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| | | Year : 2009 | Volume : 20 | Issue : 1 | Page : 114-116 | | | Rhinolith | | | Karthikeya Patil, Mahima V Guledgud, Suchetha N Malleshi
Department of Oral Medicine and Radiology, JSS Dental College, SS Nagar, Mysore 570 015, India
Click here for correspondence address and email | Date of Submission | 20-Apr-2008 | | Date of Decision | 18-Aug-2008 | | Date of Acceptance | 19-Aug-2008 | | |      | |  Abstract | | | Rhinoliths are rare entities encountered in clinical practice. They are calcified masses found within the nasal cavity. Which lesions can be encountered incidentally upon a routine dental radiograph. This article reports a case of such an incidental finding of rhinolith on a dental radiograph. Keywords: Computed tomography, dental radiograph, rhinolith How to cite this article:
Patil K, Guledgud MV, Malleshi SN. Rhinolith. Indian J Dent Res 2009;20:114-6 |
| Case Report | |  |
A 40-year-old male patient presented for prosthetic rehabilitation. His periodontally compromised status necessitated a panoramic radiograph, which incidentally revealed a well-defined, roughly oval, mixed radiolucent radiopaque lesion measuring approximately 10 mm x 20 mm above the apices of the left lateral incisor, canine, and first premolar. A thick, well-defined radiopaque border enclosed this entire mass. Internally apart from the specks of radiopacities, a radiopaque concentric ring was present duplicating the periphery [Figure 1].
Re-evaluation of the patient revealed no nasal symptoms. He was unable to recall any history of intranasal foreign body introduction or trauma. An extra oral examination revealed no facial swelling or sensory disturbance. An intranasal examination using a speculum and rhinoscope revealed a grayish-white irregular mass along the floor of the nose just below the inferior turbinate.
A poster-anterior (PA) view of the skull, lateral nasal view, and maxillary occlusal view radiographs were obtained for localization of the mass. The PA view showed the predominantly radiopaque mass located in the nasal cavity close to the nasal floor on the left side [Figure 2]. The lateral nasal view revealed similar findings. A well-defined circular radiopaque mass was apparent in the left palatal region on the maxillary occlusal radiograph [Figure 3].
A computed tomography (CT) scan revealed a well-defined ovoid structure with hyperdense edges and an area of central low-density measuring roughly 20 mm located in the left nasal cavity adjacent to the left turbinate [Figure 4],[Figure 5]. It was free of any obvious osseous insertion. The sinus walls were intact.
A diagnosis of rhinolith was given based on the clinical and radiographic presentations. Under general anaesthesia, the rhinolith was crushed and removed. The patient made an uneventful recovery.
Macroscopically, the excised mass showed a core that was surrounded by concentric stony-hard layers. Histopathologic sections of the excised mass showed calcification. The nidus, though, was not identifiable.
| Discussion | | |
Rhinoliths are mineralized masses found within the nasal cavity. Polson first defined rhinoliths as the result of a partial or complete encrustation of an intranasal foreign body by mineral salts precipitated onto them. [1] Their pathogenesis is unclear. [1],[2] They are considered to be exogenous in origin if the nidus is a foreign body like paper, a safety pin, beans, beads, impression material, buttons, etc. and endogenous if encrustation occurs around either normal or abnormal body tissue such as teeth, sequestra, mucus, bone, or blood clot. [1],[2],[3] Most of these are introduced through anterior nares, although some foreign bodies have been reported to have entered through the choana during vomiting or coughing. [4],[5],[6] A 15-year growth period has been suggested for rhinolith formation. [1]
Bartholin first identified rhinoliths in 1654. [4] Since then, over 600 cases have been reported in literature. [4],[5] Their incidence is 1 in every 10,000 otolaryngo outpatients. [4] The usual range of age for diagnosis is between 8 to 25 years old and a female predilection exists. [5],[6] They are usually found in floor of the nose, about halfway between the anterior and posterior portion of the nares. [5] Small sized rhinoliths are usually asymptomatic. Larger ones may cause unilateral nasal discharge, nasal pain, nasal obstruction, foul smelling breath, epistaxis, pain, nasal or facial swelling, sinusitis and anosmia or remain asymptomatic. [2],[7],[8] Erosions of the septum, maxillary sinus, and perforations have also been cited in literature. [5],[8] Rarely, bilateral rhinoliths may be observed. [5] Macroscopically, they appear as grayish irregular masses and feel hard, bony, and gritty on probing. [7] The differential diagnosis must include calcified nasal polyps, tori, impacted teeth, mycolith, odontoma, osteoma, osteosarcoma, ossifying fibroma, hemangioma, chondrosarcoma, and syphilitic and tuberculous calcification. [1],[4],[5],[8]
MacIntyre gave the first radiographic description of a rhinolith in 1900. [8] Radiographically, they may present as homogenous or heterogeneous radiopacities of varying size and shape depending on the nature of the nidus. [9] If the object is of low density, it may not be visible radiographically until calcification occurs. Once calcified, it characteristically shows a heterogeneous density with corrugated radiopaque borders; although variations may occur. [5] Sometimes they may have laminations and occasionally their densities may exceed that of the surrounding bone. [9] Radiographs for evaluation should include several projections taken from different angles to evaluate the shape, size, extent, location, and relation to surrounding tissues. [2],[5] A CT scan is recommended due to its sensitivity in recognizing even small amounts of calcification and it also provides information about adjacent structures and thus helps distinguish rhinoliths from other entities. [3],[4],[6],[8]
Surgical removal, debridement, and control of infection with appropriate antibiotics is the treatment of choice. [3],[6] Recurrence after removal has never been reported. [1]
The maxillofacial domain harbors numerous pathologies including calcifications, which may manifest as incidental findings on dental radiographs. Therefore, it is imperative that the clinicians be cognizant and scrutinize the radiographic images even beyond the confines of the jaws for precise judgment of the conditions.
| References | | |
| 1. | Shaw LC. Rhinolith of endogenous origin: A rare entity. Surg Pract 2007;11:48-50.  | | 2. | Barros CA, Martins RR, Silva JB, Souza JB, Ribeiro-Rotta RF, Batista AC, et al . Rhinolith: A radiographic finding in a dental clinic. Oral Surg Oral Med Oral Pathol Oral Radiol Endod 2005;100:486-90. [PUBMED] [FULLTEXT] | | 3. | Hadi U, Ghossaini S, Zaytoun G. Rhinolithiasis: A forgotten entity. Otolaryngol Head Neck Surg 2002;126:48-52. [PUBMED] [FULLTEXT] | | 4. | Pitt SK, Rout PG. Rhinoliths presenting during routine radiography: Two cases. Dent Update 2000;27:505-7. [PUBMED] | | 5. | Appleton SS, Kimbrough RE, Engstrom HI. Rhinolithiasis: A review. Oral surg Oral med Oral Pathol 1988;65:693-8. [PUBMED] | | 6. | Munoz A, Pedrosa I, Villafruela M. "Eraseroma" as a cause of rhinolith: CT and MRI in a child. Neuroradiology 1997;39:824-6. | | 7. | Burbuk PK, Garstecka A, Betlelewski. Nasal foreign body in an adult. Eur Arch Otorhinolaryngol 2005;262:517-8. | | 8. | Royal SA, Gardner RE. Rhinolithiasis: An unusual pediatric nasal mass. Pediatr Radiol 1998;28:55-5. | | 9. | White SC, Pharoah MJ. Soft tissue calcification and ossification. Oral Radiology - Principles and Interpretation. 5th ed. Missouri: Mosby; p. 607- 8. |
Correspondence Address:
Karthikeya Patil
Department of Oral Medicine and Radiology, JSS Dental College, SS Nagar, Mysore 570 015
India
DOI: 10.4103/0970-9290.49062 PMID: 19336872
[Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5] | |
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