An Unusual Mid-Line Nasal Mass in a Child: A Case Report

Introduction

Pediatric nasal masses represent a diagnostic challenge due to their relatively rare occurrence and diverse differential diagnosis (1). An unusual mid-line nasal mass in a child may be indicative of various underlying conditions, which could range from benign congenital anomalies, such as a dermoid cyst or encephalocele, to more serious malignancy (2). The clinical presentation can be ambiguous, often including symptoms like nasal obstruction, epistaxis, or a visible external deformity. However, for instance, these masses may remain asymptomatic, leading to delayed diagnosis and treatment (3–5).

Case Presentation

A 3-year-old girl presented on the midline nasal dorsum with an atypical firm, non-fixed, slightly erythematous mass measuring approximately 2x2 cm, an uncommon size for such mass. Physical examination revealed a mass explicitly located in the anterior region of the right side of the nasal cavity, causing an obstruction. The patient experienced symptoms such as open-mouth sleeping, snoring, attention deficit, constant nasal congestion, nasal discharge, and difficulty learning due to the growth of the mass on the nasal dorsum. The mass had been present since birth and had progressively increased in size, noticed as a 2x3 mm lesion on the nasal dorsum at birth.

Visual examination was regular and confirmed that the mass did not obstruct the visual field, thus eliminating the potential risk for amblyopia. Imaging studies, including a computed tomography (CT) scan, revealed a mass on the nasal dorsum with smooth surfaces, solid components, and microcysts but caused no bone defects on the nasal bone, a relatively unusual finding. Furthermore, magnetic resonance (MR) imaging with contrast identified a right nasal encephalocele. Interestingly, the mass on the nasal dorsum was independent of encephalocele. A neurosurgery consultation was obtained as necessary.

The patient underwent excision of the nasal dorsal mass and endoscopic encephalocele repair. No graft was used following the nasal dorsal mass excision—the encephalocele repair involved harvesting a graft from the fascia lata. The patient experienced no postoperative complications, and no cerebrospinal fluid (CSF) leakage was observed during the 3-day follow-up. Pre- and postoperative photographs of the patient are shown in Figure 1.

Pathological examination of the excised nasal dorsum sample revealed hypertrophied fibrous tissue containing a foreign body reaction and eccrine gland structures in the dermis. The skin tissue was covered with stratified squamous epithelium. These findings are consistent with a dermoid cyst.

Materials and Methods

The surgical procedure was initiated with an endoscopic repair of the nasal encephalocele. The region of the encephalocele was cauterized using a nasal bipolar coagulator, facilitating a reduction in the mass size towards the cranium. Subsequently, a graft was harvested from the fascia lata and applied to the anterior ethmoid area's defect using fibrin tissue adhesive. Attention was then shifted to the mass on the nasal dorsum. A regional hydrodissection was performed to isolate the mass.

The mass excision was carried out from the upper to lower midline of the nasal dorsum. The defect was closed using an advancement flap with 5/0 polydioxanone sutures. Throughout the procedures, meticulous attention was paid to minimizing trauma to surrounding tissues. The patient was then closely monitored during the postoperative period for any potential complications, including cerebrospinal fluid leakage. The excised tissue sample from the nasal dorsum was sent for histopathological examination to confirm the diagnosis and further understand the nature of the mass.

Discussion

Congenital midline nasal masses are rare, with a prevalence of 1 in 20,000 to 40,000 births (1). Differential diagnosis of midline nasal masses includes nasal glioma, dermoid cyst, lipoma, hemangioma, and encephalocele (2). The nasal dermoid was commonly present as a midline mass and may be located on the nasal dorsum or the nasoglabellar region (3).

An exciting aspect observed during the treatment was a tissue resembling granulation tissue seen in foreign body reactions. A foreign body reaction is a complex process where the body responds to a foreign object, such as surgical sutures, splinters, or implants, forming granulation tissue. Further study on occurrence and implications of this in congenital nasal mass treatment could be a topic of interest.

Computed tomography (CT) and magnetic resonance imaging (MRI) scans are the gold standards for radiographic evaluation of nasal dermoids. MRI may be sufficient to determine intracranial extension (4, 5). Advancement flaps are important reconstructive options after skin mass removal. The flaps are mainly used for defects located on the superior two-thirds region of the nose (6, 7). A notable aspect of this case is the closure of the skin using an advancement flap without a graft following tumor excision. This approach facilitated a faster recovery for the child compared to grafted reconstruction.The length of stay was reduced due to the accelerated recovery (8). The treatment of congenital nasal dorsal masses is typically surgical. It's crucial to approach surgeries, especially in children, with great caution, given the potential impact on their psychological development. The findings from this case highlight the importance of meticulous surgical techniques.

An encephalocele and a dermoid cyst co-occurred incidentally in this patient, as there is no physical connection between two lesions. This presents unique learning point and extends our understanding of the complexity and variability of congenital nasal dorsal masses. In the one-year follow-up period, no recurrence or growth was observed at the excision site. In conclusion, this case report demonstrates the co-occurrence of an encephalocele and a dermoid cyst of the nasal dorsum, with no connection between the two. The successful surgical management, which included skin closure with an advancement flap without grafting, highlights the potential benefits of this technique in reducing patient recovery time and length of hospital stay. The careful handling of such cases, including long-term follow-up, adds to our understanding of congenital nasal dorsal masses and can potentially improve the overall outcomes for affected children.