Retained tooth in the nasal cavity: a rare cause of nasal congestion

Abstract

A 59-year-old man presented with unilateral nasal congestion and discharge. Clinical examination revealed a mass in the floor of the nasal cavity. Sinus CT indicated a retained tooth or a dermoid cyst. It was removed by endoscopic surgery. Histology confirmed the diagnosis of a retained tooth. At follow-up, the patient reported no nasal symptoms. A retained nasal tooth is rare, and the symptoms are variable. It can resemble other diseases such as chronic rhinosinusitis. Surgical removal is recommended to confirm the diagnosis and eliminate symptoms.

Background

An intranasal retained tooth is a rare finding with an incidence ranging from 0.1% to 1% in the general population. It can be located in several places in the nasal cavity and paranasal sinuses. Clinical presentation is variable. It can easily be missed, particularly since a retained tooth can be asymptomatic. Diagnosis is important since it potentially can cause morbidity.

Common nasal symptoms like congestion and discharge are often signs of chronic rhinosinusitis, but differential diagnosis must always be considered. Due to the rarity of a retained tooth the literature on this subject is sparse.

Case presentation

A 59-year-old man was referred to the otorhinolaryngology department at our tertiary university centre with a history of nasal congestion, chronic purulent discharge and hyposmia through a 2-year period. The symptoms were most prevalent on the left side. He had tried topical nasal steroids for a month without improvement.

In his youth he had suffered a facial trauma resulting in both mandible fracture and nasal fracture. The latter requiring repositioning.

Examination revealed a septum deviating to the left and an ipsilateral bone spur. A mass was found in the floor of the nasal cavity. Endoscopic removal was scheduled preceded by a CT scan. The patient was instructed in using nasal saline irrigation and ten days of antibiotics were prescribed.

Investigations

The CT scan showed normally pneumatised sinuses and a 13×6 mm sized tumour located in the floor of the nasal cavity covered by nasal mucosa beneath the left inferior turbinate (figure 1). An impacted tooth or a dermoid cyst was suspected.

Figure 1.

CT scan of nasal cavity and sinuses (left nasal cavity).

Differential diagnosis

Dermoid cyst.

Osteoma.

Exostosis.

Neoplasm.

Foreign body.

Calcified polyp.

Rhinolith.

Treatment

Endoscopic sinus surgery was performed (figure 2) on general anaesthesia. The mass appeared solid and was extracted with a Weil-Blakesley forceps (figure 3). An endoscopic removal of a septal spur and bilateral turbinoplasty was performed in addition.

Figure 2.

Endoscopic view before extraction.

Figure 3.

Extracted tooth.

Outcome and follow-up

The patient recovered well, and had no further symptoms at follow-up 1 month later. The specimen was sent to pathological examination, which described a tooth and inflamed nasal mucosa.

Discussion

A retained tooth in the nasal cavity is rare. It can be found in children and adults alike. A review of the literature found a male predominance of 60% and no side predilection.¹ Aetiology is unclear. It can be due to trauma, odontogenic or rhinogenic infections and developmental disturbances such as cleft lip or cleft palate. In our case there was no obvious explanation. A retained tooth can be a supernumerary or a permanent tooth. The most common location for a supernumerary tooth is the upper incisor area, known as the mesiodens. An inverted growth can lead to an intranasal tooth.²

The clinical presentation includes a variety of symptoms, especially unilateral nasal congestion, chronic discharge, ulceration and crusting of the nasal mucosa.^{1 3 4} Other case reports mention foreign body feeling, epistaxis, external nasal deviation, septal abscess and facial pain.^{3 4}

Examination of the nose often reveals a protruding mass, which can be covered by mucosa and surrounded by debris or tissue granulation. A CT scan complements the findings, and sometimes determines the diagnosis.

Treatment is surgical extraction. Even if asymptomatic, extraction should still be considered, since it can cause symptoms at a later point.^{2 4} Our patient most likely had the intranasal retained tooth most of his life, but had late onset of symptoms. The exact surgical procedure differs depending on the location of the tooth. An endoscopic approach is recommended throughout the literature because it ensures clear visualisation and is minimally invasive.²

The patient had competing conditions causing nasal stenosis and discharge (retained tooth, septal spur, conchal hypertrofia) and all were addressed during the procedure. It seems most likely though, that inflammation around the supernumerary tooth was the main problem. The symptoms had developed over a few years, and a septal spur is not very likely to increase in size and cause any change in symptomatology. Symptoms were all unilateral, making symmetrical inferior conchas less likely to contribute to the pathology.

Previous case reports describe displacement of teeth following facial trauma.^{5 6} A displaced tooth might later erupt into the nasal cavity. Our patient suffered a facial trauma in his youth, causing both mandibular and nasal fracture. However, there was no evidence of bone or tooth involvement, making a connection unlikely in the present case.

Due to the rarity of intranasal teeth, mostly case reports cover the topic. Kirmeier et al ⁷ made a literature review and found 23 patients with intranasal supernumerary teeth in the period 1959–2008. This case report adds to the existing body of evidence on symptomatology and treatment. We find it to be a relevant reminder of a rare condition. Furthermore we present endoscopic pictures that to our knowledge are not previously shown in such a case.

Our case report indicates that a surgical approach is easy and safe and has the potential to eliminate all symptoms. Intranasal teeth are a rare finding but important to recognise since nasal congestion, chronic discharge and hyposmia can decrease quality of life.

Learning points.

• An intranasal tooth can present with various symptoms and is a differential diagnosis to chronic rhinosinusitis.

• An untreated intranasal retained tooth can cause nasal symptoms.

• Sinus CT can complement the diagnosis.

• Endoscopic surgical procedure is recommended for extraction and usually eliminates symptoms.