What is the likely diagnosis for swelling off the top nasal bridge, potentially related to rhinosinusitis or nasal furuncle, in a patient with possible allergies or nasal trauma?

Swelling of the Top Nasal Bridge: Likely Diagnosis

The most likely visiting diagnosis for swelling at the top of the nasal bridge is acute rhinosinusitis with periorbital extension, though nasal furuncle, trauma-related soft tissue swelling, or less commonly, a structural mass must be considered in the differential.

Primary Diagnostic Considerations

Acute Rhinosinusitis with Periorbital Extension

• Swelling at the nasal bridge often indicates ethmoid sinusitis with anterior soft tissue involvement, as the ethmoid sinuses lie directly beneath this anatomical region 1
• Look for accompanying symptoms including nasal congestion, purulent nasal discharge, facial pressure or pain, and fever 1
• The presence of symptoms for 10 days or more, or worsening after initial improvement ("double worsening"), strongly suggests acute bacterial rhinosinusitis rather than viral upper respiratory infection 1
• Unilateral swelling with erythema, warmth, and tenderness raises concern for complicated sinusitis requiring urgent evaluation for orbital or intracranial extension 1

Nasal Furuncle (Infected Hair Follicle)

• A localized, tender, erythematous swelling at the nasal bridge or nasal tip suggests folliculitis or furuncle, particularly if there is a visible pustule or central point of infection 2
• This typically presents as a discrete, painful nodule rather than diffuse swelling 2

Trauma-Related Swelling

• Recent history of nasal trauma, even minor, can cause localized edema and hematoma formation at the nasal bridge 2
• Assess for nasal bone tenderness, deformity, or septal hematoma on examination 3

Structural Abnormalities or Masses

• Unilateral swelling, especially when associated with bleeding, pain, or progressive symptoms, should raise suspicion for neoplasm 2
• Nasal polyps typically present bilaterally and are semi-translucent on examination, though unilateral masses warrant biopsy consideration 4

Critical Physical Examination Findings

External Nasal Assessment

• Inspect for erythema, warmth, fluctuance, or visible deformity at the nasal bridge 3
• Assess for saddle nose deformity, which may indicate chronic inflammatory processes or previous trauma 3

Anterior Rhinoscopy

• Examine for purulent discharge, mucosal erythema, and edema, which suggest acute bacterial sinusitis 2, 3
• Document any visible polyps, masses, or structural abnormalities 3
• Unilateral findings are more concerning for structural problems, foreign bodies, or tumors 2

Associated Findings

• Check for periorbital edema, proptosis, or ophthalmoplegia, which indicate orbital complications requiring immediate imaging and specialist consultation 1
• Examine for fever, which supports infectious etiology 1

Diagnostic Workup Algorithm

When to Image

• CT imaging is NOT indicated for uncomplicated acute rhinosinusitis 1
• Obtain CT of the paranasal sinuses if:
  • Complications are suspected (orbital involvement, intracranial extension) 1
  • Symptoms persist despite optimal medical management 2
  • Unilateral mass or structural abnormality is identified 4
  • Alternative diagnosis such as neoplasm is considered 2

When to Consider Allergy Testing

• Patients with recurrent rhinosinusitis or chronic symptoms should be evaluated for underlying allergic rhinitis, as up to 60% have substantial allergic sensitivities 2
• Skin testing is the preferred method when allergy evaluation is indicated 2

Management Approach Based on Diagnosis

If Acute Bacterial Rhinosinusitis

• Amoxicillin is first-line antibiotic therapy for most adults 1
• Provide analgesic treatment based on pain severity 1
• Reassess at 7 days if the patient worsens or fails to improve to confirm diagnosis and exclude complications 1

If Nasal Furuncle

• Warm compresses and topical antibiotics for early, localized infection 5
• Systemic antibiotics if cellulitis is present 5
• Avoid manipulation or incision of nasal furuncles due to risk of cavernous sinus thrombosis

If Allergic Component Suspected

• Intranasal corticosteroids are first-line for both allergic and non-allergic rhinitis and may reduce sinus ostial obstruction 6
• Oral antihistamines have limited efficacy for nasal congestion but may help associated symptoms 2

Critical Pitfalls to Avoid

• Do not rely on mucosal appearance alone to distinguish allergic from non-allergic rhinitis, as both can present with similar findings 2, 3
• Avoid plain radiography, as it has no benefit in rhinosinusitis workup; CT is the preferred imaging modality when indicated 2
• Do not prescribe antibiotics for viral rhinosinusitis (symptoms <10 days without worsening) 1
• Recognize red flags for complicated sinusitis: severe headache, visual changes, altered mental status, or significant periorbital swelling requiring urgent evaluation 1
• Unilateral nasal findings warrant heightened suspicion for alternative diagnoses including neoplasm, requiring biopsy consideration 2, 4