Matthew C. Miller and David Rosen

Patients are often referred to otolaryngologists for evaluation of facial lesions. When confronted with a patient with a facial mass it is helpful to first determine whether the lesion is confined to the epidermis or whether deeper structures are involved. Further characterization among these groups will assist in narrowing the differential, guiding potential biopsy techniques, and ultimately making the correct decisions regarding treatment.

Cutaneous masses may be subcategorized based upon their general appearance as being nodular or papular, scaly, vascular, or pigmented. Masses confined to the subcutaneous tissues can be divided into those with and without overlying skin discoloration. Bony lesions represent a separate subgroup and may be suspected after simple palpation. Special consideration must be given to masses identified in the periorbital, perinasal, and preauricular regions because certain pathological processes have a predilection for these areas. Masses specific to these regions are listed under separate subheadings following here.

Facial masses encompass a wide variety of benign and malignant processes, many of which are discussed in detail elsewhere in this text. This chapter reviews many of those clinical entities and organizes them by appearance and location, rather than by pathology or etiology.

Cutaneous Nodules and Papules

Skin tags (acrochordons): Small pedunculated lesions that are usually flesh colored. They often appear in clusters on the eyelids and in the periorbital region and are typically 1 to 2 mm in size.

Fibrous papules (angiofibroma/adenoma sebaceum): Smooth, tan to gray, dome-shaped papules measuring 1 to 2 mm in size. Typically seen on the nose and midface of middle-aged individuals. Usually, they are solitary but if multiple lesions are present, the diagnosis of tuberous sclerosis should be considered.

Senile sebaceous hyperplasia: Yellow to tan papules that may become dome-shaped and umbilicated. May develop superficial telangiectasias, mimicking basal cell carcinoma. Common in the geriatric population.

Neurofibroma: Soft, flesh-colored tumors that tend to invaginate into the skin surface when compressed. Multiple lesions should alert to the possibility of neurofibromatosis type 1.

Warts

Flat (verruca plana): Slightly elevated tan to yellow papules appearing in clusters on the forehead and shaved regions of the face. Tend to be less than 5 mm in diameter.

Hypertrophic scar and keloid: Both appear as firm pink to tan masses in regions of previous trauma or surgical scar. Can be differentiated from one another by virtue of the fact that keloids are more often symptomatic (pain or itching), extend beyond the borders of the original scar, and are more common in blacks than in Caucasians.

Basal cell carcinoma (BCC): Most common malignant tumor in humans. Appearance varies based on histologic type, but the most common variant (nodular BCC) is a slow-growing papule with a pearly surface. Generally glistening and round with a telangiectatic surface.

Fibrosarcoma: Firm, painless, fleshy mass that is tan in color. Patients may report a history of previous radiation exposure.

Pilomatrix carcinoma: Most arise in preexisting pilomatrixomas. Tend to be asymptomatic, irregular, very firm masses with variable growth patterns. Generally appear as solitary tan, nodular masses.

Scaly Cutaneous Masses

Actinic keratosis: Premalignant lesions seen in areas of preexisting sun damage. More common in patients with low Fitzpatrick scores. Scaly, indurated lesions with yellow to tan coloration. Poorly demarcated from the surrounding tissues. Most are less than 1 cm in size.

Keratoacanthoma: Rapidly growing mass seen in areas of previous sun damage. More common in the elderly population. Characterized by rapid growth phase, plateau, and subsequent involution over several months. May reach several centimeters in size and can appear as keratinized horns. In most cases they will develop a central crater during the involution phase. Difficult to differentiate clinically from squamous cell carcinoma.

Squamous cell carcinoma: May present in a variety of ways, but typically appears as a scaly patch on an erythematous and often ulcerated base. They may arise in preexisting actinic keratoses.

Cutaneous Vascular Masses

Pyogenic granuloma: Bright red/yellow glistening lesions typically less than 1.5 cm in size. Often arise in regions of prior trauma. Hormone sensitive and may appear during pregnancy. May bleed profusely when traumatized.

Angiosarcoma: Painless red to purple macule typically found on the forehead or scalp of elderly Caucasian males. May ulcerate or bleed in advanced or aggressive cases. Can be confused with benign lesions such as vascular malformations or even bruises.

Kaposi sarcoma: Blue-red to violet nodules that may have superficial ulceration. Most often seen in association with human immunodeficiency virus/acquired immunodeficiency syndrome.