Rhinolithiasis.

A 66-year-old woman with a history of hearing loss and vertigo had been followed in our department. On one occasion, she mentioned a long-standing history of fetor (an unpleasant odor) emanating from her left nostril and ipsilateral nasal obstruction. This condition had not responded to several courses of antibiotics and nasal steroid sprays prescribed by her general practitioner.

Anterior rhinoscopy and rigid 0[degrees] endoscopy revealed the presence of a large concretion on the floor of the left nasal cavity; the mass was surrounded by foul-smelling pus (figure 1). The patient had no history of nasal foreign-body impaction, nasal trauma, or sinonasal surgery. In view of the concretion's size, irregular surface, and impingement on the adjacent inferior turbinate, she was scheduled to undergo removal of the rhinolith under general anesthesia.

[FIGURE 1 OMITTED]

Intraoperative examination confirmed the clinic findings. Our initial attempts to extract the rhinolith intact were unsuccessful despite prior decongestion of the nasal mucosa. We then contemplated pushing the rhinolith posteriorly into the nasopharynx, which would have allowed us to retrieve it through the oropharynx. However; after we broke off some fragments with a Tilley-Henckel forceps, we were able to remove the stone anteriorly with a wax hook.

Macroscopic examination of the rhinolith revealed that it had a small pith-like core, the exact origin of which could not be determined (figure 2). The core was encircled by stony, hard concentric layers. The patient was reviewed in the clinic a few weeks later, and she reported that her symptoms had resolved completely. Examination showed that her nasal cavities were healthy and patent.

[FIGURE 2 OMITTED]

Rhinoliths are rare. They are calcareous concretions that are formed by the deposition of salts on an intranasal foreign body. (1) The foreign body, which acts as the nucleus for encrustation, can be either endogenous or exogenous. Dessicated blood clots, ectopic teeth, and bone fragments are examples of endogenous matter. Exogenous materials include fruit seeds, plant material, beads, cotton wool, and dental impression material. (2)

Although the pathogenesis remains unclear; a number of factors are thought to be involved in the formation of rhinoliths. These include entry and impaction of a foreign body in the nasal cavity, acute and chronic inflammation, obstruction and stagnation of nasal secretions, and precipitation of mineral salts. (2) Development and progression are believed to take a number of years.

Most patients complain of purulent rhinorrhea and/or ipsilateral nasal obstruction. Other symptoms include fetor, epistaxis, sinusitis, headache and, in rare cases, epiphora. In some patients, rhinoliths are discovered incidentally. Examination should include anterior rhinoscopy and rigid endoscopy. Computed tomography of the paranasal sinuses can accurately determine the site and size of the rhinolith and identify any coexisting sinus disease that might also require treatment. (3)

Treatment should include surgical removal as well as drug therapy for infection and symptomatic relief of pain and congestion. Large impacted rhinoliths can be removed piecemeal with a variety of surgical instruments. Lithotripsy has also been used to debulk large stones. (4) If access remains restricted, a submucosal resection of the nasal septum and a bony turbinoplasty will allow for further exposure and will facilitate extraction. Irrigation and suction can help remove smaller fragments. Granulation tissue at the site of contact between a stone and the nasal mucosa can be cauterized with silver nitrate. Local infection is treated with appropriate antibiotics.

References

(1.) Polson CJ. On rhinoliths. J Laryngol Otol 1943;58:79-116.

(2.) Ezsias A, Sugar AW. Rhinolith: An unusual case and an update. Ann Otol Rhinol Laryngol 1997;106:135-8.

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

(4.) Mink A, Gati I, Szekely J. [Nasolith removal with ultrasound lithotripsy]. HNO 1991;39:116-17.