Dark Appearance on Either Side of Nasal Bridge in Toddlers

Primary Differential Diagnosis

The American Academy of Allergy, Asthma, and Immunology recommends that allergic shiners appear as dark circles under the eyes and are characteristic findings in children with allergic rhinitis, resulting from venous pooling and congestion in the periorbital area due to chronic nasal obstruction 1
Parents of children with allergic rhinitis often describe associated symptoms including sniffing, snorting, throat clearing, chronic gaping mouth, halitosis, cough, poor appetite, sleep disturbances, malaise, and irritability 1
The physical examination of children with allergic rhinitis typically reveals pale, edematous nasal mucosa, though this finding is not specific to allergic rhinitis and can occur in nonallergic rhinitis as well 1

The American Academy of Pediatrics notes that in infants and young children, nasal congestion or obstruction commonly results from structural problems such as adenoidal hypertrophy or functional problems such as laryngopharyngeal reflux 2
Adenoidal hypertrophy is the most common acquired anatomic cause of nasal obstruction in infants and children, which commonly results in mouth breathing, nasal speech, and snoring 2

Symptoms that are primarily unilateral suggest a structural problem such as a nasal polyp, foreign body, septal deformity, or rarely a tumor, according to the American Academy of Otolaryngology 1
Rapidly growing nasal malignancies may cause nasal obstruction early in the disease and may present with bleeding, hyposmia or anosmia, pain, and/or otalgia 2

The American Academy of Allergy, Asthma, and Immunology recommends assessing for duration of symptoms, seasonality, associated symptoms, environmental exposures, and family history of atopy 1
Inquiring about sleep quality, mouth breathing, snoring, and behavioral changes that may indicate chronic nasal obstruction is recommended by the American Academy of Pediatrics 2, 1

The American Academy of Allergy, Asthma, and Immunology recommends that confirmation of allergic rhinitis requires correlation of symptoms with specific IgE testing to relevant allergens 1
Environmental control measures and allergen avoidance are first-line interventions for allergic rhinitis, according to the American Academy of Allergy, Asthma, and Immunology 1
Adenoidal hypertrophy causing significant obstruction may require surgical intervention, particularly when associated with sleep apnea, chronic adenoiditis, or chronic sinusitis, as recommended by the American Academy of Otolaryngology 2

The American Academy of Allergy, Asthma, and Immunology recommends not assuming food allergy is causing nasal symptoms, as only a small percentage of food hypersensitivity in children is associated with rhinitis symptoms 2
The American College of Radiology recommends not ordering imaging studies for uncomplicated nasal congestion, as abnormal findings are common in healthy children and do not guide management 4