What should I do about a persistent bump under my nose?

Persistent Bump Under the Nose: Evaluation and Management

You need to see a healthcare provider for direct examination and possible nasal endoscopy, as a persistent unilateral or non-healing nasal lesion requires evaluation to exclude serious pathology including malignancy, benign tumors, or chronic inflammatory disease. 1

Immediate Red Flags Requiring Urgent Evaluation

Any of the following warrant immediate referral to an otolaryngologist:

• Unilateral presentation (bump on only one side) - this is a red flag for neoplastic disease 1
• Non-healing characteristics over weeks to months 1
• Bleeding from the lesion, especially recurrent or difficult to control 2, 1
• Crusting or ulceration of the bump 2, 1
• Progressive growth or change in appearance 1

Why This Requires Professional Evaluation

Nasal malignancies commonly present as unilateral lesions with obstruction and crusting, and life-threatening bleeding has been associated with delayed diagnosis. 1 While many bumps are benign, anterior rhinoscopy alone (looking in the nose with a light) is insufficient for unilateral disease, as tumors may not be visible with limited examination. 1

Differential Diagnosis to Consider

The location "under the nose" could represent several entities:

External nasal lesions:

• Acne-associated angiofibromas - flesh-colored dome-shaped papules, particularly in adolescent males with acne history 3
• Infantile hemangiomas (in children) - require early evaluation as nasal tip lesions often need multimodal treatment 2
• Inflammatory acne sequelae - papular scarring that can be disfiguring 3

Internal nasal cavity lesions:

• Nasal polyps - typically bilateral, mobile, grey, smooth masses that are insensitive to touch 2, 4
• Pyogenic granuloma - benign but can bleed 2
• Inverted papilloma - benign but locally aggressive tumor requiring different management 1
• Nasal malignancy - presents with unilateral obstruction in 66.7% and bleeding in 55% of cases 2
• Juvenile nasopharyngeal angiofibroma (adolescent males) - presents with profuse unilateral bleeding in 60-76% 2

Required Diagnostic Workup

Your healthcare provider should perform:

1. Detailed history focusing on:

   • Duration and progression of the bump 1
   • Associated symptoms: bleeding, obstruction, pain, discharge 2, 1
   • History of trauma, prior nasal surgery, or cocaine use 2
   • Systemic symptoms suggesting granulomatous disease 2

2. Physical examination including:

   • Nasal endoscopy to examine the entire nasal cavity and nasopharynx - this is essential for unilateral lesions 1
   • Assessment of whether the lesion is mobile, sensitive to touch, and its exact location 2
   • Evaluation for septal perforation, crusting, or other mucosal abnormalities 2

3. Imaging if indicated:

   • CT of paranasal sinuses for unilateral disease to evaluate for masses, bone destruction, and extent of involvement 1
   • Look specifically for osseous destruction or extrasinus extension suggesting malignancy 1

4. Biopsy for histologic confirmation - any unilateral non-healing nasal lesion requires tissue diagnosis 1

Common Pitfalls to Avoid

• Do not assume a persistent bump is benign without proper evaluation - the radiographic and endoscopic appearance of unilateral polypoid disease may represent fungal disease, inverted papilloma, or malignancy 1
• Do not delay referral if you cannot perform nasal endoscopy yourself - refer to otolaryngology for complete examination 1
• Do not rely on external appearance alone - internal pathology may not be visible without endoscopy 2, 1

When Benign Inflammatory Disease is Confirmed

If evaluation reveals nasal polyps or chronic inflammatory disease:

• First-line treatment: Intranasal corticosteroids twice daily are more effective than once-daily dosing 5
• For severe polyposis: Short course of oral prednisone (25-60 mg daily for 5-20 days) followed by maintenance intranasal corticosteroids 5
• Adjunctive therapy: Saline irrigation may improve mucociliary clearance 5
• Surgery is indicated when polyps obstruct drainage and persist despite appropriate medical treatment, or when there is recurrent infectious sinusitis despite adequate medical management 2

The critical first step is obtaining proper visualization and diagnosis through professional examination with nasal endoscopy. 1