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# Necrotizing lesions of the nose and upper airway

- Lesion

Three different diseases can destroy the nose and palate: an invasive fungus, an ANCA vasculitis, and an EBV-driven lymphoma.

Updated Nov 12, 2026

## Key points

- Mucormycosis: diabetic ketoacidosis, neutropenia, steroids, iron overload; broad, non-septate hyphae with right-angle branching invade vessels: black necrotic eschar.
- GPA: necrotising granulomatous inflammation and vasculitis of upper and lower airways and kidney; PR3-ANCA; saddle-nose deformity.
- Extranodal NK/T-cell lymphoma, nasal type: EBV-positive cytotoxic cells, angiocentric and angiodestructive growth with necrosis; more common in East Asian and Latin American populations.
- Other causes: cocaine use (can mimic vasculitis), tuberculosis, leishmaniasis (mucosal), syphilis.

## What it is

Ulcerating, necrotising lesions of the nasal cavity and midface have three main causes, which the biopsy must separate: invasive fungal infection (especially Mucorales), granulomatosis with polyangiitis, and extranodal NK/T-cell lymphoma, nasal type. All can perforate the septum or palate; treatment is completely different for each.

## Structure

- Mucormycosis: infarcted, necrotic tissue with hyphae in vessel walls and thrombi.
- GPA: geographic necrosis with basophilic debris, scattered giant cells, poorly formed granulomas and necrotising vasculitis.
- NK/T-cell lymphoma: atypical lymphoid cells around and inside vessel walls with extensive necrosis; CD56, cytotoxic granules, EBER positive.
- Biopsies are often mostly necrotic; repeat or deep biopsies may be needed.

## Step by step

- Mucorales spores germinate in the sinuses when neutrophils and acidosis fail to stop them; hyphae invade arteries and cause infarction.
- In GPA, ANCA activate primed neutrophils that injure vessel walls and provoke granulomas.
- In NK/T-cell lymphoma, EBV-infected NK or T cells proliferate around vessels and destroy them.
- All three lead to ischaemic necrosis of mucosa, cartilage and bone.

## Destructive midline lesions

| Disease | Cause | Key biopsy finding | Test |
| --- | --- | --- | --- |
| Mucormycosis | Mucorales fungi | Broad non-septate hyphae in vessels | Silver stain, culture |
| [Granulomatosis with polyangiitis](https://durgical.com/en/conditions/granulomatosis-with-polyangiitis/) | ANCA vasculitis | Geographic necrosis, granulomas, vasculitis | PR3-ANCA |
| [NK/T-cell lymphoma, nasal type](https://durgical.com/en/conditions/non-hodgkin-lymphoma/) | EBV-driven lymphoma | Angiocentric atypical cells, necrosis | CD56, EBER |

## Markers

- PR3-ANCA
- EBER
- CD56
- Grocott methenamine silver

## Clinical notes

- A diabetic with facial pain, black nasal eschar and cranial nerve palsies needs emergency treatment for mucormycosis.
- Chronic sinusitis, epistaxis and nasal crusting with hemoptysis or kidney disease suggest GPA.
- Nasal-type NK/T-cell lymphoma is aggressive and fatal without treatment; localised disease responds to radiotherapy.

## Memory aid

Fungus, vasculitis, lymphoma: three thieves that steal the nose.

## Test yourself

Think of the answer, then tap the question to see it.

## What are the three main causes of necrotising lesions of the nose?

Invasive fungal infection (mucormycosis), granulomatosis with polyangiitis and extranodal NK/T-cell lymphoma, nasal type.

## Which virus is associated with extranodal NK/T-cell lymphoma, nasal type?

Epstein–Barr virus, shown in tumour cells by EBER in situ hybridisation.

## What antibody is typical of granulomatosis with polyangiitis?

PR3-ANCA (c-ANCA).

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## Connections

## Related 3

- [Diffuse alveolar hemorrhage](https://durgical.com/en/general-pathology/diffuse-alveolar-hemorrhage/)
- [Rhinitis, sinusitis, pharyngitis and tonsillitis](https://durgical.com/en/general-pathology/rhinitis-sinusitis-pharyngitis-and-tonsillitis/)
- [Sinonasal tumours](https://durgical.com/en/general-pathology/sinonasal-tumours/)

## Related conditions 3

- [Granulomatosis with polyangiitis](https://durgical.com/en/conditions/granulomatosis-with-polyangiitis/)
- [Non-Hodgkin lymphoma](https://durgical.com/en/conditions/non-hodgkin-lymphoma/)
- [Type 1 diabetes mellitus](https://durgical.com/en/conditions/type-1-diabetes-mellitus/)

## Microorganisms 2

- [Mucorales (Rhizopus, Mucor)](https://durgical.com/en/microbiology/mucorales/)
- [Epstein–Barr virus](https://durgical.com/en/microbiology/epstein-barr-virus/)

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Educational content on the mechanisms of disease; not a diagnostic or treatment guide and no substitute for a health professional's advice. No doses are given.

Sources: [Sinusitis](https://medlineplus.gov/sinusitis.html) (MedlinePlus, US National Library of Medicine, 2025).

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Representative model, for educational purposes only.

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Source: https://durgical.com/en/general-pathology/necrotizing-lesions-of-the-nose-and-upper-airway/
License: CC BY 4.0 (https://creativecommons.org/licenses/by/4.0/). Cite as: DurgiPedia (durgical.com), https://durgical.com/en/general-pathology/necrotizing-lesions-of-the-nose-and-upper-airway/