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A 2-month-old infant with unilateral nasal discharge containing blood and mucus since birth raises concern for a congenital or structural cause rather than a typical infectious etiology. Here is a differential diagnosis (DDx) prioritized by likelihood and severity:
🔑 Top Differential Diagnoses
1. Nasal Dermoid Cyst or Sinus
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Congenital midline mass that can track intracranially.
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Can cause chronic discharge, sometimes bloody.
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Look for a pit or dimple on the nasal dorsum.
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Risk: meningitis if intracranial extension.
2. Encephalocele
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Herniation of intracranial contents through a defect in the skull base.
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Can present with persistent nasal discharge, may be CSF mixed with blood/mucus.
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Transilluminates, enlarges with crying/straining.
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Urgent imaging needed (MRI).
3. Nasal Glioma (Nasal Heterotopia)
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Firm, noncompressible congenital mass.
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Not true tumors, but glial tissue trapped during development.
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May cause obstruction and discharge, sometimes blood-tinged.
4. Choanal Atresia (Unilateral)
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Common congenital nasal obstruction.
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Often leads to persistent unilateral discharge.
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May not have blood unless traumatized or infected.
5. Congenital Nasolacrimal Duct Obstruction with Infection (Dacryocystocele)
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Can cause unilateral mucopurulent discharge that may be blood-streaked if irritated.
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Look for swelling at medial canthus.
6. Intranasal Foreign Body
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Less likely from birth but should be ruled out.
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May cause foul-smelling, bloody discharge.
⚠️ Less Common but Important Considerations
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Hemangioma of the nasal cavity: vascular lesions that may bleed.
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Iatrogenic trauma from suctioning or nasogastric tubes in neonates.
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Neonatal rhinitis: unlikely to be unilateral or present since birth.
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Neoplasm (rare): e.g., rhabdomyosarcoma, teratoma – would usually present with mass and obstruction.
🧪 Recommended Workup
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Nasopharyngoscopy or ENT referral for direct visualization.
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MRI brain and face: to assess for encephalocele, dermoid sinus.
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CT scan if bony abnormalities (choanal atresia, sinus tract) suspected.
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Ophthalmologic evaluation if lacrimal system involved.
🚩Red Flags Needing Urgent Imaging
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Midline lesions
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Discharge that increases with crying or straining
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Signs of intracranial communication
Would you like help creating an evaluation plan or imaging decision guide based on these differentials?
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