Clinical Pediatrics 2015, Vol. 54(7) 700–702 © The Author(s) 2015 Reprints and permissions: sagepub.com/journalsPermissions.nav DOI: 10.1177/0009922815569208 cpj.sagepub.com Resident Round Case Report An 8-year-old, otherwise healthy girl presents with a 2-month history of focal swelling in her right nasal root area. The swelling improves when she sits upright and worsens with supine positioning, facial movements, and physical activity. The mother reports prominent veins on her nose since birth and smaller superficial vessels on her eyelids and chin. She has diminished visual acuity, a “popping” sensation in the corner of her right eye, and nasal congestion with tenderness. Because of significant pain caused by the nasal swelling and improperly fitting eyeglasses, she experienced difficulties in school and began homeschooling. She was unable to play softball because of inability to see without her eyeglasses. After a prior sinus computed tomography scan revealed an ethmoid sinus infection, she was treated with antibiotics. Her fever and tenderness resolved but the swelling was unchanged. There is no history of nasal trauma, relevant family history, or other areas of similar swelling. Examination revealed an ill-defined, nonpulsatile, nontender, reducible subcutaneous mass with surround- ing soft tissue edema on the right aspect of the nasal root. Mild yellowish discoloration of the nasal bridge with 2 overlying dilated veins were noted, but no pig- ment, nodularity, or epidermal changes were present. The mass and edema are most visible when in a Trendelenburg position and bulge with Valsalva maneu- vers (Figure 1A). The fullness decreases quickly on sit- ting upright (Figure 1B). Clinical Course After being seen by 17 physicians with workup including sinus computed tomography, brain magnetic resonance imaging (MRI), magnetic resonance angiography/venog- raphy, nasal endoscopy, chest radiography, and blood- work, a Doppler ultrasound and MRI were performed. Doppler ultrasound over the right nasal bridge showed a small soft tissue mass containing numerous dilated slow flow veins. Axial T2-weighted MRI at the level of the upper nares and ethmoid sinus revealed a 1.7 × 0.7 × 0.6 cm high signal, homogenously enhancing irregular soft tissue mass in the subcutaneous region closely associated with the right angular vein (Figure 2). Incidental ethmoid mucosal edema was present, and the adjacent nasal bone was dehiscent, suggesting a slowly growing chronic lesion. Surgical excision was considered but, because of proximity to the eye and possible cosmetic morbidity, percutaneous sclerotherapy was performed instead and swelling rapidly resolved. Digital subtraction venogram during direct needle puncture of the malformation showed venous outflow in a medial periorbital vein. The venous egress was compressed in order to avoid optic or intracra- nial effects of sclerotherapy agent. There were no compli- cations following sclerotherapy, and no other treatment was given. At the 2-month posttreatment follow-up, the venous malformation (VM) remained asymptomatic and the patient’s eyeglasses were able to fit, allowing her to return to school and return to playing softball. No addi- tional follow-up was needed at this time, but the possibil- ity of recurrence during puberty, pregnancy, or due to trauma was explained to the patient’s mother. Diagnosis Nasal root venous malformation. Discussion Patients with VMs often experience high rates of misdi- agnosis because of challenges in distinguishing VMs from other vascular anomalies. Classification of vascu- lar abnormalities can be based on both vascular kinetics and clinical aspects. 1 Two major classifications include vascular tumors, which are caused by endothelial hyper- plasia and vascular malformations, which are due to dysmorphogenesis rather than abnormal endothelial growth. 1 Hemangiomas are the most common type of vascular tumor, occurring on the skin of 4% to 10% of infants. 2 Because of their prevalence, VMs are fre- quently misdiagnosed as hemangiomas despite biologic 569208CPJ XX X 10.1177/0009922815569208Clinical PediatricsVuong et al research-article 2015 1 University of North Carolina at Chapel Hill, Chapel Hill, NC, USA Corresponding Author: Kim T. Vuong, 9925 Park Walk West, Charlotte, NC 28269, USA. Email: kim_vuong@med.unc.edu Nasal Root Venous Malformation Kim T. Vuong 1 , Katherine M. Varman, MD 1 , Joseph Stavas, MD 1 , and Dean S. Morrell, MD 1