Abstract
Introduction
Rhinolithiasis is a rare condition often underdiagnosed due to its long asymptomatic nature.
Case presentation
We report the case of an 18-year-old female with a year-long history of right-sided nasal obstruction and nasal discharge. Physical examination identified a mass in the right nasal cavity. A paranasal sinus CT scan confirmed the diagnosis of rhinolithiasis. The mass was successfully removed endoscopically under general anesthesia and was found to be mineralized around a synthetic pearl. The patient was discharged the following day, with no complications observed at follow-up.
Clinical discussion
Rhinolithiasis is easy to diagnose and to treat. Diagnostic is based on clinical examination and CT-scan. Treatment is made by extracting the rhinolithiasis endoscopically.
Conclusion
Our case illustrates a rare cause of nasal discharge and highlights the importance of early detection and prompt removal.
Keywords: Rhinolithiasis, Endoscopic extraction, Case report
Highlights
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Rhinolithiasis is a rare entity, often underdiagnosed due to its long asymptomatic nature.
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Diagnostic is based on clinical examination.
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Treatment is made by extracting the rhinolithiasis endoscopically.
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Early detection of the rhinolith is crucial to prevent serious complications.
1. Introduction
Rhinolithiasis is solid calcium concretion by progressive deposition of calcium salts around a central foundation resorbable or not of various shapes and dimensions. The central foundation can be either ectopic tooth, fruit seeds, blood clot, vegetables or any other foreign body. Rhinolithiasis is a rare entity, often underdiagnosed due to its long asymptomatic nature, and is reported in the literature only in small series [1]. This case report was carried out according to the SCARE criteria [2]. This study aims to discuss presentation, symptoms, diagnosis, and treatment modalities.
2. Case presentation
An 18-year-old female with no past medical history and no mental disorder, presented to our department with a 12-month history of right-sided persistent nasal obstruction, intermittent nasal discharge and epistaxis. Physical examination revealed a yellow colored, irregular surfaced, hard stony mass in the right nasal cavity (Fig. 1A). There was no history of foreign body insertion in the nose during childhood. A paranasal sinus CT-scan revealed a calcified mass in the right nasal cavity between the septum and the inferior turbinate (Fig. 1B). Extraction was performed endoscopically under general anesthesia; the rhinolithiasis was found between the inferior turbinate and the septum, and was easily extracted without bleeding using a Blakesley instrument. It was a mineralized mass centered on a synthetic pearl (Fig. 1C). The patient was discharged on the first postoperative day. There were no complications during a one-year follow-up.
Fig. 1.
A (Above) Anterior rhinoscopy: yellow colored, irregular surfaced mass (arrow) B (Middle) paranasal sinus CT-scan: calcified mass in the right nasal cavity (arrows) C (Below) rhinolith split discovering a synthetic pearl inside it.
3. Discussion
Rhinolithiasis is solid calcium concretion by progressive deposition of calcium salts around a central foundation resorbable or not of various shapes and dimensions [1]. The central foundation can be either ectopic tooth, fruit seeds, blood clot, vegetables or any other foreign body [3]. Rhinolithiasis is a rare entity. In the published literature, large series of rhinoliths have been recorded in less-developed countries [4]. Rhinolithiasis can occur at any age, but it is predominantly observed in adult, with an average age of 44 years, and it is typically found in individuals with specific psychological traits, such as intellectual disabilities and schizophrenia, or among those who wear magnetic piercings. It predominantly affects young women. Rhinolithiasis can be unilateral or bilateral, and the stones can be single or multiple. It is more often found in the right nasal cavity, occurring in about 65 % of cases. This is likely due to the higher prevalence of right-handed individuals [4,5]. Rhinolithiasis is often revealed by a chronic non-specific unilateral nasal symptomatology (rhinorrhea, nasal obstruction, epistaxis, and headache) [5]. Diagnostic is based on clinical examination; anterior rhinoscopy and nasal endoscopy [6]. Endoscopic examination might detect bleeding around the granulation tissue, prompting suspicion of a malignant tumor [5,6]. As a result, imaging would be required for a more thorough evaluation. CT scan is the examination of preference given its good sensitivity and specificity in identifying calcifications and foreign bodies. It allows specifying the exact location and dimensions of the rhinolithiasis as well as its relationship with the surrounding structures [1]. It is usually located between the inferior turbinate and the septum [4,5]. X-rays lack sensitivity compared to CT scans [1]. Differential diagnoses are dominated by tumours especially bone tumours (nasal osteoma, fibroma, hemangioma and osteosarcoma), or a calcified nasal polyp or even nasal tuberculosis with calcification [5]. If left untreated, Rhinoliths can act as a nidus for infection, potentially leading to chronic sinusitis. This infection may spread to surrounding sinuses, resulting in pansinusitis. Additionally, the ongoing inflammation and pressure from the rhinolith can cause ulceration of the nasal mucosa, which may eventually lead to septal and palate perforation. In severe and rare cases, the complications may extend beyond the nasal cavity, potentially affecting the orbital region or leading to intracranial infections [7]. Treatment is made by extracting the rhinolithiasis endoscopically under local or general anesthesia [6]. External surgery is exceptionally indicated and it is primarily reserved for “historical” large rhinoliths, or for the repair of a septal perforation [8,9]. Lithotripsy can be proposed for large rhinolithiasis that cannot be extracted [6]. In case of mucosal injury, the placement of a Silastic sheet for about ten days helps prevent turbino-septal synechia.
4. Conclusion
Rhinolithiasis is a rare and often unrecognized medical condition. However, it is easy to diagnose and to treat using nasal endoscopy and CT-scan, with good outcomes. Its early detection and prompt removal of the rhinolith are crucial to prevent serious complications and to maintain normal nasal function.
Author contribution
Chaima Ben Ammar: Writing - Original draft.
Makram Tbini: Writing - Original draft.
Houssem Eddine Kamel: Writing - Review & editing.
Sarra Idriss: Writing - Review & editing.
Mamia Ben Salah: Supervision.
Patient consent
Written informed consent was obtained from the patient for publication of this case report and accompanying images.
Ethical approval
Case reports are exempt from ethical approval by the ethical committee of our hospital.
Guarantor
Makram Tbini.
Funding
None.
Declaration of competing interest
None.
Data availability
Data used during this study is available from the corresponding author on reasonable request.
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Associated Data
This section collects any data citations, data availability statements, or supplementary materials included in this article.
Data Availability Statement
Data used during this study is available from the corresponding author on reasonable request.