensively with her obstetrician. The benefits were deemed to outweigh the risks given the patient's extensive blood volume loss over several weeks and the gestational age of the fetus, which was past the period of major organ development.

Intraoperatively, the right nasal cavity was examined and a large ulcerated lesion was noted on the anterosuperior septum. The lesion was excised to its base and cauterized with bipolar electrocautery. Absorbable packing was placed on the surgical bed. The surgical pathology report of the excised lesion was consistent with a pyogenic granuloma. Epistaxis did not recur.

In another case, a 42-year-old pregnant woman presented with several weeks' history of intermittent epistaxis. She was in the third trimester of an otherwise uneventful pregnancy. On endoscopy, a 1.5-cm, ulcerated, bleeding point was noted on the left nasal septum. This was cauterized with initial control of epistaxis. However, the patient presented 2 days later with recurrent epistaxis. Based on the volume of blood loss and frequency of epistaxis, the recommendation was made for excision of the lesion.

The patient declined excision under general anesthesia despite the size of the lesion and instead opted for local anesthesia. The lesion was removed entirely, but the perichondrium was not exposed. The surgical pathology report of the excised lesion was consistent with a pyogenic granuloma.

Four weeks later, the patient presented with recurrent growth and epistaxis. Surgical intervention was deferred until after delivery.

Management and treatment of rhinologic issues in pregnant patients can be complex because of the limited availability of safety data. Conservative management is suggested as first-line therapy, with adequate analysis of the risk-benefit ratio for both the patient and the fetus. Typically, surgical excision is the preferred method of treatment in nonpregnant patients to prevent recurrence of the lesion. Risks of general anesthesia in pregnant women include a possible increased preterm labor rate and the effect of anesthetics and narcotics on the fetus; surgical treatment is therefore a last resort. (1)

Despite conservative management, bleeding and recurrence are typical of these lesions. (2,3) Our patients demonstrated recurrent episodes of epistaxis and failure of prior cauterization attempts. Surgical excision is often best in order to gain appropriate access and to enable complete resection. As evidenced by the second case, when the lesion is located posteriorly, access can be difficult, thereby preventing complete excision to the perichondrium. This is a risk factor for recurrence, which occurred in the second case.


(1.) Goldstein G, Govindaraj S. Rhinologic issues in pregnancy. Allergy Rhinol (Providence) 2012;3(1):e13-15.

(2.) Choudhary S, MacKinnon CA, Morrissey GP, Tan ST. A case of giant nasal pyogenic granuloma gravidarum. J Craniofac Surg 2005;16(2):319-21.

(3.) Scott PM, van Hasselt A. Case report of a bleeding nasal polyp during pregnancy. Ear Nose Throat J 1999;78(8):592.

Alex Fernandez, MS; Jason Hamilton, MD, FACS; Raphael Nach, MD

From the Osborne Head and Neck Institute, Los Angeles.
COPYRIGHT 2014 Vendome Group LLC
No portion of this article can be reproduced without the express written permission from the copyright holder.
Copyright 2014 Gale, Cengage Learning. All rights reserved.

Article Details
Printer friendly Cite/link Email Feedback
Author:Fernandez, Alex; Hamilton, Jason; Nach, Raphael
Publication:Ear, Nose and Throat Journal
Article Type:Case study
Date:Aug 1, 2014
Previous Article:Balloon sinus dilation in the office setting.
Next Article:Acoustic neuroma: an investigation of associations between tumor size and diagnostic delays, facial weakness, and surgical complications.

Terms of use | Copyright © 2018 Farlex, Inc. | Feedback | For webmasters