Approach to the Problem
Swelling of the nasal bridge is an uncommon problem that can present a diagnostic dilemma to the practitioner. Lesions resulting in swelling can be divided into congenital and acquired etiologies. Congenital lesions of the nose occur in 1 in 20,000 to 40,000 live births. The most common congenital lesions to consider in the differential diagnosis include hemangiomas, dacryocystoceles, dermoid cysts, gliomas, and encephaloceles. Teratomas, lymphangiomas, lipomas, and angiofibromas are less frequently encountered. Acquired lesions occur secondary to trauma or infection.
Key Points in the History
• Rapid growth of the lesion in the first weeks to months of life is suggestive of a hemangioma.
• Multiple cutaneous hemangiomas are associated with diffuse neonatal hemangiomatosis.
• Increased size when crying or straining raises the possibility of a connection to the central nervous system consistent with an encephalocele.
• Intermittent discharge of sebaceous material can occur with nasal dermoid cysts.
• Fever can be evidence of an infected congenital cystic lesion or meningitis complicating lesions that extend to the central nervous system.
• Anterior encephaloceles are associated with hydrocephalus, agenesis of the corpus callosum, and other brain malformations.
• A history of trauma may result in a nasal fracture or contusion.
Key Points in the Physical Examination
• Reddish or bluish discoloration and telangiectasias are most consistent with hemangiomas, but may be seen in gliomas.
• Cystic lesions located on the lateral aspect of the nose just under the medial canthus indicate the presence of a dacryocystocele.
• Dermoid cysts are midline lesions.
• Hair protruding from a midline mass most likely represents a dermoid cyst.
• Compressible lesions suggest encephaloceles and hemangiomas.
• Transillumination may be evident in encephaloceles.
• A positive Furstenberg sign, represented by enlargement of the mass with compression of the jugular veins, makes the diagnosis of an encephalocele probable.
