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| CLINICAL NOTE |
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| Year : 1999 | Volume
: 1
| Issue : 2 | Page : 94-96 |
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Rhinolithiasis
Adel A Banjar1, Mohammed A Al-Shihri2
1 Department of Oto-Rhinolaryngology, Ohud Hospital, P.O. Box 779 Madina, Saudi Arabia
2 Department of Oto-Rhinolaryngology, King Abdulaziz University Hospital, P.O. Box 245, Riyadh 11411, Saudi Arabia
| Date of Web Publication | 16-Jun-2020 |
Correspondence Address:
FRCS (Ed) Adel A Banjar
ENT Department, Ohud Hospital P.O. Box 779 Madina
Saudi Arabia
 Source of Support: None, Conflict of Interest: None
DOI: 10.4103/1319-8491.286869
Rhinolith is a known clinical entity and can remain silent for many years and present as an incidental finding on radiography performed for other reasons. Furthermore, the diagnosis of rhinolith can be difficult even when the patient is symptomatic, and may not be made even when the patient presents to an otolaryngology clinic. We describe a clinical case of rhinolith with symptoms but because of unusual circumstances {inadequate history and the presence of extensive granulation tissue), operative examination was necessary to establish the definitive diagnosis and to discard other lesions.
Keywords: Rhinoliths, Diagnosis, Granulation tissue
How to cite this article:
Banjar AA, Al-Shihri MA. Rhinolithiasis. Saudi J Otorhinolaryngol Head Neck Surg 1999;1:94-6 |
| Introduction | |  |
Rhinolith is a mineralized mass found in the nose. The mineralization is generally secondary to an object that has become lodged in the nasal cavity. [1],[2] There have been more than 600 cases of rhinoliths reported in the literature. [1],[2] The diagnosis of a rhinolith can be difficult even when the patient is symptomatic.[2] The clinical features and radiological findings may be mistaken with other lesions. We describe a symptomatic case of rhinolith but inadequate history and nasal examination (including endoscopy) delayed the final diagnosis. The clinical features of rhinoliths, the etiology, the differential diagnosis and The pathogenesis are discussed.
| Case Report | | |
70 years old lady with senile dementia was referred from a local dispensary to the ENT Clinic at Ohud Hospital, Madina, Saudi Arabia. Her daughter noticed a blood-stained discharge from right nostril for three years which became foul in smell about one year ago. Because of the mental status of the patient, surgical and medical history was not available and the daughter could not provide us with significant medical history. Anterior rhinoscopy revealed a mass of granulation tissue with gritty feeling in the right nasal cavity. Nasal examination and the use of endoscopy was limited due to the bleeding from the granulation tissue. Other ENT examinations were unremarkable.
The clinical features of the nasal mass was suggestive of a solid mass and the possibly of rhinolith was raised, but other pathological lesions such as tumour were considered especially with the patient’s age.
The patient was admitted and blood transfusion was given to encounter severe iron deficiency anaemia which was discovered on routine investigations. C.T. Scan of the nose and paranasal sinus revealed 5 calcified objects surrounded by mucosal thickening without bone destruction. [Figure 1]. Medical consultation was arranged to assess the patient’s condition. Mental status of the patient did not permit repeated local examination. The patient was examined under general anaesthesia and the granulation tissue was excised and a rhinolith was seen underneath. The stone was removed piece- meal [Figure 2]. The bleeding was excessive and controlled by nasal packs. A wide nasal cavity without bone destruction was observed by the endoscope. | Figure 1: Axial CT Scan showing a clacified foreign body surrounded by muscosal thickening located in the right nasal fossae with adjacent maxillary sinusitis. No bone destruction
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 | Figure 2: Rhinolith was removed piece meal (calibration in the forcep is in centimeters)
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Biopsy was considered unnecessary and the rhino- lith was not sent for analysis and no obvious nidus was found.
The patient had an uneventful recovery and follow- up showed resolution of the nasal symptoms.
| Discussion | | |
Rhinolith is a term used to designate a mineralized object located in the nasal cavity. [1],[2] Rhinoliths are formed from a completely or partially encrusted nasal foreign body, either exogenous or endogenous, depending on the origin of the nucleus on which encrustation occurs. [3]
The object or the foreign body enters the nose through the anterior portion of the nares or through the posterior portion of the nares during sneezing oremesis.{l},[4] Rhinoliths are considered endogenous if they arise around normal body materials such as teeth, sequestra or dried blood clots. {3,4} Rhinoliths are considered exogenous if non-human material or objects such as beads, buttons, fruit stones, cotton wool or impression materials gain access to the nasal cavity and act as the nidus for precipitation. [3],[4]
It is assumed that the predisposing factor for the formation of rhinolith is the entry and lodgment of a foreign body and it is necessary for the foreign material to evoke inflammation and suppuration. Further requirement are: precipitation of salts, obstruction and stagnation.[1],[3] Air currents which probably help concentration and crystallization are also needed. [1],[3] The analysis of the inorganic components of the rhinoliths show that calcium and magnesium are the common elements followed by sodium, chlorine, aluminum and phosphorous
In the cases reported, females out number males and patients ages range from 6 months to 82 years.[1]
The most frequent signs and symptoms of rhinoliths after a latent period are unilateral foul nasal dischagre, obstruction and epistaxis. Other unusual presentation include pain, headache, sinusitis, epiphora, halitosis, post nasal drip and nasal regurgitation. [1].[2],[3],[4]
Bilateral rhinoliths, perforation of the nasal sputum, perforation of the palate and meningitis with death have been reported. [1],[2],[3],[5]
A symptomatic rhinolith can remain silently in situ for many years; up to 64 years in one case. [2] It may present as an incidental finding on radiography performed for other reasons such as dental work up. [2],[4],[6]
Rhinolith is most often found on the floor of the nose about half way between the anterior and posterior portion of the nares and these areas are routinely shown in dental radiographs, so the dentist may be the first professional to diagnose this conditional} Dental radiological features can be mistaken for tumour or other developmental and pathologic entities such as retained roots, impacted teeth, odontogenic tumor and tori.[1] Differential diagnosis include every space occupying lesion in the nose that gives the picture of a calcified mass on radiography such as calcified nasal polyp, ossifying fibroma, odontoma, osteoma, osteosarcoma, chondroma and calcifying angiofibroma.[1],[3],[4]
The diagnosis can be facilitated by using rigid endoscopy supplemented by CT-Scan to delineate the lesion. [2],[3] Sometime examination under general anesthesia maybe required to establishe the diagnosis as in our case.
Most rhinoliths are removed anteriorly with the use of local anesthesia [1] and more extensive surgery maybe necessary for complicated and impacted stones.
| Conclusion | | |
Rhinoliths are uncommon though not rare. Our case illustrates that the diagnosis can be difficult even when the patient is symptomatic.
Otolaryngologist and dentist should be aware of the condition as a symptomatic rhinolith may present as an incidental finding on radiography. Adequate history and proper examination using endoscopy supplemented by radiological investigations (operative examination may be necessary in some cases) should be applied to establish the correct diagnosis and to save the patient much anxiety and needless trauma.
| References | | |
| 1. | Appleton SS„ Kimbrough RE., Engstrom FHM. Rhinolithiasis: A review. Oral Surg 1988;65:693-8.  |
| 2. | Stoney P, Bingham B, Okuda I, Hawke M. Diagnosis of rhinoliths with rigid endoscopy. J Otolaryngol 1991;20:408-11. |
| 3. | Ezsias A, Sugar AW. Rhinolith: An unusual case and an update. Ann Otol Rhinol Laryngol 1997;106:135-8. |
| 4. | Harbin W, Weber Al. Rhinoliths. Ann Otol Rhinol Laryngol 1979; 88:578-9. |
| 5. | Wickham MH, Barton RPE. Nasal regurgitation as the presenting symptom of rhinolithiasis. J Laryngol Otol 1988;102:59-61. |
| 6. | Damm DD, Ziegler RC. Factitious rhinolith. Oral Surg Oral Med Oral Pathol 1985;59:662. |
[Figure 1], [Figure 2]
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