What are the differential diagnoses and recommended workup for swelling on the side of the nose?

Differential Diagnosis and Workup for Lateral Nasal Swelling

Swelling on the side of the nose requires systematic evaluation to distinguish between infectious, inflammatory, traumatic, neoplastic, and granulomatous etiologies, with biopsy indicated if the lesion persists beyond 2 weeks or appears atypical. 1

Initial Clinical Assessment

External Examination

• Inspect for deformities, asymmetry, or saddle nose deformity, which may indicate trauma, previous surgery, cocaine abuse, or inflammatory processes such as granulomatosis with polyangiitis (Wegener's) or relapsing polychondritis 2, 1
• Assess for erythema, warmth, fluctuance, or skin changes that suggest infection (cellulitis, abscess, furuncle) versus inflammatory or neoplastic processes 2
• Palpate for tenderness, induration, or underlying mass to differentiate superficial from deep-seated pathology 2

Anterior Rhinoscopy

• Use a nasal speculum with adequate lighting to visualize internal structures, documenting septal position, turbinate size, mucosal characteristics, and presence of masses or polyps 2
• Look for mucopurulent discharge, which suggests acute bacterial rhinosinusitis as a potential cause of facial swelling 3
• Apply topical decongestant to distinguish mucosal edema from structural abnormalities—reduction after decongestant suggests reversible mucosal swelling rather than fixed anatomic pathology 2

Key Differential Diagnoses

Infectious Etiologies (Prevalence ~3%)

• Acute bacterial rhinosinusitis with facial cellulitis: Presents with purulent nasal drainage, nasal obstruction, facial pain/pressure, and symptoms persisting ≥10 days or worsening after initial improvement ("double sickening") 3
• Nasal vestibulitis or furuncle: Localized infection of nasal vestibule hair follicles causing tender, erythematous swelling 1
• Invasive fungal sinusitis: Maintain extremely high suspicion in immunocompromised patients (diabetes, hematologic malignancies, transplant recipients, chronic steroid use) presenting with facial swelling, fever, facial pain, proptosis, or facial necrosis—this is a medical emergency with 50% mortality if untreated 3, 1, 4

Inflammatory/Autoimmune Etiologies (Prevalence ~11%)

• Granulomatosis with polyangiitis (Wegener's): Presents with nasal ulceration, crusting, epistaxis, and saddle nose deformity; may cause lateral nasal swelling from granulomatous inflammation 1, 5
• Sarcoidosis: Can present as nasal masses or swelling with granulomatous inflammation 1, 5
• Relapsing polychondritis: Causes recurrent inflammation of cartilaginous structures including the nose, potentially leading to saddle nose deformity 1
• Chronic rhinosinusitis with nasal polyps: Causes nasal obstruction and facial fullness, though typically bilateral 3, 4

Traumatic Etiologies (Prevalence ~39%)

• Nasal trauma with hematoma or soft tissue injury: Most common cause of nasal swelling; obtain history of recent trauma 1, 6
• Septal hematoma: Requires urgent drainage to prevent cartilage necrosis and saddle nose deformity 6

Neoplastic Etiologies

• Inverted papilloma: Most common benign sinonasal tumor, characteristically unilateral and polypoid in appearance 3
• Squamous cell carcinoma or other malignancies: Present with unilateral nasal obstruction, epistaxis, facial swelling, proptosis, or cranial nerve dysfunction; early signs are nonspecific 3
• Juvenile angiofibroma: Vascular posterior nasal mass in adolescent males—do not biopsy due to hemorrhage risk 3

Drug-Induced Etiologies (Prevalence ~3%)

• Cocaine-induced midline destructive lesions: Causes nasal ulceration, septal perforation, and lateral nasal swelling; unfortunately has high prevalence of positive c-ANCA, limiting ability to distinguish from Wegener's 1, 5
• Rhinitis medicamentosa: Rebound congestion from overuse of topical decongestants 1

Diagnostic Workup Algorithm

Immediate Evaluation (All Patients)

1. Obtain detailed history: Duration of swelling, associated symptoms (fever, epistaxis, pain, nasal obstruction, purulent discharge), trauma history, medication use (topical decongestants, cocaine, ACE inhibitors), immunocompromised status, occupational exposures 1
2. Perform anterior rhinoscopy with nasal speculum to document internal findings 2
3. Assess for signs of complications: Proptosis, ophthalmoplegia, visual changes, severe headache, altered mental status, facial necrosis 3

Laboratory Testing (Selective Based on Clinical Suspicion)

• Complete blood count: Indicated for persistent swelling to rule out hematologic disorders 1
• c-ANCA (PR3) and p-ANCA (MPO): If granulomatosis with polyangiitis suspected, though beware that cocaine use causes false-positive c-ANCA 1, 5
• ACE level: If sarcoidosis suspected 1
• Fungal staining and culture: Mandatory if invasive fungal sinusitis suspected in immunocompromised patients—early diagnosis is critical for survival 3

Imaging Studies

• CT maxillofacial without contrast: Indicated for suspected chronic rhinosinusitis (symptoms ≥12 weeks), recurrent acute rhinosinusitis (≥3 episodes/year), suspected complications (orbital/intracranial involvement), or presurgical planning 4
• Do NOT obtain imaging for uncomplicated acute rhinosinusitis <4 weeks duration—CT cannot distinguish bacterial from viral etiology 3, 4
• MRI with and without contrast: Mandatory when invasive fungal sinusitis suspected in immunocompromised patients, as it better demonstrates soft tissue invasion, vascular complications, and intracranial extension 4

Tissue Biopsy (Critical Decision Point)

Biopsy is indicated when: 1

• Swelling/ulcer persists beyond 2 weeks despite conservative treatment
• Malignancy suspected based on appearance (unilateral mass, epistaxis, cranial nerve signs)
• ANCA or ACE levels are abnormal
• Granulomatous disease, fungal infection, or neoplasia in differential
• Exception: Do not biopsy suspected juvenile angiofibroma (vascular mass in adolescent male) due to hemorrhage risk 3

Management Based on Etiology

Acute Bacterial Rhinosinusitis with Facial Swelling

• First-line antibiotic: Amoxicillin with or without clavulanate for 5-10 days 3
• Adjunctive therapy: Topical intranasal corticosteroids, nasal saline irrigation, analgesics for symptomatic relief 3
• Reassess at 7 days—if worsening or no improvement, consider complications or alternative diagnosis 3

Invasive Fungal Sinusitis (Medical Emergency)

• Voriconazole is the preferred antifungal agent with 90% response rate 1
• Urgent surgical debridement is essential to prevent embolic complications and CNS extension (mortality 20% even with treatment) 1

Granulomatous Disease

• Systemic corticosteroids for confirmed sarcoidosis 1
• Refer to rheumatology for granulomatosis with polyangiitis management (cyclophosphamide, rituximab, or alternatives like methotrexate/leflunomide) 5

Conservative Management for Idiopathic/Traumatic Swelling

• Nasal saline irrigation, topical emollients, discontinuation of causative medications (70% success rate) 1
• Immediate nasal reconstruction is ideal for trauma when medically possible to decrease long-term sequelae 6

Specialist Referral Criteria

Refer to otolaryngology when: 1

• Swelling persists beyond 2 weeks despite treatment
• Biopsy needed for tissue diagnosis
• Suspected neoplasm or invasive fungal disease
• Surgical intervention required

Refer to allergy/immunology when: 1

• Chronic/recurrent rhinosinusitis present
• Immunodeficiency evaluation needed

Critical Pitfalls to Avoid

• Do not delay biopsy in persistent or atypical lesions—early tissue diagnosis is essential for neoplasms and granulomatous diseases 1
• Do not obtain surface cultures of nasal vestibule—they reflect normal flora rather than pathogens; if bacterial sinusitis suspected, cultures must be from middle meatus under endoscopic guidance 1
• Do not miss invasive fungal sinusitis in immunocompromised patients—maintain high index of suspicion and obtain urgent MRI and biopsy 3, 4
• Do not rely on mucosal appearance alone to distinguish etiologies—both allergic and nonallergic conditions can present with similar findings 2