Differential Diagnosis of Nasal Mass

Differential Diagnosis of Nasal Mass

When a patient presents with a nasal mass, the key is to systematically consider the possible causes and use clinical history and examination findings to narrow down the options.

In this post, we'll classify the various conditions that can present as a nasal mass and describe the typical clinical appearance of each.

✨ Classification of Nasal Mass Causes

Nasal masses can arise from various pathological processes. We can classify them into the following groups:

1. Congenital Causes
2. Inflammatory Causes
3. Tumors (Benign and Malignant)
4. Granulomatous Diseases (Specific and Nonspecific)
5. Fungal Sinusitis
6. Miscellaneous Causes

Let's delve into each category and the appearance of the masses they cause.

📍 Clinical Appearance of Nasal Masses by Category

1. Congenital Causes of Nasal Mass

These arise from developmental abnormalities.

• Glioma:

What is Glioma? What are the different types of Glioma?

• Extranasal Glioma (60%): Presents as a firm, subcutaneous swelling on the bridge or side of the nose, or near the inner canthus.

• Intranasal Glioma (30%): Presents as a mass within the nasal cavity. It is firm, non-compressible, non-pulsatile. Does NOT enlarge on crying or straining (Negative Furstenberg Sign). Does not transilluminate.

• Mixed (10%): Components both inside and outside the nose.

• Meningocele / Encephalocele / Meningoencephalocele:

What is a Meningocele, Encephalocele and Meningoencephalocele?

• Appearance: Bluish and soft mass.

• Compressible: Can often be pushed back up (if the bony defect is large enough).

• Translucent.

• Enlarges on crying or straining (Positive Furstenberg Sign) - this is a key differentiator from Glioma.

2. Inflammatory Causes of Nasal Mass

• Antrochoanal Polyp (Killian's Polyp):

  • Usually solitary.

  • Appearance: Pale or greyish, glistening, soft mass.

  • Location: Usually originates from the maxillary antrum (antrum part), extends into the nasal cavity (choanal part), and often reaches the choana posteriorly. Seen between the septum and inferior turbinate anteriorly.

  • Characteristics: Smooth surface, mobile, insensitive to touch/probing.

  • Does NOT bleed on touch (relatively avascular).

  • Probe can usually be passed all around the mass.

  • Posterior rhinoscopy: Globular, smooth mass in the choana.

What is the site of origin of Antrochoanal Polyp?

• Ethmoidal Polyp:

  • Usually always bilateral.

  • Appearance: Multiple pale, greyish-white, soft masses resembling a bunch of grapes.

  • Location: Originate from the ethmoid sinuses, typically prolapsing into the nasal cavity via the middle meatus.

  • Characteristics: Smooth surface, mobile, insensitive to touch/probing.

  • Does NOT bleed on touch (relatively avascular).

What is the site of origin of Ethmoidal Polyp?

3. Tumors of Nose

Nasal tumors can be benign or malignant.

Benign Tumors of Nose:

• Squamous Papilloma:

  • Appearance: Warty (verrucous) lesions, like skin warts on the nasal mucosa.

What is the site of origin of Squamous Papilloma?

• Inverted Papilloma:

  • Appearance: Fleshy mass, pinkish or greyish. Can be soft or firm.

  • Characteristics: Usually friable, bleeds easily on touch (vascular).

  • Insensitive to touch (key differentiator from malignant tumors).

What is the site of origin of Inverted Papilloma?

What are the other names of Inverted Papilloma?

• Hemangioma: Vascular tumors.

  • Capillary Hemangioma (Bleeding Polypus of the Septum): Soft, dark red, pedunculated or sessile mass. Arises from the anterior part of the nasal septum. Bleeds heavily on touch (very vascular). Usually smooth surface, but can be ulcerated.

  • Cavernous Hemangioma: Reddish or purplish mass. Usually arises from the turbinates on the lateral wall (e.g., middle turbinate). Bleeds on touch.

What is the site of origin of Capillary and Cavernous Hemangioma?

• Angiofibroma (Juvenile Nasopharyngeal Angiofibroma):

  • Appearance: Globular, pinkish, smooth mass. Often shows visible vessels on the surface. Firm in consistency.

  • Highly vascular, bleeds profusely on touch.

What is the site of origin of Angiofibroma?

What is the most common age group of Angiofibroma?

• Schwannoma: Rare, arises from nerve sheath.

  • Appearance: Usually rounded nasal mass, firm to rubbery. May be yellowish. May have surface blood vessels.

What is the site of origin of Schwannoma?

• Chondroma: Very rare tumor of cartilage.

  • Appearance: Smooth, firm, lobulated mass.

What is the site of origin of Chondroma?

• Pleomorphic Adenoma: Very rare minor salivary gland tumor in the nose.

Malignant Tumors of Nose:

Malignant nasal masses often share some common characteristics, but specific types have distinguishing features.

• General Malignant Appearance:

  • Irregular shape with everted margins.
  • Pinkish or grayish mass.
  • Friable, bleeds very easily on touch.
  • Sensitive to touch (differentiates from inverted papilloma).
  • Firm consistency.
  • May show ulceration.
  • Associated symptoms often include pain, nasal obstruction, discharge (often blood-stained/purulent), facial swelling/numbness, visual symptoms (if sinus extension), loosening of teeth.

• Squamous Cell Carcinoma:

  • Most common malignant nasal tumor.

  • Typically in 6th-7th decade, more common in males.

What is the site of origin of Squamous Cell Carcinoma?

• Adenocarcinoma:

  • Common in 6th-7th decade, more common in males.

  • Strong association with woodworkers (exposure to hardwood dust).

What is the site of origin of Adenocarcinoma?

• Adenoid Cystic Carcinoma:

  • Most common minor salivary gland tumor in the nose.

  • More common in females than males.

  • Grows slowly but has early perineural and vascular spread.

• Esthesioneuroblastoma (Olfactory Neuroblastoma):

  • More common in females.

  • Bimodal age distribution (peaks around 20 and 50 years).

  • Often expresses neuroendocrine markers (NSE, synaptophysin, chromogranin).

Where does Esthesioneuroblastoma arise from?

• Melanoma:

  • Appearance: Polypoidal, fleshy mass. Can be heavily pigmented (black) or non-pigmented (amelanotic melanoma - pink). Solitary or multicentric.

  • Common in the elderly, more common in females.

What is the site of origin of Melanoma?

• Hemangiopericytoma:

  • Appearance: Soft, grey, polypoidal mass. Bleeds profusely on touch.

4. Granulomatous Diseases

These involve chronic inflammation with granuloma formation. Can be specific (caused by a known agent) or nonspecific.

Specific Granulomatous Diseases:

• Bacterial:

  • Rhinoscleroma:

    • Stages: Atrophic (resembles atrophic rhinitis - atrophy, crusts, discharge), Granulomatous (Presents as a nasal mass/nodules - painless, non-ulcerative), Cicatricial (scarring, stenosis - e.g., nares).

  • Tuberculosis: Rare in nose. Starts in anterior septum/inferior turbinate.

    • Nodular infiltration → ulceration → perforation (cartilaginous septum).

  • Leprosy: Site similar to TB. Excessive discharge, red/swollen mucosa, nodular lesions → ulceration → perforation. Leads to atrophic rhinitis, depressed nasal bridge, columellar retrusion.

  • Syphilis: Causes Gumma formation in nasal septum. Leads to destruction of both bony and cartilaginous septum.

• Fungal:

  • Rhinosporidiosis:

    • Appearance: Friable, red, polypoidal, "strawberry-like" mass studded with white dots (sporangia). Very vascular, bleeds easily on touch. Forms from granulation tissue.

  • Mucormycosis:

    • Appearance: Black, necrotic mass filling nasal cavity.
    • Destructive, often erodes septum and hard palate.

Nonspecific Granulomatous Diseases:

• Sarcoidosis:

  • Appearance in nose: Characteristic "strawberry skin" appearance (tiny pale granulomas against hypertrophic erythematous mucosa). Often friable.

• Wegener's Granulomatosis (Granulomatosis with Polyangiitis):

  • Appearance in nose: Very destructive. Leads to destruction of intranasal structures (septum, turbinates, sinuses) with formation of a single large cavity. Often involves septal perforation and nasal collapse (Saddle nose deformity).

5. Fungal Sinusitis

• Allergic Fungal Sinusitis (AFS):

  • Presents with unilateral or bilateral nasal polyposis (often large).

  • Characteristic finding: Thick, sticky, yellowish or greenish mucus known as "allergic mucin", described as having a "peanut butter-like" consistency.

6. Miscellaneous Causes of Nasal Mass

Other less common or non-pathological entities.

• Hypertrophied Inferior Turbinate:

  • Appearance: Soft, pinkish mass arising from the inferior part of the lateral wall.

  • Distinguishing Feature: Shrinks significantly on application of nasal decongestant (due to vasoconstriction of underlying vascular tissue).

  • Not mobile (fixed structure), sensitive to touch.

• Rhinolith: A stone (calcified mass) within the nasal cavity, usually forming around a foreign body.

  • Appearance: Greyish-brown or greenish-black mass with a very irregular surface.

  • Stony hard consistency.

  • Location: Usually between nasal septum and turbinates.

  • Often brittle and breaks on manipulation.

• Blob of Mucus:

  • Sometimes a large, dried or inspissated clump of mucus can resemble a mass.

  • Key differentiation: Easily removed with suction or irrigation. Not attached tissue.