Lobular capillary hemangioma (LCH) is a benign vascular growth of the skin and mucous membranes commonly affecting the head and neck [¹, ²]. The evolving terminology associated with this lesion reflects a change in the understanding of its etiology. In 1897, Poncet and Dor published the first report of “pea to nut-sized” vascular tumors on the fingers and arms of four patients [³]. The authors referred to this condition as “human botryomycosis,” speculating that the lesions were secondary to a fungal infection thought to cause morphologically similar lesions in horses. In 1904, Hartzell coined the term “pyogenic granuloma” to describe these lesions which he presumed to be granulation tissue arising in response to a bacterial infection [⁴]. In 1980, Mills et al., noting the paucity of evidence to support an infectious origin, proposed the term “lobular capillary hemangioma” derived from the characteristic microscopic features of this tumor [¹].

The etiology of LCH remains unknown, though there is some evidence to support both trauma and hormonal influences. The relative frequency of LCH developing at the anterior nasal septum and the anterior aspect of the inferior turbinate, as well as the increased incidence of LCH in recurrent nose pickers or those with a history of nasal packing lends credence, give to the belief that local trauma plays arole in the genesis of LCH [⁵, ⁶]. Many theorize that these lesions represent an overgrowth of granulation tissue produced by a hyperactive inflammatory response [⁵, ⁷, ⁸].However, a retrospective study of 112 patients by Pagliai and Cohen found a history of trauma in only 5 patients (4.5%) with clinically diagnosed LCH [⁷]. Further investigation of suspected inciting sources, including insect bites, hemangiomas, dermatologic conditions, and telangiectasias, revealed that 76.8% of patients had no history of these various traumatic, dermatologic, and vascular pathologies thought to be associated with LCH. Other plausible etiologies that have been proposed include viral oncogenes, microscopic arteriovenous malformations, and overproduction of angiogenic growth factors [⁶].

There is a well-established relationship between LCH and pregnancy. LCH commonly occurs in women who are pregnant and those who use oral contraceptives [⁹, ¹⁰]. These lesions regress after delivery, implicating a role of hormones in the growth of LCH [⁹, ¹¹, ¹²].

Though LCH frequently presents in the head and neck, it rarely occurs in the nasal cavity [¹, ², ⁹, ¹¹, ¹³].There are only nine reports describing cases in the pediatric population (Table 1).We present two cases of LCH occurring in the nasal cavities of female adolescents.

LCH occurs at any age, but most commonly develops in the third to fifth decade of life [⁶]. In adults, LCH occurs in as many as 5% of all pregnant women [⁶, ⁹, ¹²]. Pagliai and Cohen found that, among 115 children presenting with LCH, more than 60% were male [⁷]. The same study identified the most common location of these lesions in children to be the head and neck (76.9%). Among those patients with head and neck LCH, the majority had lesions on the skin (36.1% on the cheek, 12% on the forehead, 9.6% on the scalp). Other studies report the frequent appearance of these lesions on the gingiva, lips, tongue, buccal mucosa, and rarely in the nasal cavity [¹, ², ⁵]. When the nasal mucosa is affected, the lesions typically involve the anterior portion of the inferior turbinate or Little's area on the anterior nasal septum [⁵, ²⁰, ²¹]. The relative increase in incidence at these sensitive sites nearest the nares lends support to the theory that local trauma may precede the development of LCH [⁶].

Patients with LCH of the nasal cavity commonly present with epistaxis, nasal obstruction, epiphora, or purulent rhinorrhea [⁶, ⁸]. The diagnosis is often made clinically, based on a characteristic history of a rapidly enlarging, pedunculated mass with intermittent epistaxis [⁷].

Radiographic studies are frequently used to diagnose an intranasal mass.CT can be important in determining the presence of bony destruction by a rapidly growing intranasal mass or in evaluating intracranial extension of a mass originating on the roof of the nasal cavity [⁶, ¹³, ²¹].T2-weighted MRI will reveal characteristic findings for a hemangioma: vascular tissue with multiple flow voids surrounding an inner matrix of higher-intensity tumor [²¹]. In children, congenital malformations such as meningoceles, dermoid cysts, angiomatous polyp, schwannoma, angiofibroma,and gliomas should be considered in the differential diagnosis of an intranasal mass and can be differentiated by CT or MR imaging [¹⁶, ¹⁷].

In this case series, each patient underwent an in-office biopsy of her intranasal lesion. In each case, suspicion for angiofibroma or a lesion that extended intracranially such as a meningocele or meningomyelocele was sufficiently low that we felt a biopsy could be performed safely. In both instances, the biopsy established a previously uncertain diagnosis and resulted in minimal bleeding that was easily controlled in the office.

The recommended treatment of LCH in the nasal cavity is conservative local excision with cautery at the base of the tumor for hemostasis [⁷, ¹⁵].This technique is associated with low rates of recurrence [¹, ⁷].Transnasal endoscopic resection is favored over a rhinotomy due to the relatively minimal morbidity of the procedure, the low rate of recurrence, and the better visualization of the tumor and the surrounding anatomy [¹³, ¹⁵, ¹⁶, ²¹].Our institution has previously demonstrated the utility of image guidance in sinonasal endoscopic surgery in the pediatric population [²²].

Nasal LCH is a rare cause of an intranasal mass and is associated with unilateral epistaxis, nasal obstruction, epiphora, and purulent rhinorrhea.We advocate for image-guided endoscopic excision ofLCH in the adolescent population.

The authors received no funding for this study and have no conflicts of interest to disclose.