A bluish lump beside my newborn's nose: dacryocystocele and when to call

You are changing a nappy, or holding your baby near a window, and you see it: a small, soft, bluish or grey-blue swelling just below the inner corner of one eye, beside the nose. It may have been there since birth, or it may have appeared in the first days. Either way, a newborn with an odd lump is enough to keep anyone awake.

The most likely cause is a swollen tear sac, called a dacryocystocele (also written dacryocele). Many are managed with simple care and some need a small procedure. A few signs mean the baby should be seen the same day, and they are set out below.

What is the bluish lump beside my newborn's nose?

It is usually a dacryocystocele: the tear sac, the small pouch beside the nose where tears collect on the way down to the nose, swollen with fluid. AAO EyeWiki describes it as a bluish, cystic mass just below and to the nose side of the inner corner of the eye, and says babies usually have it at birth or within the first few days.

AAPOS, the American paediatric eye specialists' association, calls it a bluish bump near the inner corner of the eye. A 2023 case report in the Pakistan Journal of Medical Sciences says it usually appears in the first week or month of life. EyeWiki adds that it is most often on one side but can be on both, in up to 30 percent of babies who have it.

The action: do not press on it to see what happens. Take a clear photo in daylight, note the date you first saw it, and arrange for a doctor to look.

Why does the tear sac swell, and how common is it?

Because the tear duct is blocked at both ends. AAPOS says that when the duct is blocked in both the upper and lower parts, fluid can become trapped and form a bluish bump. EyeWiki gives the detail: the lower blockage is usually a thin membrane, and mucus made by the sac, or amniotic fluid, is trapped behind it. The swollen sac can then close off its own entrance, so the fluid has nowhere to go in either direction.

It is uncommon. EyeWiki says a dacryocele is present in about 3 percent of infants who have a congenital blocked tear duct. The blocked duct itself is common, and AAPOS says more than 5 percent of infants have symptoms of one. So this is the uncommon end of a common newborn problem.

Nothing you did in pregnancy or since birth caused it. It is how the drainage channel formed. The action: put the blame down, and get a doctor's look.

Is it the same as the usual blocked tear duct?

It is the same blockage in a different form. The usual picture is a baby with a watery, sticky eye and no lump, which is explained in our page on watery eyes and blocked tear ducts. A dacryocystocele has a swelling because the sac is sealed at both ends, and the sac can also bulge down into the nose.

That matters for the plan. For the ordinary blocked duct, AAPOS says most open by themselves in the first year and probing is considered if it persists past 12 months. EyeWiki gives a much shorter wait for a dacryocele: a procedure if there is no improvement within the first one to two weeks of life, or if there are signs of infection. So waiting until the first birthday is not the default for this swelling. The action: if you read that tear ducts clear by themselves, still have this one looked at.

What will the doctor do about it?

Start with an examination, then choose between watching with simple care and a small procedure. EyeWiki says conservative care, with gentle massage of the tear sac and preventive antibiotics, may resolve it. If there is no improvement in the first one to two weeks, or infection appears, surgery is the next step. Wait for the doctor to show you before you try massage yourself.

The procedure is probing: a thin probe is passed through the tear duct into the nose to open the blockage, as AAPOS describes for blocked ducts. EyeWiki says probing alone resolves about 75 percent of dacryoceles, and about 25 percent of babies may not clear completely. It adds that combining probing with a look inside the nose by endoscope, and opening the cyst there (marsupialisation), raises success to more than 95 percent. If your baby has a probing, the days afterwards are in after the tear duct probing: recovery at home.

Two further points from the sources. If the sac is infected, EyeWiki says antibiotics go in first and surgery follows once the infection has settled. It also says that draining an infected swelling through a cut in the skin is discouraged, because it can leave a persistent fistula, a small channel that keeps draining. That is one more reason not to squeeze, prick or lance a lump at home.

A small review in J AAPOS (Paysse and colleagues, 2000) of 22 babies with 30 dacryoceles found a swelling inside the nose too in 77 percent, and the authors advised considering a probing of both sides in babies with one swollen side, because the other duct was often involved without showing. A small series shows what can happen, not how often. The action: ask the doctor whether the other side needs checking too.

Which signs mean my baby needs a doctor today?

Go the same day if the lump changes, the baby is unwell, or the breathing is not right. AAPOS describes an infected tear sac, dacryocystitis, as a medical emergency, with a painful, red, swollen bump, yellow-green discharge, and fever or fatigue. It says an infected dacryocele may need IV antibiotics and hospital care. The signs to act on are:

• The skin over the lump turns red or feels hot.
• The lump gets bigger or firmer, or the baby cries when it is touched.
• Yellow-green discharge from the eye.
• Fever, or a baby who is unusually sleepy, floppy or not feeding well.
• Noisy or laboured breathing, or struggling to breathe during feeds.

The breathing sign is the one parents do not expect. EyeWiki says that in severe cases with a large cyst inside the nose, or with both sides blocked, babies can have breathing difficulty when feeding, and in the worst case acute respiratory distress, which needs urgent nasal endoscopy to remove the cyst. In the Paysse review, respiratory distress occurred in 5 of 7 babies with cysts inside the nose on both sides and in 2 of 9 with one side. For difficulty breathing, go to an emergency department now, not a booked clinic.

The 2023 case report lists cellulitis, and rarer spread of infection such as septicaemia, meningitis and brain abscess, among the complications of an infected swelling. The same-day rule exists to prevent these. The action: if you are asking yourself whether it has changed, assume it has and go.

Could it be something else, like a birthmark or a growth?

Sometimes, and that is why a doctor should look rather than a photo from a group chat. EyeWiki lists other lumps in the same area: a haemangioma (a strawberry-type birthmark, which it says has irregular borders and is not present at birth), a dermoid cyst (well defined, mobile, skin-coloured, above the inner corner), an encephalocele (a swelling that comes through the skull, also above the inner corner), and, rarely, a fast-growing tumour. The 2023 case report notes that a blue cystic lump with no other signs can be hard to tell from a haemangioma, and that ultrasound can help.

The position helps the doctor: a dacryocystocele sits below the inner corner, beside the nose. A flat blue-grey patch of skin is another matter, covered in blue-grey birthmark around a baby's eye. The action: let the doctor decide what it is, and do not put anything on it.

What should I do about it this week?

Have it examined soon, even if the baby seems well and the lump looks calm. EyeWiki says infection may develop within the first few weeks if a dacryocele does not resolve, and that the treatment decision is made in the first one to two weeks. Tell your baby's paediatrician or GP, and ask for a referral to an eye doctor who sees newborns. If the baby has a red or hot swelling, a fever, feeding trouble or breathing trouble, skip all of that and go the same day.

Meanwhile, keep hands off the lump and keep the photo and the date. Your baby's wider first check-up is described in your baby's first eye check. In clinic I would rather see a worried parent with a calm lump than meet a lump after it has become a problem. You are not overreacting by asking.

Common questions

References

1. AAO EyeWiki · Dacryocele · eyewiki.aao.org
2. AAPOS · Nasolacrimal duct obstruction (glossary) · aapos.org
3. Pakistan Journal of Medical Sciences · Special congenital dacryocystocele (Han, Wang and Zhang, 2023) · pmc.ncbi.nlm.nih.gov
4. Journal of AAPOS · Management and complications of congenital dacryocele with concurrent intranasal mucocele (Paysse et al., 2000) · pubmed.ncbi.nlm.nih.gov

By Dr Chan Li Yen. General information only. It does not replace a consultation. If you are worried about your child's eyes or vision, please see an eye doctor.