Granuloma refers to round mass compactly formed by cells of inflammation, especially the mononuclear cells. A granuloma is the product of a complex interactions and mechanisms involving the foreign invader, drugs, chemical mediators, other endogenous or exogenous irritant components, a long-lasting circulation of antigen in body, immunological activities especially associated with macrophages, Type-I helper T-cells activity, Plasma (B-cells) cellular response, circulating immunoglobulins and other extensive mediators of biochemical nature.¹

The nasal granulomatous lesions are broadly classified as; infective, inflammatory/allergic and neoplastic. One of the bacterial causes of granulomatous diseases of nose is Mycobacterium tuberculosis.² Tuberculosis is a disease caused by acid fast bacilli of the family Mycobacteriaceae (Mycobacterium tuberculosis, Mycobacterium bovis, Mycobacterium microti and Mycobacterium africanumi).³

The lung is the most affected organ in tuberculosis infection in the immunocompetent host, with estimates of lung involvement in subjects with active tuberculosis of 79 - 87%. As per World Health Organization (WHO) (2025) more than 10 million people remain ill with TB every year and more than 1 million die from this disease, making it the world’s leading cause of death from a single infectious agent and among the top 10 causes of death worldwide.⁴ Tuberculous involvement of the nose is rare. When it occurs, it is usually secondary either to pulmonary tuberculosis or to lupus vulgaris of the facial skin.

A 55-year-old female patient came to our ENT OPD at a tertiary care centre with 20-day history of left nasal block and nosebleed. There were no relevant systemic illnesses from which the patient suffered. The patient had a habit of tobacco and betel nut chewing since the past 40 years. Patient was clinically examined to visualize a bright red mass in left nasal cavity (Figure 1a). The lesion had a firm consistency on probing with tendency to bleed on touch. It could be probed all around except laterally. Diagnostic nasal endoscopy of the nose was done to reveal the presence of a reddish polypoid mass on the middle turbinate in the left nasal cavity (Figure 1b). Figure 1a: Reddish polypoid mass in the left nasal cavity seen on anterior rhinoscopy Figure 1b: Reddish polypoid mass on the Middle turbinate in the left nasal cavity (Diagnostic nasal endoscopy) A computed tomography of Nose and Paranasal Sinuses was done to reveal a heterogeneously enhancing soft tissue attenuation lesion measuring 3.2 x 1.7 x 2.5 cm (AP x TR x CC) in the left nasal cavity with its epicentre in the left middle meatus. The lesion showed multiple hypo-enhancing hypodense areas within. The lesion caused moderate obstruction to the left middle meatus. Medially, it was abutting and causing mild mass effect upon the bony nasal septum with displacement of the bony nasal septum towards the right. Superiorly, it was abutting the left middle turbinate and left ethmoidal bulla. Inferiorly, it was abutting and causing mild mass effect upon left inferior turbinate and is extending into the left inferior meatus. Inferiorly, it was abutting the hard palate on left side. No evidence of bony erosions seen (Figure 2a and 2b). Figure 2a: CT PNS (Axial View) depicting a mass in left nasal cavity Figure 2b: CT PNS (Coronal View) depicting a mass in left nasal cavity A biopsy was taken from the lesion arising from the left middle meatus. under general anaesthesia. Minimal bleeding was noted following the procedure. Biopsy which was sent for histopathological examination revealed Necrotizing Granulomatous inflammation of Koch's etiology (Figure 3a and 3b). Figure 3a: Microscopic picture of the histopathological specimen. Figure 3b: Many well-formed epithelioid granulomas noted along with Langerhans type of multinucleated giant cells Patient was treated with 6 months of antitubercular treatment (HRZE with an intensive phase of 2 months and continuation phase of 4 months). Post treatment patient reported to ENT OPD for regular follow-up and a diagnostic nasal endoscopy was performed. The nasal mass which appeared initially had regressed completely with the middle meatus and nasopharynx being visible (Figure 4). Patient was symptomatically better with no further complaints of nasal obstruction or bleed from the nose. Figure 4: Diagnostic Nasal Endoscopy of left nasal cavity post antitubercular treatment.

Mass in nasal cavity could be of an inflammatory origin like a polyp, mucocele or of a neoplastic origin, benign ones like osteoma, inverted papilloma, angiofibroma or malignant ones like squamous cell carcinoma, adenocarcinoma or of a congenital origin like teratoma, glioma or of an idiopathic origin like fibrous dysplasia.⁵

Nasal Tuberculosis is a rare condition which is usually always associated with primary TB patients. Patient may present with ulcerative, polypoidal or nodular lesions. Lesions are most seen involving the anterior part of septum, inferior turbinate and anterior choanae. On microscopic examination epitheloid granulomas, Langerhans’s giant cells and extensive caseation is seen.⁶

Other mycobacteria like Mycobacterium balnei and Mycobacterium leprae can also cause granulomatous lesions in nose and sinuses. The primary disease is caused either by inhaling infected particles or a traumatic digital injury. It has also been postulated that the nasal mucosa is inherently resistant to mycobacterial growth.

To the best of our knowledge very few studies are reported in India. This study is in line with a case reported by Nayar et. al in 2004 ⁷ and Kameswaran M et. al in 2007 ⁸.  Further studies are recommended to screen such patients at a community level and refer them to tertiary care centres for early diagnosis and prompt management.

Any mass in nasal cavity with an history of epistaxis, alongside with lesions like angiofibroma, inverted papilloma or malignancy of nasal cavity, nasal tuberculosis should always be kept in mind. Mindful management of the pathology will help in avoiding spread of tuberculosis to adjacent sites, avoiding recurrence and drug resistance. The presence of mind not only helps the clinician with diagnosis but also helps the patient as well in reducing complications from improper diagnosis.

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