What is the management plan for swelling on the bridge of the nose that is affecting the eyes?

Management of Nasal Bridge Swelling with Periorbital Extension

Immediate imaging with contrast-enhanced CT of the orbits and paranasal sinuses is mandatory to exclude orbital cellulitis, which requires emergent hospitalization with IV antibiotics to prevent vision loss, meningitis, or death. 1

Critical Red Flag Assessment

The first priority is determining whether this represents preseptal versus orbital involvement, as orbital cellulitis is a medical emergency:

• Examine for proptosis, impaired or painful extraocular movements, decreased visual acuity, ophthalmoplegia, severe headache, or photophobia - any of these findings indicate orbital cellulitis requiring immediate hospitalization 1
• Obtain contrast-enhanced CT of orbits and paranasal sinuses if any clinical suspicion exists for orbital involvement, especially with associated sinusitis 1
• Perform fluorescein staining to detect corneal involvement, which requires immediate ophthalmology referral 1

Differential Diagnosis by Mechanism

Trauma-Related Causes

If there is history of nasal trauma (even remote):

• Consider naso-orbital-ethmoid fracture - presents with swelling of the upper nasal bridge, periorbital ecchymosis, telecanthus, and potential for enophthalmos 2
• Evaluate for orbital wall fractures - medial orbital wall fractures can cause dramatic eyelid swelling, decreased vision, and orbital emphysema, particularly after nose blowing 3
• CT imaging is the gold standard for identifying midface fractures, as these injuries often involve multiple facial bones and can cause permanent vision loss if untreated 2

Infectious/Inflammatory Causes

If no trauma history or trauma remote:

• Preseptal cellulitis - eyelid swelling without orbital signs; can be managed outwardly with oral antibiotics only if eyelid <50% closed, no proptosis, no visual changes, and no impaired extraocular movements 1
• Ethmoid sinusitis - particularly in children under 5 years, can cause periorbital swelling and progress to orbital cellulitis 1
• Dacryocystitis - infection of the nasolacrimal sac presents with erythema, swelling, warmth, and tenderness over the lacrimal sac area; requires early treatment to prevent orbital cellulitis, meningitis, or sepsis 4

Vascular/Allergic Causes

• Allergic rhinitis with secondary venous congestion - can cause periorbital "allergic shiners" (blue-grey discoloration) and nasal mucosal swelling, though typically bilateral 2, 5
• Nasolacrimal duct obstruction - most common in infants <1 year, presents with persistent tearing and swelling over nasolacrimal sac 4

Management Algorithm

If Orbital Cellulitis Suspected:

1. Immediate hospitalization with IV antibiotics 1
2. Urgent ophthalmology and ENT consultation 1
3. Serial examinations for vision and extraocular movements 1

If Preseptal Cellulitis (All Criteria Met):

1. High-dose amoxicillin-clavulanate orally 1
2. Mandatory reassessment within 24-48 hours - failure to improve or worsening requires immediate hospitalization with IV antibiotics 1
3. Warm compresses and elevation 1

If Trauma-Related:

1. CT scan to identify fractures - naso-orbital-ethmoid fractures require early surgical management to prevent telecanthus, enophthalmos, and lacrimal obstruction 2
2. Ophthalmology referral for orbital wall fractures - medial wall fractures may resolve spontaneously but require monitoring for vision changes 3
3. Conservative management initially for isolated soft tissue trauma with observation 6

If Inflammatory/Allergic:

1. Intranasal corticosteroids for allergic rhinitis with mucosal swelling 2
2. Oral antihistamines for associated allergic symptoms 2
3. Topical decongestants (short-term only, <3 days) to assess mucosal versus bony contribution 2

Common Pitfalls to Avoid

• Missing orbital involvement - any doubt requires CT imaging, as clinical examination alone can miss early orbital cellulitis 1
• Delaying imaging in trauma patients - naso-orbital-ethmoid fractures require early intervention to prevent permanent cosmetic and functional deficits 2
• Prescribing oral antibiotics for preseptal cellulitis without ensuring proper follow-up - patients must be reassessed within 24-48 hours as progression to orbital cellulitis can be rapid 1
• Assuming bilateral periorbital swelling excludes serious pathology - bilateral involvement can occur with S-shaped septal deviations or systemic inflammatory conditions 2
• Overlooking nasolacrimal system involvement - dacryocystitis requires urgent ophthalmology referral due to high complication risk 4

Specific Treatment Considerations

For confirmed preseptal cellulitis without orbital signs:

• First-line: High-dose amoxicillin-clavulanate orally 1
• Duration: Continue until 24-48 hours after clinical improvement 1
• Follow-up: Mandatory reassessment within 24-48 hours 1

For allergic/inflammatory swelling:

• Intranasal corticosteroids (e.g., fluticasone, mometasone) are most effective for nasal mucosal inflammation 2
• Oral antihistamines provide relief for associated ocular symptoms 2
• Avoid prolonged topical decongestant use (>3 days) to prevent rhinitis medicamentosa 2

For post-traumatic swelling:

• Immediate reconstruction is ideal when medically possible to decrease long-term sequelae 6
• Surgical correction of naso-orbital-ethmoid fractures should occur early to prevent permanent deformity 2