Rhinolith is an uncommon nasal mass in children and adolescents. We report a 8 years old boy with a history of long standing foul smelling right sided nasal discharge, progressive nasal obstruction and recurrent epistaxis, which was clinically suspected as being due to the presence of a long standing foreign body. Rhinolith in the right nasal cavity was diagnosed on   rigid   endoscopic   examination.   Rhinolith   was   removed   by   using   a   00  rigid   nasal   endoscope.Key Words: Rhinolith, Endoscop

Ghanbari, H.

Mohebbi, A.-R.

Salarian, S.

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See discussions, stats, and author profiles for this publication at: https://www.researchgate.net/publication/26538851A Case of RhinolithiasisArticle  in  Online Journal of Health and Allied Sciences · April 2008Source: DOAJCITATIONS15READS2676 authors, including:Some of the authors of this publication are also working on these related projects:Spectrophotometric determination of natural colourant obtained from the flowers of different plants and their isolation and characterisation View projectCongenital hypofibrinogenemia – A cause for neck swelling View projectSaurabh VarshneyAll India Institute of Medical Sciences Rishikesh211 PUBLICATIONS   700 CITATIONS   SEE PROFILESampan S BistHimalayan Institute of Medical Sciences120 PUBLICATIONS   545 CITATIONS   SEE PROFILESanjeev KishoreAll India Institute of Medical Sciences Rishikesh61 PUBLICATIONS   204 CITATIONS   SEE PROFILEAll content following this page was uploaded by Saurabh Varshney on 16 April 2014.The user has requested enhancement of the downloaded file.Peer Reviewed, Open Access, FreePublished QuarterlyMangalore, South IndiaISSN 0972-5997Volume 7, Issue 2; Apr-Jun 2008A Case of Rhinolithiasis  AuthorsRakesh Kumar Singh, Saurabh Varshney, Sampan Singh Bist, Nitin Gupta, Rajat Bhatia,Department of Otolaryngology Head and Neck Surgery,Sanjeev Kishor, Department of pathology,Himalayan Institute of Medical Sciences, DehradunAddress For CorrespondenceDr. Rakesh Kumar Singh,Department of Otolaryngology Head and Neck Surgery,Himalayan Institute of Medical Sciences,Jollygrant, Doiwala,DehradunE-mail: rksent5@gmail.com CitationSingh RK, Varshney S, Bist SS, Gupta N, Bhatia R, Kishor S. A case Of Rhinolithiasis. Online J Health Allied Scs.  2008;7(2):7URLhttp://www.ojhas.org/issue26/2008-2-7.htmhttp://ojhas.org Case ReportSubmitted: May 6, 2008; Accepted: June 28, 2008; Published: July 21, 2008Abstract:Rhinolith is an uncommon nasal mass in children and adolescents. We report a 8 years old boy with a history of long standing foul smelling right sided nasal discharge, progressive nasal obstruction and recurrent epistaxis, which was clinically suspected as being due to the presence of a long standing foreign body. Rhinolith in the right nasal cavity was diagnosed on  rigid  endoscopic  examination.  Rhinolith  was  removed  by  using  a  00 rigid  nasal  endoscope.Key Words: Rhinolith, EndoscopyOJHAS  Vol 7 Issue 2(7) Singh RK, Varshney S, Bist SS, Gupta N, Bhatia R, Kishor S. A case Of Rhinolithiasis.Introduction:Rhinoliths  are  calcareous  concretions  around  calcinated intranasal foreign bodies within the nasal cavity.1 They are usually found in the anterior part of the nasal cavity and are usually diagnosed on history and anterior rhinoscopy.2 In such a condition, radiological evaluation is only needed for  differential  diagnosis  and  to  detect  any  related complications.  Radiology  may  be  useful  in  a  posteriorly situated mass which may cause difficulties in diagnosis.3,4 However, endoscopic examination can be of immense help in such situations.2,5 We present a rare case of posteriorly situated rhinolith in a child that was diagnosed and treated with the help of a rigid nasal endoscope. Case Report:A 8 years old boy presented with a 3 year history of right sided  nasal  obstruction,  foul-smelling  purulent  nasal discharge, intermittent nasal bleeding and posterior nasal drip.  The  patient  did  not  give  any  history  of  putting  a foreign  object  inside  the  nose.  There  was  no  history  of prior  nasal  trauma or nasal  surgery.  Anterior  rhinoscopy revealed  hyperaemic  nasal  mucosa  on  the  right  side, purulent  nasal  discharge  and  suspicious  mass  in  the posterior part of the nasal cavity. Probing revealed a hard stony  mass  with  gritty  sensation.  Posterior  rhinoscopy showed purulent discharge trickling along the lower part of the eustachian tube opening.  The initial  clinical  suspicion was that of a long standing foreign body in the right nasal cavity. After proper decongestion with Oxymetazoline and anaes-thetising the nasal cavity with 2% Xylocaine, the nasal cavity was evaluated with a 00 rigid nasal endoscope. Endoscopic examination of the nasal cavity revealed an irregular hard foreign body extending from the roof to the floor of the posterior part of the right nasal cavity (Fig. 1).Fig 1: Endoscopic picture of rhinolith present in the right nasal cavityThe object was situated lateral  to the nasal  septum and medial to the inferior and middle turbinates, displacing the middle  turbinate  laterally.  The  object  also  encircled  the free  ends  of  the  middle  and  inferior  turbinates.  The surrounding  mucosa  was  hyperaemic  and  edematous.  A plain CT scan of the nose and paranasal sinuses showed a homogenous  well-defined  calcified  object  with  central translucency at the floor of nasal cavity without any bony erosion (Fig. 2).Fig 2: Coronal CT scan of nose and paranasal sinuses showing  a  rhinolith  in  right  nasal    cavity  and collection of fluid in right maxillary antrumBased on above findings, clinical diagnosis of rhinolith of the right nasal cavity was made and the patient was taken up for surgery under general anaesthesia. With the help of a 00 rigid nasal endoscope, the mass was visualized and a blunt dissector was passed all around the object with the purpose of freeing it from the surrounding mucosa. It was pushed into the nasopharynx  and was taken out via  the oral cavity (Fig 3).Fig  3:  Specimen  of  rhinolith  after  endoscopic assistated removalUncinectomy,  middle  meatal  antrostomy  and  anterior ethmoidectomy was done to clear the maxillary sinus. The specimen was sent for histopathological examination. The http://ojhas.orgOJHAS  Vol 7 Issue 2(7) Singh RK, Varshney S, Bist SS, Gupta N, Bhatia R, Kishor S. A case Of Rhinolithiasis.histopathological  report  revealed  calcium  crystals  over degenerated materials suggestive of rhinolith (Fig: 4).Fig  4:  Microscopic  picture  of  the  rhinolith  showing calcium  crystals  and  degenerated  material  (H  &  E, X40)Minimum bleeding was encountered during the procedure which  was  controlled  by  anterior  nasal  packing  with Merocel.  Antibiotics,  nasal  decongestant  and  anti-inflammatory  drugs  were  given to the  patient  for  seven days  post  surgery. The  patient  was  relieved  of  the presenting  symptoms  after  surgery  and  no  complication was noted postoperatively.Discussion:Rhinoliths  are  grey  to  brown  coloured,  foul-smelling, rough-surfaced,  friable  structures  often  situated  in  the anterior  half  of  the  nasal  cavity  most  commonly  on  its floor2.  The other  locations  reported are  in  the maxillary and frontal sinuses.1 Bertholin gave the first documented discription in 1654.2 Rhinoliths usually present in the third decade of  life  and rarely  occur in  children with females more commonly affected than male.4The pathogenesis of rhinolith is not clear. It has been spec-ulated that a foreign body incites a chronic inflammatory reaction, with the deposition of mineral salts. The foreign body acts as a nidus that causes obstruction of nasal secre-tions, acute and chronic inflammation, deposition of min-erals  and  enzymatic  activities  of  bacterial  pathogens.2,3 Most  foreign  bodies are  exogenous,  such as beads,  but-tons, pieces of paper, cherry pits, stones, sand, fruits, peas, parasites, wood or glass and they usually enter through the anterior nares. Rare endogenous agents causing true rhino-lith include clotted blood, bacteria, leukocytes, bone frag-ments and teeth.6Axmann carried out the first chemical analysis of rhinolith in 1829.2 Since then, several techniques have been used for mineralogical analysis such as Electron-ray microprobe, X-ray  differactometry  and  infrared-spectroscopy.  The  pre-dominant material (up to 90%) is inorganic. Calcium phos-phate,  calcium carbonate  and  magnesium phosphate,  as well as other rare substances, have been described. The or-ganic  components may derive from nasal  secretions and lacrimal fluid.1,2The typical symptoms of rhinolith are unilateral nasal ob-struction, foul smelling purulent nasal discharge and epis-taxis. Other symptoms include crusting, swelling of nose or face, anosmia,  epiphora and headache.6 At rhinoscopy,  a mass  or  nodule  with  well-  or  ill-defined borders  with  a hard gritty sensation on probing is often found.5 In 1900, MacIntype gave the first radiological description of rhinolith.4 The typical radiological features are radio-opaci-ty with central  translucency.  On CT scan, it appears as a homogenous, high-density lesion with smooth mineraliza-tion. The central portion of the lesion, which may contain organic material, may be of a somewhat lower density, or a foreign-body nidus may be seen. CT cannot differentiate a rhinolith from any other calcified mass, but can detect the related complications of rhinoliths.3,4Rigid endoscopy has a great role in establishing a diagnosis, and in evaluating the posterior extent of a rhinolith with-out providing any risk of radiation exposure. It is a cost-ef-fective diagnostic as well as therapeutic method. The endo-scopic nasal surgery provides an opportunity for manipula-tion  and removal  of  the  entire  mass  under direct  visual control.  At the same time it  is  helpful  in  managing  any complications of rhinolith.1,3,5The most important differential diagnosis include haeman-gioma, osteoma, calcified polyps, enchondroma, dermoid, chondrosarcoma,  osteosarcoma,  syphilis  and tuberculosis. The complications reported are sinusitis, septal perforation, palatal  perforation,  recurrent  otitis  media,  and recurrent dacryocystitis.1,4,6 Our  patient  developed ipsilateral  maxil-lary  sinusitis  that  was  treated  with  uncinectomy,  middle meatal antrostomy and anterior ethmoidectomy.In  most  cases,  rhinolith  of  nasal  cavity  can be removed through the nostrils. Only in rare cases are extended surgi-cal approaches, for e.g. alar release or lateral rhinotomy, necessary for complete removal of the stone. A rhinolith that cannot be removed surgically could be disintegrated using a lithotripsy.3 The use of the nasal endoscope has be-gun a new method in the diagnosis  and management of rhinolith. The diagnosis is straightforward and easy with a rigid endoscope. Endoscopically controlled surgery can also be immensely helpful in complete and uneventful removal of the rhinolith and in dealing with complications such as sinusitis.  It is a cost-effective and more accurate method for diagnosis  and treatment.2,5 Ours is a typical  case with respect to the age and sex of the patient, the location, di-agnostic and therapeutic approach for a rhinolith.http://ojhas.orgOJHAS  Vol 7 Issue 2(7) Singh RK, Varshney S, Bist SS, Gupta N, Bhatia R, Kishor S. A case Of Rhinolithiasis.References:1. Keck T, Liener K, Strater J, Rozsasi A. Rhinolith of the nasal septum.  Int J Pediatr Otorhinolaryngol 2000;53:225-228.2. Sinha B K, Bhandary S, Singh R K, Karki P. Giant rhinolith  with  nasopharyngeal  extension-a  rare case  report.  Pakistan  J  Otolaryngol 2005;21:42-43.3. Hadi U, Ghossaini S, Zaytoun G. Rhinolithiasis: a forgotten  entity.  Otolaryngol  Head  Neck  Surg 2002;126:48-51. 4. Royal S A, Gardner R E. Rhinolithiasis: an unusual pediatric  nasal  mass.  Pediatr  Rediol  1998;28:54-55.5. Ogretmenoglu O. The value of endoscopy in the diagnosis of rhinolith: a case report. Kulak Burun Bogaz Ihtis Derg 2003;11:89-92.6. Aksungur E H, Binokay F B, Bicakci K et al. A rhi-nolith which is mimicking a nasal benign tumor. Eur J Radiol 1999;31:53-55.http://ojhas.orgOJHAS  Vol 7 Issue 2(7) Singh RK, Varshney S, Bist SS, Gupta N, Bhatia R, Kishor S. A case Of Rhinolithiasis.View publication stats

A case of rhinolithiasis

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A case of rhinolithiasis

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