Clinical Note |

Nasoseptal Cholesterol Granuloma:  A Case Report and Review of Pathogenesis

Arjuna B. Kuperan, MD; Megan M. Gaffey, MD; Paul D. Langer, MD; Neena M. Mirani, MD; James K. Liu, MD; Jean Anderson Eloy, MD
Arch Otolaryngol Head Neck Surg. 2012;138(1):83-86. doi:10.1001/archoto.2011.218.
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Cholesterol granulomas are rare inflammatory deposits that can be located corporally, but are classically found in the petrous apex and other pneumatized areas of the temporal bone. Originally thought to be a response to hypoventilation due to mucosal swelling and occlusion of air cells, the pathogenesis of cholesterol granulomas recently has come under speculation. This is partly due to new theories of the importance of a rich blood supply in the lesion's development. Cholesterol granulomas have been reported in uncommon areas of the head and neck, such as surrounding the endolymphatic sac and pterygoid process of the sphenoid sinus.1 This entity has been described within the paranasal sinuses, including the maxillary, ethmoid, sphenoid, and frontal sinus locations. To our knowledge, we report the first case of a nasoseptal cholesterol granuloma.

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Figure 1. Preoperative 4-mm, 30°-endoscopic right (A) and left (B) nasal examination revealed a submucosal mass extending on both sides of the nasal septum (NS) and abutting the bilateral lateral nasal wall. The middle turbinates are completely obstructed by the lesion. Asterisk indicates cholesterol granuloma; LIT, left inferior turbinate; NS, nasal septum; and RIT, right inferior turbinate.

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Figure 2. Preoperative axial acquisition computed tomographic imaging (A), with coronal (B), and sagittal (C) reformats show a destructive lesion with bony remodeling in the periphery centered over the nasal septum. Axial (D) T1-weighed and (E) T2-weighted preoperative magnetic resonance images of the paranasal sinuses show a hyperintense lesion on both views. The lesion is centered over the superior nasal septum with right orbital involvement.

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Figure 3. Intraoperative 4-mm, 30° endoscopic view looking medially from the left nasal cavity shows (A) a septal incision just anterior to the lesion with septal flap (SF) elevation and brown cyst content (CC). NS indicates nasal septum. B, After septal flap elevation, the cyst wall (CW) can be easily visualized posterior to the defect in the quadrangular cartilage (QC). C, The cyst wall is subsequently removed using Blakesley forceps and Frazier suction with a bimanual technique. Photomicrographs of the resected superior septal lesion showing (D) reactive foreign body giant cells and the residual clefts of cholesterol crystals (hematoxylin-eosin, original magnification ×100), (E) many histiocytes and multinucleated foreign body giant cells surrounding the cholesterol clefts (hematoxylin-eosin, original magnification ×400).

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Figure 4. Eight-months postoperative 4-mm, 30° endoscopic right (A) and left (B) nasal examination revealed a well-healed and mucosalized nasal cavity without evidence of recurrence. LMT indicates left middle turbinate; NS, nasal septum; and RMT, right middle turbinate.




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