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Rhinolith: A Case Report and Review of Literature

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Rhinolith: A Case Report and Review of Literature
CASE REPORT

Rhinolith: A Case Report and Review of Literature

1
S Sudhakar, 1B Praveen Kumar, 2MPV Prabhat
1
Senior Lecturer, Department of Oral Medicine and Radiology, St. Joseph Dental College and Hospital, Eluru
Andhra Pradesh, India
2
Associate Professor, Department of Oral Medicine and Radiology, St. Joseph Dental College and Hospital, Eluru
Andhra Pradesh, India
Correspondence: S Sudhakar, Senior Lecturer, Department of Oral Medicine and Radiology, St. Joseph Dental College and
Hospital, Eluru, Andhra Pradesh-534003, India, e-mail: drsudhakaroralmed@yahoo.co.in

ABSTRACT
Rhinoliths are calcareous concretions around calcinated intranasal foreign bodies within the nasal cavity. They are commonly seen in the anterior part
of the nasal cavity and are diagnosed based on history and presenting illness. Developing lesions are usually asymptomatic and can be a supplementary
finding during routine radiography. We report a case of rhinolith, found incidentally in a dental radiograph.
Keywords: Rhinolith, Orthopantomograph, Calculi, Ozena, Lithotripsy.

INTRODUCTION
Rhinolith is an uncommon condition and it is rarely encountered
in a dental setting. If evident they can be seen on a dental
radiographs as a radiopaque object in the nasal fossa. Rhinoliths
are usually asymptomatic; as they progress they can develop into
a symptomatic destructive entity. Hence early diagnosis is
mandatory to avoid possible sequela.

CASE REPORT

A 35-year-old female reported to Department of Oral Medicine

and Radiology with a complaint of bleeding from her lower front Fig. 1: OPG showing radiopaque mass on the right nasal cavity
gums since a month. After thorough clinical examination, a
provisional diagnosis of chronic generalized periodontitis was
arrived and the patient was advised an orthopantomograph (OPG).
The OPG showed generalized horizontal bone loss and missing
16, 18, 26, 36, 38 and 46 (Fig. 1). In addition, the OPG also revealed
a well defined mixed radiopaque-radiolucent mass roughly oval
in shape ranging 35 × 20 mm in size on the right turbinate region.
The mass had a thick radiopaque periphery and the internal
structure appeared nonhomogenous with concentric radiopacity
interspersed with a central radioluceny.
Re-evaluation of the patient did not reveal any history of
symptoms such as nasal stuffiness, discharge, pain, paraesthesia,
anosmia, foul breath, epistaxis and headache. Patient did not recall
any history of foreign body intrusion into the nostrils; either
intentionally or following trauma. There was no relevant medical
or surgical history. Extraoral examination did not reveal any notable
changes. Intranasal examination using an anterior rhinoscope
showed presence of a grayish-black mass near the right turbinate;
however, the surrounding mucosa appeared normal.
Paranasal (PNS) view showed the radiopaque mass in the right
turbinate region close to the floor of the nose. Bilaterally the sinus
appeared normal and there was no evidence of septal deviation Fig. 2: PNS view showing radiopaque mass on the right nasal cavity
(Fig. 2).
Computed tomography (CT) images showed a hyperdense oval No evidence of sinus encroachment or osseous destructions was
shaped mass ranging 25 × 15 mm in size with a hypodense nucleus. noticed (Fig. 3).

Journal of Indian Academy of Oral Medicine and Radiology, July-September 2010;22(3):165-167 165
S Sudhakar et al
Fig. 3: Coronal CT showing radiodense mass on the
right nasal cavity
Fig. 4: Excised specimen
Fig. 5: Postoperative OPG
Based on the history, clinical and radiographic findings a
provisional diagnosis of rhinolith was rendered. The mass was
surgically approached intranasally through the turbinates. The mass
was removed (Fig. 4). Histopathological examination showed
presence of calcareous materials, however there was no evidence
of any nidus. The postoperative period was uneventful and the
periodontium was rehabilitated (Fig. 5).
166
DISCUSSION
Rhinolith also called as nasal calculi are calcareous concretions
that arise secondarily to the complete or partial encrustation of
intranasal foreign bodies.1 Polson in 1943 reported that his
colleague had seen a rhinolith as big as a pinecone.2 Bartholin
gave the first documented description in 1654.
Rhinolithiasis is an uncommon condition.3 The pathogenesis
of rhinolith is not clear. It has been speculated that a foreign body
in the nose acts as a nidus and incites a chronic inflammatory
reaction with deposition of mineral salts and forms a rhinolith.1,4
The foreign body is expected to enter through the anterior nares,
although some have been reported to have entered through the
choana during vomiting or coughing. Based on the nature of foreign
body involved, rhinoliths are classified as true and false rhinoliths.5
Most foreign bodies are exogenous (false) such as beads, pebbles,
buttons, paper, food, cherry pits, stones, sand, fruit seeds, peas,
parasites, dirt, cloth, wood, glass, jewellery, plastic, cotton wool
or retained nasal packings.1,4 A rare case of opioma (codeine and
opium) associated with rhinolith has also been reported.6 The
endogenous (true) agents causing rhinolith includes bacteria,
leukocytes, misplaced teeth, sequestra, blood clots, dried pus,
mucus, desquamated epithelia, nasal crusts and bone frag-
ments.1,4,5,7
Rhinoliths are usually single and unilateral.7,8 They are more
or less spherical and appear gray, brown, or greenish-black in
color.4,7 It may range from few millimeters to centimeters in size
and usually conform to the shape of the nasal cavity.8 A rare case
of rhinolith appearing like a hen’s egg weighing 115 gm has also
been reported.5
Rhinoliths are usually present in the third decade of life with
females more commonly affected than males.2-4 They are most
commonly seen on the inferior meatus or between the inferior
turbinate and the nasal septum.3,7,8 The typical symptoms of
rhinoliths include pain, unilateral nasal obstruction and epistaxis.3,9
Other symptoms include crusting, swelling of nose or face,
anosmia, epiphora, ozena and headache.7,8 Complications consist
of ipsilateral otitis media, bacterial or fungal sinusitis, septal
perforation, palatal perforation, fistulous tract formation and
recurrent dacryocystitis.3,8,10
Diagnosis of rhinolith is usually made by inspection with the
aid of a rhinoscopy and endoscopy. Rhinoscopy may reveal a mass
or nodule with well or ill-defined borders. Endoscopy plays an
important role in evaluation of the extent of the rhinolith without
providing any risk of radiation exposure.4,10
Radiologic examinations include orthopantomograph (OPG),
maxillary occlusal view, water’s view, lateral skull views and CT.5
In 1900; MacIntype gave the first radiological description of
rhinolith. The typical radiological features are mixed radiopaque-
radiolucenct mass arranged in a concentric circle or in the form of
lamellations.10 The other radiological features such as coral-like
mass, displacement, perforation, thinning, expansion and
destruction of the nasal wall have also been listed.5 CT (Computed
tomography) appearance includes a homogenous, high-density
periphery with central area of lower density.10 CT also plays an
important role in exact localization of the mass and in
demonstration of any associated complications.8
JAYPEE

The radiographic differential diagnosis includes calcified
polyps, hemangioma, ossifying fibroma, odontoma, osteoma,
chondroma, antro-tooth, fungus ball calcification, calcifying
angiofibroma, syphilis and tuberculosis.3,10,11 Other rare benign
nasal mass lesions such as nasal glioma, septal dermoid, and
enchondroma can also resemble a rhinolith.10,11
First chemical analysis of rhinolith was performed by Axmann
in 1829. It is found that they predominately contain inorganic
materials such as calcium phosphate, magnesium, carbonate,
oxalate and urates.3,7 Other materials such as siderite (FeCO3) and
ferrihydrite with a nidus of high iron content has also been
reported.11 over the years, various methods have been employed
for mineralogical analysis of rhinolith and this includes electron-
ray microprobe, X-ray differactometry and infrared-spectroscopy.4
The treatment is removal of the rhinolith. In most cases,
rhinoliths are removed through the nostrils using local anesthesia
either by crushing or as a complete fragment.7 Endoscopically
controlled surgery can be helpful in complete and uneventful
removal of the rhinolith. A rhinolith that cannot be removed
surgically could be disintegrated using a lithotripsy.10 In case of
septal or antral perforation the surgical option includes alar release,
Caldwell-Luc or lateral rhinotomy.3,10 Rarely, in extensively
destructive cases, reconstruction of sinonasal anatomy may be
required.11
Journal of Indian Academy of Oral Medicine and Radiology, July-September 2010;22(3):165-167
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Rhinolith: A Case Report and Review of Literature
REFERENCES
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of rhinolithiasis. OJHAS 2008;7(2):7-9. (Online journal)
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Chapter 19 “Soft tissue radiopacities”. Williams and Wilkins, Baltimore
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Postgrad Med J 1968;44(512):478-79.
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9. Appleton SS, Kimbrough RE, Engstrom HIM. Rhinolithiasis: A review.
Oral Surg Oral Med Pathol 1988;65:693-98.
10. Royal SA, Gardner RE. Rhinolithiasis: An unusual pediatric nasal mass.
Pediatr Rediol 1998;28:54-55.
11. Lo SH, Wu YY, Wang PC. Maxillary anthrolith. Mid Taiwan J Med
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