This 2-year-old boy presented to the otolarynology department with a discharging midline nasal lesion. The lesion, present since birth, had occasionally discharged some pus-like fluid. It was usually treated with oral antibiotics, but, on this occasion, it had failed to respond, and there was some associated local swelling (fig 1). The child was pyrexial but otherwise well.

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Figure 1 Clinical photograph showing a midline nasal punctum with some widening of the nasal bridge.

CT and MRI revealed the lesion to be a nasal dermoid with a meningeal communication. There was associated dural enhancement (fig 2). Pneumococcus was isolated from blood cultures. The acute infection was managed with intravenous antibiotics before being evaluated by the local craniofacial team.

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Figure 2 Sagittal T2-weighted magnetic resonance image showing hyperintense nasal dermoid and sinus with meningeal enhancement.

Nasal dermoids arise when there is failed involution of the dural projection which extends through the foramen caecum in the first trimester. Encephaloceles and nasal gliomas may form in the same way.1 The nasal dermoid may have an associated sinus on the nasal dorsum and discharge hairs or sebaceous material.1 Around 20% have a persisting dural communication, which may result in the development of intracranial complications.1 2

CT and MRI enable accurate evaluation of bony detail and the detection of intracranial disease. Complete surgical excision is the treatment of choice. This may be performed by a variety of approaches depending on the size and extent of the lesion.3

Midline nasal lesions may not always be clinically impressive. However, they should be taken seriously, given the potential complications associated with them, and referred early for surgical evaluation.