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White Nontender Papule On Nasal Septum. History Of Drug Abuse. Occasional Nasal Allergies. Any Ideas?

Posted on Tue, 12 Jun 2012

Question: Hi, I'm a PA student, and I'm learning how to do a physical assessment. When I was practicing on my roommate yesterday, I noticed a white nontender papule on the right side of his nasal septum with irregular but well-defined borders, and it's not raised as much as a bump or polyp, but is slightly raised and less than 1 cm. across, looks almost like it could wipe off, but apparently it does not, as he used a neti pot and blew his nose and let me look again. I didn't try to move it or touch it. He inhaled drugs such as oxycontin and cocaine for a few years but denies current use, and I believe him as I have seen no evidence otherwise, and I also examined his eyes, etc. several times recently impromptu. After scouring my pathology book, the only thing it looks like might be the area around epistaxis that is not labeled on those example pictures you can see in an ENT book. He is in his late thirties and has no recent history of nosebleeds, trauma, deviation, and is in good health, but does have some occasional nasal allergies. I'm just knowledgeable enough to be XXXXXXX and I have that medical student syndrome that turns every little lesion into an episode of House, so I don't even want to keep reading until I ask someone. Not really comfortable asking my professors on this one. Any ideas?

Answered by Dr. Naveen Kumar Nanjasetty (1 hour later)

Hi XXXXXXX

Thanks for the query

The description of the swelling you have mentioned could be either a granuloma of the septum (probably a pyogenic granuloma) or a septal spur.

Septal granuloma is usually seen in those individuals having repeated trauma to the nose (in this condition snorting could be the prime cause) and if in females, it could be due to the hormonal changes. Secondly, any spur over the septum can also appear like a swelling or a polyp.

It is indeed difficult to comment without direct examination of the lesion. If you can send us a photograph of the lesion, we would be able to help you in a better way. You have an option to upload the pictures on the right hand panel of the website, please utilize it.

I will be looking forward for your reply with the photograph.

Regards
Dr. Naveen Kumar N.
ENT and Head & Neck Surgeon

Above answer was peer-reviewed by : Dr. Yogesh D

Follow up: Dr. Naveen Kumar Nanjasetty (2 hours later)

Dr. XXXXXXX
Thank you for the response. It might be close enough to the edge, but I'm not sure I can get a camera up there (not sure he'll be happy about that either as he thinks I'm nuts already) but I will ask him. My book has 1 paragraph about pyogenic granulomas. His lesion is very white and not really red at all like the pregnancy one it shows in a lady's mouth. I know this cannot be a substitute for an exam, but from my description, is this something you would be concerned about if it were your friend? I'll try to get him to go have it looked at, but he is of the opinion that "a white blotch I can't even see and doesn't hurt" isn't cause for a visit. I'd like to agree but I've read too much about all those scary pathology things to leave the poor guy alone. Trying not to look for zebras or scare him. Besides telling him to make sure he stays away from drugs for lots of obvious reasons, what would you recommend I tell him? He's kind of my brother in law and I'd like to have him around for awhile, but a medical XXXXXXX for something silly will probably mean I have one less nose to practice on, haha. Thank you for your help!

Answered by Dr. Naveen Kumar Nanjasetty (21 hours later)

Hi again XXXXXXX

Thank you for writing back.

I do understand the concern for your friend, he must be lucky enough to have a friend like you.

Well, coming back to the discussion, the septal lesions are indeed difficult to comment by the description alone, as many of these lesions get altered due to various causes.

The best thing I can do is to give you a differential diagnosis:
1. Papilloma - Squamous or wart
2. Septal Spur
3. Granulomatous lesions
4. Pyogenic granuloma
5. Capillary haemangioma

Secondly, pyogenic granuloma need not always look red, if there is fibrosis of the lesion due to constant irritation, it can appear grayish or dull white. If the lesion does not bleeding on touch, then hemangioma is also ruled out.

Going by your description (nontender papule on the right side of his nasal septum with irregular but well-defined borders, slightly raised and less than 1 cm. across, the area around epistaxis) I do feel the lesion could be either a squamous papilloma or a pyogenic granuloma.

I do not want to scare you by mentioning about a rare diagnosis, whatever I have mentioned in my discussion are the commonest causes. Hope you will be convinced with this answer.

Wishing your friend and you good health.

Regards
Dr. Naveen Kumar N.
ENT and Head & Neck Surgeon

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Above answer was peer-reviewed by : Dr. Yogesh D