Recurrent purulent rhinorrhea in an otherwise healthy woman.

An 18-year-old woman presented with recurrent mucopurulence from the left nostril and nasal congestion that had become progressively worse during the previous 4 weeks. She had been treated with various antibiotics, including amoxicillin, without improvement. She denied any antecedent trauma, previous nasal surgery, or history of nasal foreign bodies. She was a nonsmoker.

On physical examination, her tympanic membranes were clear and intact, and her oral cavity, oral pharynx, and hypopharynx were clear. Intranasal examination revealed the presence of a hard mass with yellow-black discoloration and a foul-smelling, yellow-green discharge. Findings on the remainder of the examination were unremarkable.

After administration of a topical anesthetic and decongestant, a complete fiberoptic nasal endoscopy was performed. The irregular mass appeared to be confined to the left anterior nasal cavity, which deviated slightly to the left (figure, A).

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While awaiting the results of a culture, we ordered computed tomography (CT) of the paranasal sinuses and treated the patient empirically with a fourth-generation quinolone (gatifloxacin) and a topical nasal steroid spray. Culture and sensitivity testing demonstrated a heavy growth of Morganella morganii and Klebsiellapneumoniae. Both organisms were susceptible to quinolones.The contrast-enhanced CT images were taken at 3-mm intervals through the sinuses in both coronal and axial planes. CT showed an abnormally contoured area of attenuation in the left inferior turbinate that appeared to be as dense as bone (figure, B). We interpreted this finding as either a possible old fracture or a possible foreign body.

The patient was taken to the operating room for removal of the mass. After general anesthesia was induced, we placed cocaine intranasally and injected the septum with 1% lidocaine with 1:100,000 epinephrine. We moved the nasal septum to the right and secured the mass. During removal, the mass broke into several pieces (figure, C). We cleared the left nasal passageway (figure, D) and transferred the patient to the recovery room in stable condition.

Final pathology confirmed that the mass was a rhinolith, which arose secondary to impaction of a sunflower seed. The patient later learned from her mother that she had indeed inserted a sunflower seed into her nose when she was a young child, but she thought that it had fallen out. Surgical intervention resulted in the complete resolution of her mucopurulence and nasal congestion.

Foreign bodies in the nasal cavity are common among young children, and they often cause unilateral nasal obstruction and a foul-smelling, bloody discharge. (1,2) Mineral salts can accumulate on a long-retained foreign body and produce a rhinolith. (1-3) Most patients with a rhinolith present with nonspecific nasal complaints such as purulent rhinorrhea and nasal obstruction. (1, 3) However, rhinoliths are much less common among adults, and many are discovered incidentally. Small rhinoliths can be removed in the office under local anesthesia, while largerones require extraction under general anesthesia.

References

(1.) Hadi U, Ghossaini S, Zaytoun G. Rhinolithiasis: A forgotten entity. Otolaryngol Head Neck Surg 2002;126:48-51.

(2.) Keck T, Liener K, Strater J, Rozsasi A. Rhinolith of the nasal septum. Int J Pediatr Otorhinolaryngol 2000;53:225-8.

(3.) Balatsouras D, Eliopoulos P, Kaberos A, Economou C. Rhinolithiasis: An unusual cause of nasal obstruction. Rhinology 2002;40: 162-4.

Dr. Goldberg is an otolaryngologist in private practice in Miami, where Mr. Mercado is employed as a physician assistant.