rhinolith

Rhinolith

A rhinolith is an object that has become lodged in the nasal cavity and has slowly calcified 1). The word rhinolith is derived from the roots rhino- and -lith, it literally can be translated as “stone of the nose” 2). Rhinolith is not a foreign body per se as it is not introduced from outside but it develops inside the nasal cavity by continuous, slow, layer-by-layer deposition of calcium and magnesium salts present in the nasal secretions over a nidus 3). The nidus may be endogenous or exogenous 4). Endogenous nidus means something that belongs to your body itself like thick dried mucus, dried blood clot, an ectopic tooth, a piece of mucus membrane or bone fragment. Exogenous nidus is always a foreign body like a piece of paper, tissue, a bead or a fruit seed introduced into the nasal cavity. This is usually seen in small children or those who are mentally challenged. This process takes years to develop.

A rhinolith is usually of irregular shape but sometimes they grow quite big and their size and shape gives an appearance not unlike that of a staghorn calculus of renal pelvis, may be grey or brownish pink in color. A rhinolith was like that hence the name staghorn rhinolith is sometimes used 5). Rhinoliths are friable, and they crumble readily under pressure.

Rhinoliths are rare, incidence reported as 1 in 10,000 ENT outpatients in one of the studies 6) and not to be confused with dried nasal mucus.

Over a period of time, rhinoliths grow into large irregular masses that fill the nasal cavity. They may cause pressure necrosis of the nasal septum or lateral wall of nose. Rhinoliths can cause nasal obstruction, epistaxis, headache, sinusitis and epiphora. Sometimes patients may have no nasal symptoms at all and may present with halitosis 7). Rarely, they may cause palatal perforation 8).

The diagnosis of a rhinolith can be diagnosed from the history with unilateral foul-smelling blood-stained nasal discharge or by anterior rhinoscopy. These days, availability of rigid and fibre-optic nasal endoscopes can make a rhinolith diagnosis really straightforward. On probing, the probe can be passed around all its corners. But sometimes patients either do not seek medical care or are sometimes misdiagnosed and prescribed treatment on the lines of rhinosinusitis often over considerable period of time 9).

Although diagnosis of rhinolith is straightforward sometimes they have to be differentiated from inflammatory conditions like sinusitis and neoplastic conditions like osteoma, ossifying fibroma and odontoma and other malignancies. However, clinical and radiological examinations can easily rule them out 10).

Very rarely, the rhinolith is discovered as an incidental finding during radiological tests of skull for some other reason 11). Plain X-ray of skull usually corroborates the clinical diagnosis showing radio-opaque irregular object in the nasal cavity surrounded by haziness. However, CT scan sometimes has to be done 12), the rhinolith could hardly be discerned on plain radiography but clearly demonstrated in the CT scan. Moreover, 3-D reconstruction of CT image can clearly show the irregular shape of the object thus useful in planning removal.

Small rhinoliths can be removed by a foreign body hook. Whereas large rhinoliths can be removed either by crushing with Luc’s forceps or by Moore’s lateral rhinotomy approach.

Rhinolith causes

A rhinolith is an object that has become lodged in the nasal cavity and has slowly calcified 13). The presence of foreign bodies cause local inflammatory reaction, leading to deposits of carbonate and calcium phosphate, magnesium, iron and aluminum, in addition to organic substances such as glutamic acid and glycin, leading to slow and progressive increase in size 14). Rhinolith is not a foreign body per se as it is not introduced from outside but it develops inside the nasal cavity by continuous, slow, layer-by-layer deposition of calcium and magnesium salts present in the nasal secretions over a nidus 15). The nidus may be endogenous or exogenous 16). Endogenous nidus means something that belongs to your body itself like thick dried mucus, dried blood clot, an ectopic tooth, a piece of mucus membrane or bone fragment. Exogenous nidus is always a foreign body like a piece of paper, tissue, a bead or a fruit seed introduced into the nasal cavity. This is usually seen in small children or those who are mentally challenged. This process takes years to develop.

Rhinolith symptoms

Firmly impacted and unrecognized foreign bodies can in time become coated with calcium, magnesium, phosphate, or carbonate and become a rhinolith. Rhinoliths are radio-opaque and typically are found on the floor of the nasal cavity. Rhinoliths can remain undetected for years and only upon growth produce symptoms that lead to their discovery. Rhinoliths tend to go unrecognized for longer periods of time than do foreign bodies in the ear because they usually produce fewer symptoms and are more difficult to visualize. As a result, the symptoms are slow and insidious and may consist of nasal blockade, unilateral persistent or intermittent rhinorrhea, usually with a foul smell and occasionally blood-stained 17). Sometimes patients may have no nasal symptoms at all and may present with halitosis 18). Rarely, they may cause palatal perforation 19).

Rhinolith complications

The most common complication of rhinoliths is minor epistaxis. Rarely, a rhinolith may cause palatal perforation 20).

Although the foreign body itself may cause irritation, morbidity is primarily caused by the resulting inflammation and mucosal damage, as well as extension into adjacent structures. Reported complications include the following:

  • Sinusitis
  • Acute otitis media
  • Nasal septal perforation
  • Periorbital cellulitis
  • Meningitis
  • Acute epiglottitis
  • Diphtheria
  • Tetanus

Local inflammation from rhinoliths can result in pressure necrosis. This, in turn, can cause mucosal ulceration and erosion into blood vessels, producing epistaxis. Moreover, the swelling can obstruct sinus drainage and lead to secondary sinusitis. Organic foreign bodies tend to swell and are usually more symptomatic than are inorganic foreign bodies.

A delay in the diagnosis of rhinolith complications can result in prolonged morbidity. This outcome can be avoided by performing a thorough examination and by reexamining the nasal cavity after removal of the rhinolith.

Rhinolith diagnosis

Rhinolith can be diagnosed from the history with unilateral foul-smelling blood-stained nasal discharge or by anterior rhinoscopy. These days, availability of rigid and fibre-optic nasal endoscopes can make a rhinolith diagnosis really straightforward. Examination of the patient includes anterior rhinoscopy, nasal endoscopy and probing of the mass. On probing, the probe can be passed around all its corners. In case endoscopy is not available, radiography of the paranasal sinuses may be helpful, although a negative examination will not rule out rhinolith in a symptomatic patient. If diagnosis and extension are not clear, simple X-ray and paranasal sinuses CT scan can provide accurate details for the location, size and extension of the rhinolith, and any other local diseases that need treatment 21).

Diagnosis of rhinolith is straightforward sometimes they have to be differentiated from inflammatory conditions like sinusitis and neoplastic conditions like osteoma, ossifying fibroma and odontoma and other malignancies. However, clinical and radiological examinations can easily rule them out 22).

Rhinolith treatment

Small rhinoliths that are easily accessible can be removed by a foreign body hook in the office followed by anterior nasal packing if needed. Whereas large rhinolith needs to be removed under general anesthesia to avoid complications such as perforation of the nasal septum or the hard palate. Large rhinoliths can be removed either by crushing with Luc’s forceps or by Moore’s lateral rhinotomy approach with some bleeding to be expected. Also if the patient is a small child or mentally challenged, then removal under general anesthesia is preferable. Afterwards if significant raw area is visible in both medial and lateral nasal walls, then to prevent adhesions and synechiae, it is highly recommended to place a silastic splint for a few days. Unless bleeding is very little, anterior nasal packing is usually needed for 24–48 hours. The patient usually makes full recovery afterwards with resolution of symptoms. Nowadays, while endoscopic removal is usually employed, very rarely lithotripsy and lateral rhinotomy have to be considered where endoscopic option is not available 23).

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