Bozzolo’s sign is defined as pulsation of arteries in the nasal mucous membrane, occasionally observed in patients with thoracic aortic aneurysms. This physical finding reflects transmitted arterial pulsations from a dilated or aneurysmal thoracic aorta.

Pathophysiology

• In thoracic aortic aneurysm, the aortic wall becomes dilated and loses elasticity, producing forceful pulsations.

• These pulsations may transmit through large vessels into peripheral branches, including the nasal arteries, resulting in observable pulsation within the nasal mucosa.

• The sign is rare and often subtle, serving as an adjunctive clinical clue rather than a definitive diagnostic indicator.

Examination Technique

• Patient positioning: Seated or supine, head slightly tilted back.

• Inspection:

  1. Use a nasal speculum and appropriate light source to examine each nostril.

  2. Observe for visible pulsations in the nasal mucosa, particularly along the septal and lateral wall arteries.

• Assessment: Note symmetry, strength, and regularity of pulsations.

• Interpretation: Detection of pulsation may suggest thoracic aortic aneurysm and warrants further evaluation.

Clinical Utility

• Adjunctive sign: Bozzolo’s sign is not pathognomonic but may raise suspicion for aortic aneurysm when correlated with other clinical findings.

• Early detection clue: May help identify high-risk patients before aneurysm rupture or symptomatic cardiovascular complications.

• Correlation with imaging: Positive sign should prompt chest X-ray, CT, or echocardiography to confirm diagnosis.

Differential Diagnosis

Management

• Confirm underlying cause:

  • Imaging studies (CT angiography, MRI, echocardiography) to assess aortic dimensions and aneurysm characteristics.

• Monitoring: Small, asymptomatic aneurysms may require periodic surveillance.

• Intervention: Large or symptomatic aneurysms may necessitate surgical repair or endovascular stenting.

• Cardiovascular risk management: Control blood pressure, cholesterol, and address other comorbidities.

Pediatric considerations

• Extremely rare in children; may be associated with congenital aortic anomalies or connective tissue disorders (e.g., Marfan syndrome).

• Gentle nasal examination is essential to prevent mucosal trauma.

Geriatric considerations

• Older adults are at higher risk for thoracic aortic aneurysms.

• Positive Bozzolo’s sign in elderly patients warrants prompt imaging, as aneurysms carry a risk of rupture.

Limitations

• Low sensitivity and specificity: Pulsation may not always be visible, and other conditions may mimic the sign.

• Adjunctive nature: Should always be interpreted alongside clinical history, physical exam, and imaging studies.

• Rarely observed: Not commonly used as a primary diagnostic tool.

Patient counseling

• Explain the purpose of nasal examination and reassure that gentle inspection is safe.

• Discuss the potential implications if a thoracic aortic aneurysm is suspected.

• Emphasize the need for further imaging and follow-up if pulsation is observed.

Conclusion

Bozzolo’s sign is a rare but noteworthy clinical indicator of thoracic aortic aneurysm. While it is not diagnostic on its own, awareness of this sign may facilitate early detection and timely evaluation, supporting safer management of high-risk cardiovascular patients.

References

1. Bozzolo A. Clinical Observations in Thoracic Aneurysms. Milan: G. Brera; 1885.

2. Buttaro TM, Tybulski J, Bailey PP, Sandberg-Cook J. Primary Care: A Collaborative Practice. St. Louis (MO): Mosby Elsevier; 2008. p. 444–447.

3. Elefteriades JA. Thoracic aortic aneurysm: reading between the guidelines. Curr Opin Cardiol. 2013;28(6):543–550.

4. Hiratzka LF, Bakris GL, Beckman JA, et al. 2010 ACCF/AHA/AATS/ACR/ASA/SCA/SCAI/SIR/STS/SVM guidelines for the diagnosis and management of patients with thoracic aortic disease. Circulation. 2010;121:e266–e369.

5. Moore KL, Dalley AF, Agur AMR. Clinically Oriented Anatomy. 9th ed. Philadelphia, PA: Wolters Kluwer; 2020.