Rhinoliths causing palatal perforation: case report and literature review

Unilateral choanal atresia and a co-existent long-standing medium-sized ipsilateral rhinolith in a 15-year old boy: Case report and literature review

INTRODUCTION AND IMPORTANCE

Unilateral choanal atresia is a congenital anomaly where a newborn baby is born with a unilateral imperforate posterior nare. In most of the time the diagnosis may be missed for years after birth. A rhinolith is an entity formed by gradual deposition and coating of different salts of calcium and magnesium over an endogenous or exogenous nidus in the nasal cavity. Coexistence of a rhinolith and choanal atresia is a very rare encounter in clinical practice and to the best of our knowledge this is perhaps the first documented case in Tanzania.

CASE PRESENTATION

We present a 15-year old boy who was attended at our department with a longstanding history of left sided non-foul smelling nasal discharge which was noticed first when he was 5 years old but at the age of 13 years, he presented with ipsilateral nose bleeding and episodic foul smelling nasal discharge. He was attended at various peripheral health facilities without relief.

CLINICAL DISCUSSION

The patient underwent left sided nasal endoscopy where unilateral choanal atresia and a rhinolith were found. Transnasal endoscopic choanal atresia release and rhinolith removal were done under general anaesthesia in operating room. Postoperatively, he was kept on a nasal decongestant, a broad-spectrum antibiotic, intranasal corticosteroid and an analgesic.

CONCLUSION

Clinicians must have a high index of suspicion so as to establish the diagnosis of unilateral choanal atresia in patients with persistent unilateral non-foul smelling discharge and also nasal foreign bodies in those with foul smelling nasal discharge.

A missed giant rhinolith retained for a decade in a paediatric patient at a zonal referral hospital in Central Tanzania: Case report and literature review

Introduction and importance

Rhinolith is an entity formed by gradual deposition and coating of different salts of calcium and magnesium over an endogenous or exogenous nidus in the nasal cavity. The type, size and duration of the rhinolith lead to multiple types of presentation. Giant rhinoliths are very rare in paediatric patients owing the size of their nasal cavities. To the best of our knowledge this is the first reported case of a giant paediatric rhinolith in Tanzania.

Case presentation

We present a 12-year old male who presented with a history of left sided nasal obstruction accompanied with foul smelling nasal discharge for 11 years and was marked by being followed by house flies. Had history of occasional episodes of headache but no facial pain. He was managed at various remote health facilities without specialist consultation for eleven years as case of allergic rhinitis and rhinosinusitis and finally was referred with a provisional diagnosis of chronic granulomatous disease of the nose. The patient underwent anterior rhinoscopy and a left sided stony hard mass was removed under topical local anaesthesia.

Clinical discussion

The patient underwent anterior rhinoscopy and a left sided stony hard mass was removed under topical local anaesthesia. Postoperatively he was kept on a nasal decongestant, a broad-spectrum antibiotic and an analgesic.

Conclusion

Any child with unilateral foul smelling nasal discharge should be considered to have a nasal foreign body until proven otherwise. The treatment of choice remains to be nasal foreign body removal under local or general anaesthesia.

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Giant rhinoliths are very rare in paediatric patients owing the size of their nasal cavities.

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Unilateral foul smelling nasal discharge in a child suggests a nasal foreign body.

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Type, size and duration of the rhinolith lead to multiple presentations.

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Rhinolith removal under local or general anaesthesia remains the treatment of choice.

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Clinicians must have a high index of suspicion to establish the diagnosis of a rhinolith.

Rhinolithiasis, a rare entity: Analysis of 31 cases and literature review

OBJECTIVE:

Rhinolithiasis is a rare condition which results from deposition of salt around a endogenous or exogenous nidus. In the literature, most of the reports are single case studies. In this study, we aimed to present the characteristics, symptoms, diagnosis, and treatment methods of 31 rhinolithiasis cases and to focus on the current literature.

METHODS:

We retrospectively reviewed 31 rhinolithiasis cases which have been diagnosed and treated in a tertiary care center between January 2014 and December 2018. Patient characteristics, presenting symptoms, concomitant sinonasal disorders, and type of surgery were noted. Descriptive statistics were carried out.

RESULTS:

Mean age was 25.4±15.7. The cases were comprised 14 female patients (45.2%) and 17 male patients (54.8%). The most common presenting symptom was nasal obstruction (71%). Malodorous unilateral rhinorrhea was present in 17 patients (54.8%). Epistaxis snoring and sleep apnea were other rare symptoms. In 21 of the cases (67.7%), rhinolith was located between inferior turbinate and septum which was the most common location seen in our series. The number of patients who were under the age of 18 was 13, in 2 of them, rhinolith was found to be formed around a plastic bead, and in 2 of them, fruit seeds were the nidus. The most common concomitant sinonasal pathology was septal deviation which was detected in 20 of the patients (64.5%), adenoid vegetation and nasal polyposis were other disorders. In 20 of the patients (64.5%), simple removal of the rhinolith using a forceps with the help of a rigid nasal endoscope was performed. Eight of the 17 patients had severe deviation and septoplasty was performed at the same time, which was the most common concomitant surgical intervention (25.8%). In 3 patients (9.6%), functional endoscopic sinus surgery was performed at the same time.

CONCLUSION:

Our series is one of the largest series in the literature. The most common presenting symptom was nasal obstruction followed by malodorous rhinorrhea. Accompanying sinonasal disorders should be addressed to improve the outcome. Rigid or flexible endoscopic examination should be used to detect a rhinolith. Computed tomography scan can diagnose a hidden rhinolith in a patient with nasal obstruction.

Case report of a maxillary antrolith

INTRODUCTION

Antroliths, which are pathological calcifications within the maxillary sinus, are a rare occurrence. While some may present with symptoms, most maxillary antroliths are asymptomatic incidental findings.

PRESENTATION OF CASE

We report a case of a 67-year-old lady with a round radiopacity within her right maxillary sinus as seen on the panoramic radiograph. Subsequent cone beam computed tomography (CBCT) scan detailed a well circumscribed radiopacity at the floor of the maxillary sinus. Surgical excision was done via Caldwell-Luc procedure.

DISCUSSION

A review of literature was carried out with particular reference to the etiology, clinical and radiographic features and management of antroliths. Radiological examination of the sinus by standard Waters, panoramic radiograph and CT scan can aid in identification and diagnosis. While biopsy may be indicated to rule out differential diagnoses with similar presentations, in otherwise small and asymptomatic antroliths, they are generally left alone and periodic check-ups appear to be the primary choice of treatment. Surgical removal is considered the treatment of choice for antroliths with complications.

CONCLUSION

With regular long term follow ups, prophylactic removal of small and asymptomatic antroliths may not be necessary. However, treatment options should be presented to the patient and the ultimate decision lies with the patient with informed consent taken.

Chronic sinusitis-associated antrolith

An antrolith is a calcified mass found in the nasal cavity or sinus, usually maxillary, described in literature as a rare phenomenon. Its presenting symptoms are variable and include symptoms associated with chronic sinusitis. We describe a 66 year old man with chronic sinusitis who presented with facial pain and epistaxis and upon further evaluation was found to have an antrolith of the left maxillary sinus.

Suspected Rhinolithiasis Associated With Endodontic Disease in a Cat

Rhinoliths are rare, intranasal, mineralized masses formed via the precipitation of mineral salts around an intranasal nidus. Clinical signs are typically consistent with inflammatory rhinitis and nasal obstruction, but asymptomatic cases are possible. Rhinoliths may be classified as exogenous or endogenous depending on the origin of the nidus, with endogenous rhinoliths reportedly being less common. This case report describes a suspected case of endogenous rhinolithiasis in a cat which was detected as an incidental finding during radiographic assessment of a maxillary canine tooth with endodontic disease. Treatment consisted of removal of the suspected rhinolith via a transalveolar approach after surgical extraction of the maxillary canine tooth.

Patient Characteristics and Frequent Localizations of Rhinoliths

Objective

A rhinolith is a rare entity affecting all people in all age groups. It is defined as a mineralized foreign body. The purpose of the present study was to reveal the distribution in age and gender and the localization, side, and prominent symptoms of rhinoliths to identify the risk groups and characteristics of the rhinoliths in a large case series.

Methods

A retrospective review was performed from the medical charts of 28 patients who were diagnosed with rhinolith and underwent surgery between May 2011 and January 2015 in Ankara Research and Training Hospital. All data, including age, gender, duration of symptoms, localization of the lesion and accompanying pathologies, were documented.

Results

In total, 28 patients (18 females and 10 males) with a mean age of 26.2±16.6 (5-62) years who were diagnosed with rhinolithiasis were reviewed. Nasal obstruction (71.4%) and nasal discharge (64.3%) were the most common complaints. The rhinolith was located in the right nasal cavity in 24 patients and in the left in four; this difference was statistically significant (p<0.001). There were 11 accompanying pathologies including nasal septal deviation (n=6), nasal polyposis (n=2), concha bullosa (n=2), and adenoid vegetation (n=1). In 21 (75%) patients, the most common site was the nasal base of the cavity between the inferior turbinate and the nasal septum.

Conclusion

If unilateral right-sided nasal obstruction with foul-smelling purulent discharge is detected in a young adult and a nasal examination reveals a mass in the floor of the cavity, a rhinolith should be strongly considered in the differential diagnosis.

Rhinolith mimicking a toothache

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Rhinoliths are uncommon clinical entities.

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Toothache is not known to be the typical presenting symptom, and has yet to be reported.

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The pathogenesis of rhinolith remains unclear.

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Symptomatic lesions will require surgical removal.

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Although rare, rhinolith should be included as a differential diagnosis of atypical odontogenic pain in the absence of obvious clinical dental pathology.

Introduction

A rhinolith is a calcified mass formed as a result of solidification of mucous foreign objects and gradual accretion of mineral salts. Toothache is not known to be the typical presenting symptom, and to our knowledge, has yet to be reported.

Case report

A 42-year old female referred by her general dental practitioner with a four month history of constant pain of the unrestored upper right central incisor tooth. Incidentally, she also gave a one year history of right-sided sinonasal congestion and intermittent blood stained rhinorrhea.

Discussion

Rhinoliths are uncommon and rarely encountered in clinical practice. This is due to the fact that they remain asymptomatic, and undetected for many years. They may present as incidental radio-opaque lesions in the nasal maxillary antrum on routine dental panoramic radiographs.

Conclusion

Rhinolith should be part of the differential diagnosis of atypical anterior maxillary dental pain in the absence of obvious clinical dental pathology.

Cone beam computed tomography for the nasal cavity and paranasal sinuses

The paranasal sinuses are 4 paired airspaces that border the nasal cavity. Dental professionals are most familiar with the maxillary sinuses as viewed in 2-D imaging (eg, periapical, panoramic projections). With increasing implementation of 3-D imaging, specifically cone beam CT, there is a high probability that much or all of the paranasal sinuses and nasal cavity will be captured in a scan. It is incumbent on practitioners to be familiar with all the structures contained within a scanned area. The purpose of this article is to provide an overview of the anatomy of the nasal cavity as well as common anatomic variants and pathologic entities.

A bizarre cause of extensive oronasal fistula

Oronasal fistula is defined as an abnormal duct, connecting the nasal with the oral cavity. We present an extremely rare case of oronasal fistula associated with rhinolithiasis. The particular case presents the unique feature of a palatal defect, being large enough to enable the in toto removal of the rhinolith. A 2-layer closure of the fistula was finally undertaken, by utilizing a vestibular and a palatal mucoperiosteal flap.

Rhinolith in the fossa of Rosenmuller--a hidden stone

This is a case report of an 80-year-old woman who presented to the ENT services with multiple non-specific upper aerodigestive tract symptoms. Despite extensive investigation and treatment, her symptoms remained unalleviated with significant impact on the psychological morbidity. During a routine flexible nasoendoscopy for worsening globus pharnygis, a mass was noted in the right Rosenmüller's fossa, where the Eustachian tube leaves the lateral wall of the nasopharynx. A CT scan showed this to be a 10 mm calcified entity within the right Eustachian tube. It was subsequently removed under local anaesthesia providing much relief to the patient. Histology showed this mass to be a rhinolith.

The rhinolith-a possible differential diagnosis of a unilateral nasal obstruction

Rhinoliths are mineralised foreign bodies in the nasal cavity that are a chance finding at anterior rhinoscopy. Undiscovered, they grow appreciably in size and can cause a foul-smelling nasal discharge and breathing problems. Giant nasal stones are now a very rare occurrence, since improved diagnostic techniques, such as endoscopic/microscopic rhinoscopy, now make it possible to identify foreign bodies at an early stage of development. We report the case of a 37-year-old patient who, at the age of 5-6 years, introduced a foreign body, probably a stone, into his right nasal cavity. On presentation, he complained of difficulty in breathing through the right nostril that had persisted for the last 10 years. For the past four years a strong fetid smell from the nose had been apparent to those in his vicinity. Under general anaesthesia, the stone was removed in toto from the right nasal cavity. The possible genesis of the rhinolith is discussed, our case compared with those described in the literature, and possible differential diagnoses are considered.

Naso-oral fistula due to rhinolithiasis: a rare presentation

Naso-oral fistula, as the name suggests, is an abnormal communication between the nasal and oral cavities. It is an extremely rare clinical entity encountered in routine rhinology clinics across the world. The occurrence of this fistula due to rhinolithiasis is much rarer. We present one such case in a 40-year-old man, who came to us for assessment of a "hole" in his palate. The cause of this naso-oral fistula was found to be a rhinolith in the right nasal cavity. This report emphasizes that trainee rhinologists should be vigilant about this little recognized and rare condition.