The Hidden Giant: A Report of an Enormous Rhinolith

Abstract

Rhinolith, commonly addressed as nasal stone is quite unusual and rare entity. It is actually a calcified mass that form within the nasal cavity, typically as a result of mineral deposits accumulating around a core of foreign material (which can be exogenous or endogenous in origin). Although often small and asymptomatic, rhinolith can occasionally grow to significant size, causing severe clinical symptoms. Case description: We report a case of this clinical entity, a tribal woman from interior Himalayan regions, where the lack of medical facilities and expertise led to missed diagnosis, years of suffering and a rhinolith of humongous proportions.

Supplementary Information

The online version contains supplementary material available at 10.1007/s12070-024-04990-4.

Significance

Although a rare clinical entity, recurrent specific symptoms, as discussed in article should raise a suspicion of Rhinolithiasis too. If diagnosed at initial stages, it can save years of torment and complications to patient.

Supplementary Information

The online version contains supplementary material available at 10.1007/s12070-024-04990-4.

Introduction

Rhinoliths develop from the gradual deposition of mineral salts around an intranasal foreign body, which can be endogenous (e.g., blood clots, desquamated epithelium) or exogenous (e.g., beads, grains, glass, wood etc.) in origin. Aspergillosis infection was mentioned as probable cause in one report [1]. Many a times the probable cause is not discernable. Over time, these deposits form a hard, stone-like mass in nasal cavity, and hence the name which is derived from Greek terminology “rhino” and “lithos” meaning nose and stone respectively.

The factors contributing to rhinolith formation are foreign bodies/nidus which are small objects lodged in the nasal cavity for certain period of time. These objects initiate the formation of rhinoliths by causing chronic Inflammation, which creates an environment conducive to mineral deposition. Sometimes Chronic rhinitis and sinusitis can be a contributing reason by causing mucosal edema and increasing mucosal secretions. All these issues lead to impaired nasal drainage or stasis of nasal secretions and decreased mucociliary clearance which further assists in calcification. Conditions such as nasal polyps or structural anomalies may exacerbate this stasis [2].

Anatomically, the nasal cavity’s structure, with its narrow passages and potential for mucus accumulation, can facilitate the development of these calcified masses. The pathophysiological process typically starts with the initial formation of a central core, followed by concentric deposition of mineral salts over months or years. The entity was reported a long time back by Bartholin in 1654 but still is rarely seen in practice. Many clinicians have never encountered this pathology in their clinics, and such a gigantic calcification is rare of rarest. So a high degree of suspicion is needed to diagnose them, especially in early stages.

Case Report

A 42 years old tribal woman from interior regions of Himalayas visited to ENT OPD with chief complaint of recurrent episodes of epistaxis from last 5 years approximately. Currently, recurrent bleeding from nose was her chief concern. On detailed history she complained of occasional foul smelling discharge from nose, an always lingering bad odour, completely blocked right nasal passage and frequent facial pain especially in infraorbital region. In so many years she became accustomed to these symptoms. On clinical examination there was widening of nose with left septal deviation in the upper half of nose. On anterior rhinoscopy the nasal cavity was filled with adherent clotted blood and there was some foreign body of greyish white color obstructing right nasal cavity. Patient didn’t have any history of inserting a foreign object or any trauma to facial area previously. Otherwise patient was completely healthy and didn’t have any cognitive impairment. The patient has previously consulted with healthcare providers in their area regarding the condition, which occasionally helped her nasal bleed to stop.

Suctioning of blood clots and endoscopic examination with (0° nasendoscope) revealed greyish white uneven shaped hard object at the level of anterior border of inferior turbinate, completely obstructing the right nasal cavity. The tissue around the mass was friable and started bleeding on probing. The space was completely obstructed and further clinical or endoscopic examination was not possible. Few small chunks of calcified mass were taken from the inferior aspect. Those chunks were sent for histopathology examination; keeping in mind few other probable differential diagnoses like calcified polyps, osteoma, odontoma, osteosarcoma etc. CT (PNS) was done for patient, which revealed a huge irregular shaped, radiopaque space occupying lesion, almost completely obliterating the right nasal cavity with its base abutting the nasal floor (Fig. 1). The dimensions of mass were approximately 5.4 cm (anterio-posterior) x 4.7 cm (cranio-caudal) X 3.0 cm (transverse). Adjacent normal nasal anatomy was distorted and there was expansion of nasal cavity on right side. Nasal septum was deviated towards left with hypertrophy of left middle and inferior turbinate. Mucosal thickening of right maxillary, ethmoid and sphenoid sinus was the additional CT finding. Histopathology report showed areas of calcification with few dead tissue fragments encapsulated in calcified mass.

Fig. 1.

Sagittal CT scan view depicting the maximum dimensions of a giant calcified lesion in right nasal cavity

Patient was then planned for endoscopic removal of rhinolith under general anaesthesia. Nasal mucosa was decongested with topical anaesthesia (4% lignocaine with adrenaline) soaked ribbon gauze. As the rhinolith was huge and irregular shaped, it was initially removed in small chunks to prevent adjacent tissue damage and to create space to approach deeper lesion. Almost half of the initial mass was removed in piecemeal fashion and the latter half became mobile in process, which was slowely detached from adjacent adhesions and removed in toto (Fig. 2). There was profuse bleeding initially, which was easily controlled after lesion removal. Paraffin and hemocoagulase dipped nasal pack was placed post irrigation. Patient was discharged on second day, after pack removal. Postoperative follow up after two weeks showed complete relief in symptoms and endoscopic examination revealed a well healed nasal mucosa.

Fig. 2.

Endoscopically excised rhinolith

Discussion

Rhinolith is a relatively rare condition and is caused by gradual deposition and coating of different salts of calcium and magnesium present in body fluids, over a nidus inside the nasal cavity [3]. The foreign bodies causing rhinolith, normally access the site anteriorly from nostril, but they may occasionally reach into the nasal cavity through the choana by cough or vomiting. [4] or it can be endogenous in origin like blood clot, thick secretion, ectopic tooth etc. The nidus leads to either obstruction or stasis of nasal secretions, which leads to localized inflammatory reaction. If the nidus is not removed or expelled at this stage, it leads to deposition of calcium carbonate and calcium phosphate, magnesium, iron, and aluminum, in addition to organic substances such as glutamic acid and glycine [5], resulting in formation and gradual progression of rhinolith. The process is continuous, slow; layer-by-layer deposition of calcium and magnesium salts present in the nasal secretions. [6] Vink et al. performed macroscopic and microscopic examination, X-ray diffraction analysis, electron microscope analysis on rhinoliths, which revealed that the they consists of a core of calcium stearate (C₃₆H₇₀CaO₄.H₂O), surrounded by concentric growth rings of sodium-containing whitlockite (Ca₁₈Mg₂(NaH)(PO₄)₁₄) predominantly. [7] Various chemical and physical factors like pH-value, acute or chronic infections, composition of the nose secretion, temperature etc. influence the consistency and growth of the rhinoliths and therefore the aeration and nasal airflow [8, 9].

These rhinoliths are generally unilateral and have female prediliction [10]. These greyish-brown to blackish, irregular surfaced structures are initially asymptomatic most of the times. At later stages patients with rhinoliths may present with a variety of symptoms, depending on the size and location of the stone. Common clinical signs include unilateral nasal obstruction, often persistent and unresponsive to standard treatments; foul-smelling nasal discharge. Chronic, unilateral purulent discharge with a distinct malodor is a hallmark of rhinoliths. Another common symptom associated with rhinoliths is recurrent epistaxis, especially with the larger ones which cause continuous mucosal irritation. Other associated symptoms like facial pain, headache, anosmia, cacosmia can also be occasionally seen.

Rhinoliths may go undiagnosed initially because of lack of symptoms or due to their small size. Many a times, they are missed on radiographs too, because of small size and less density of calcification in preliminary stages. If undetected for many years’ rhinoliths may grow large enough to cause destruction of surrounding structures apart from nasal obstruction and distortion [11, 12], as it did in our patient. There have been various reports of septal deviation and septal perforation [13] and destruction of the lateral wall of the nasal cavity with growth of the calculus to involve the maxillary sinus [14]. Rarely a large calculus may produce an oroantral fistula [15]or an oronasal fistula [16].

Although quite rare entity, it should be kept in mind while examination, if patient presents with above mentioned symptoms. A prompt investigation can aid in diagnosis. Anterior nasal endoscopy is a helpful tool as most common location of such pathology is along the floor of nasal cavity and inferior meatus. [17] CT is another helpful diagnostic tool to evaluate the extent of calcification and status of surrounding structures, as most of the times rhinoliths block nasal cavity and endoscopic examination is not possible beyond certain extent. Not all the calcifications seen in nasal cavity are rhinoliths so certain differential diagnosis should be considered while examination like calcified polyps, odontomes, granulomas, granulomatous diseases, sequestration following local osteomyelitis, osteoma, calcified odontogenic cysts, chondrosarcoma, osteosarcoma and sinonasal malignancy [18].

Mainstay treatment of rhinolith is surgical excision. The approach may depend on the location, size, status of surrounding tissues etc. Most commonly the intranasal approach serves the purpose, even if the rhinolith is humongous like in our case. A simpler way is to remove it in pieces under endoscopic view, as we did in our patient rather than trying to remove in toto.

Extra nasal approach may be required in some cases. Oguzhan et al. have reported rhinolith removal by pushing the rhinolith posteriorly into the nasopharynx and removing it through the oral cavity. [19] Adjunct procedures like Septoplasty or turbinoplasty may be required occasionally. As per available literature the recurrence rate is nil for rhinoliths.

Conclusion

Although rhinolith is not a very frequently appearing entity in head and neck clinics, but presence of certain specific symptoms like persistent or recurrent foul smelling discharge, frequent unilateral epistaxis without any other cause or continuous sensation of nasal blockage should raise suspicion of rhinolith too, apart from usual differential diagnosis. A thorough history, clinical, endoscopic or radiographic examination is important, as these can be easily missed in starting stages, which can lead to humongous lesions causing anatomical destruction and misery to patient. Based on our case we also want to emphasize the importance of specialty referral at earliest, for patient’s wellbeing.

Electronic Supplementary Material

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Funding

This research did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors.

Declarations

Research Involving Human Participants and/or Animals

Yes human participants were involved in this case report. We confirm that all the procedures were carried out in accordance with approved ethical standards.

Informed Consent

Informed consent was taken from the patient and attender.

Conflicts of Interest

We wish to confirm that there are no known conflicts of interests associated with this manuscript.