Case Report
Rhinolithiasis as cause of oronasal fistula
Gabriel Cesar Dib1,
, Rodrigo P. Tangerina2, Carlos E.C. Abreu3, Rodrigo de Paula Santos4, Luiz Carlos Gregório5
Corresponding author
gcdib@hotmail.com
Address correspondence to: Dr. Gabriel Cesar Dib – Rua Borges Lagoa 980 apt 12 Vila Clementino 04038-002 Sao Paulo SP
Address correspondence to: Dr. Gabriel Cesar Dib – Rua Borges Lagoa 980 apt 12 Vila Clementino 04038-002 Sao Paulo SP
1 Specialization in Otorhinolaryngology under course, Federal University of Sao Paulo – Escola Paulista de Medicina
2 Resident Physician in Otorhinolaryngology, Federal University of Sao Paulo – Escola Paulista de Medicina
3 Master studies in Otorhinolaryngology under course, Federal University of Sao Paulo – Escola Paulista de Medicina
4 Master; Ph.D. studies in Otorhinolaryngology under course, Federal University of Sao Paulo – Escola Paulista de Medicina
5 Head of the Discipline of Otorhinolaryngology, Sector of Rhinology, Federal University of Sao Paulo – Escola Paulista de Medicina
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Abreu, Rodrigo de Paula Santos, Luiz Carlos Gregório" "autores" => array:5 [ 0 => array:4 [ "nombre" => "Gabriel Cesar" "apellidos" => "Dib" "email" => array:1 [ 0 => "gcdib@hotmail.com" ] "referencia" => array:2 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">1</span>" "identificador" => "aff1" ] 1 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">*</span>" "identificador" => "cor1" ] ] ] 1 => array:3 [ "nombre" => "Rodrigo P." "apellidos" => "Tangerina" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">2</span>" "identificador" => "aff2" ] ] ] 2 => array:3 [ "nombre" => "Carlos E.C." "apellidos" => "Abreu" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">3</span>" "identificador" => "aff3" ] ] ] 3 => array:3 [ "nombre" => "Rodrigo" "apellidos" => "de Paula Santos" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">4</span>" "identificador" => "aff4" ] ] ] 4 => array:3 [ "nombre" => "Luiz Carlos" "apellidos" => "Gregório" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">5</span>" "identificador" => "aff5" ] ] ] ] "afiliaciones" => array:5 [ 0 => array:3 [ "entidad" => "Specialization in Otorhinolaryngology under course, Federal University of Sao Paulo – Escola Paulista de Medicina" "etiqueta" => "1" "identificador" => "aff1" ] 1 => array:3 [ "entidad" => "Resident Physician in Otorhinolaryngology, Federal University of Sao Paulo – Escola Paulista de Medicina" "etiqueta" => "2" "identificador" => "aff2" ] 2 => array:3 [ "entidad" => "Master studies in Otorhinolaryngology under course, Federal University of Sao Paulo – Escola Paulista de Medicina" "etiqueta" => "3" "identificador" => "aff3" ] 3 => array:3 [ "entidad" => "Master; Ph.D. studies in Otorhinolaryngology under course, Federal University of Sao Paulo – Escola Paulista de Medicina" "etiqueta" => "4" "identificador" => "aff4" ] 4 => array:3 [ "entidad" => "Head of the Discipline of Otorhinolaryngology, Sector of Rhinology, Federal University of Sao Paulo – Escola Paulista de Medicina" "etiqueta" => "5" "identificador" => "aff5" ] ] "correspondencia" => array:1 [ 0 => array:3 [ "identificador" => "cor1" "etiqueta" => "*" "correspondencia" => "Address correspondence to: Dr. Gabriel Cesar Dib – Rua Borges Lagoa 980 apt 12 Vila Clementino 04038-002 Sao Paulo SP" ] ] ] ] "resumenGrafico" => array:2 [ "original" => 0 "multimedia" => array:7 [ "identificador" => "fig2" "etiqueta" => "Figure 2" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr2.jpeg" "Alto" => 419 "Ancho" => 1024 "Tamanyo" => 62190 ] ] "descripcion" => array:1 [ "en" => "<p id="spara20" class="elsevierStyleSimplePara elsevierViewall">Coronal and axial CT scan sections showing large rhinolith in the left nasal fossa.</p>" ] ] ] "textoCompleto" => "<span class="elsevierStyleSections"><span id="cesec10" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="cestitle30">INTRODUCTION</span><p id="para10" class="elsevierStylePara elsevierViewall">Rhinolithiasis is an uncommon disease that may present asymptomatically, characterized by presence of mineralized tumor in the nasal cavity, which may be large and deviate neighboring structures<a class="elsevierStyleCrossRef" href="#bib1"><span class="elsevierStyleSup">1</span></a>.</p><p id="para20" class="elsevierStylePara elsevierViewall">The presence of deviation and nasal septum perforation, destruction of nasal cavity lateral wall, involvement of maxillary sinus and production of oroantral or oronasal fistula are rare complications.</p><p id="para30" class="elsevierStylePara elsevierViewall">We report one case of rhinolithiasis with presence of oronasal fistula and present literature review on the condition.</p></span><span id="cesec20" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="cestitle40">CASE REPORT</span><p id="para40" class="elsevierStylePara elsevierViewall">Female 43-year-old patient, Caucasian, single, housewife, born in Jacaúna-CE, living in Sao Paulo-SP, complained of left nasal obstruction for 11 years. She was seen in the outpatient clinic of Otorhinolaryngology, Hospital Sao Paulo, Federal University of Sao Paulo – Escola Paulista de Medicina.</p><p id="para50" class="elsevierStylePara elsevierViewall">She reported progressive nasal obstruction, only on the left nasal fossa, intermittent, that progressed to continuous obstruction, with anterior and posterior purulent discharge and cacosmia.</p><p id="para60" class="elsevierStylePara elsevierViewall">Six months before she had had perforation of hard palate, with drainage of nasal secretion into the oral cavity and regurgitation of liquids into the left nasal cavity. She did not report pain, nasal bleeding, headache, fever, loss of weight or allergic symptoms.</p><p id="para70" class="elsevierStylePara elsevierViewall">She reported that at the age of 2 years she introduced a bean seed into the left nostril, which was “removed the next day”, and she had remained without complaints up to the current presentation.</p><p id="para80" class="elsevierStylePara elsevierViewall">Rhinoscopy showed presence of purulent secretion and irregular surface tumor, which was gray and recovered by granulation tissue, stone-hard upon touch with scalpel, immovable, obstructing the left nasal fossa and affecting the floor, nasal septum, inferior and middle conchae, with nasal septum deviation to the right. The examination revealed extremely fetid odor from the nose.</p><p id="para90" class="elsevierStylePara elsevierViewall">Oroscopy presented perforation in the left anterior region of hard palate, measuring 3 × 2 mm in diameter, with irregular margins, and drainage of purulent secretion into the oral cavity (<a class="elsevierStyleCrossRef" href="#fig1">Figure 1</a>).</p><elsevierMultimedia ident="fig1"></elsevierMultimedia><p id="para100" class="elsevierStylePara elsevierViewall">Paranasal sinuses CT scan revealed bone density tumor occupying the left nasal fossa (<a class="elsevierStyleCrossRef" href="#fig2">Figure 2</a>).</p><elsevierMultimedia ident="fig2"></elsevierMultimedia><p id="para110" class="elsevierStylePara elsevierViewall">It was not possible to perform nasofibroscopy because the tumor did not allow the passage of the instrument through the left nasal fossa.</p><p id="para120" class="elsevierStylePara elsevierViewall">Based on the diagnostic hypothesis of rhinolithiasis, the patient was submitted to nasal endoscopic surgery and we removed a rhinolith measuring 4.5 × 2.5 × 1.5 cm, sent to clinical pathology analysis that evidenced chronic inflammatory process with granulation tissue and presence of filament bacteria suggestive of <span class="elsevierStyleItalic">Actinomices sp</span>. It was necessary to fragment the rhinolith so that it could be removed, owing to its extremely irregular shape and extension (<a class="elsevierStyleCrossRef" href="#fig3">Figure 3</a>).</p><elsevierMultimedia ident="fig3"></elsevierMultimedia><p id="para130" class="elsevierStylePara elsevierViewall">We decided not to close the oronasal fistula in the same surgical act owing to presence of marked local inflammatory process.</p></span><span id="cesec30" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="cestitle50">DISCUSSION</span><p id="para140" class="elsevierStylePara elsevierViewall">Rhinolithiasis was first described by Bartholin in 1654. It is an uncommon affection that is many things left undetected by patients.</p><p id="para150" class="elsevierStylePara elsevierViewall">Etiology is not always detected, and it may be exogenous (such as grains, small stone fragments, plastic parts, seeds, insects, glass, wood and others), or endogenous, resulting from dry secretion, clots, cell lysis products, mucosa necrosis and tooth fragments, which operate as foreign body<a class="elsevierStyleCrossRefs" href="#bib2"><span class="elsevierStyleSup">2,4</span></a>.</p><p id="para160" class="elsevierStylePara elsevierViewall">Foreign bodies normally access the site anteriorly, but they may occasionally reach into the nasal cavity through the choana owing to cough or vomiting<a class="elsevierStyleCrossRef" href="#bib5"><span class="elsevierStyleSup">5</span></a>.</p><p id="para170" class="elsevierStylePara elsevierViewall">Foreign bodies are normally introduced during childhood, occupying the nasal floor in most situations<a class="elsevierStyleCrossRef" href="#bib6"><span class="elsevierStyleSup">6</span></a>. Its presence causes 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<a class="elsevierStyleCrossRefs" href="#bib4"><span class="elsevierStyleSup">4,7</span></a>.</p><p id="para180" class="elsevierStylePara elsevierViewall">Symptoms are normally progressive unilateral nasal obstruction, rhinorrhea (usually purulent and fetid), cacosmia and epistaxis. Other less common symptoms are headache, facial pain and epiphora<a class="elsevierStyleCrossRefs" href="#bib8"><span class="elsevierStyleSup">8,9</span></a>.</p><p id="para190" class="elsevierStylePara elsevierViewall">There may be complications such as nasal septum perforation or deviation, oroantral and oronasal fistula, chronic sinusitis and destruction of lateral nasal wall.</p><p id="para200" class="elsevierStylePara elsevierViewall">The physical examination showed gray and dark mass, with stone-hard consistency and irregular surface.</p><p id="para210" class="elsevierStylePara elsevierViewall">Diagnosis is normally based on symptomatology, history of foreign body introduction into the nose, physical examination and complementary tests. Simple x-ray and paranasal sinuses CT scan support the diagnosis through the presence of calcified tumor in the nasal fossa, in addition to supporting the planning of surgical approach<a class="elsevierStyleCrossRef" href="#bib10"><span class="elsevierStyleSup">10</span></a>.</p><p id="para220" class="elsevierStylePara elsevierViewall">Diagnosis may be made through routine examination or revealed by imaging exam conducted by other reasons, such as for example a dental treatment<a class="elsevierStyleCrossRef" href="#bib9"><span class="elsevierStyleSup">9</span></a>.</p><p id="para230" class="elsevierStylePara elsevierViewall">Differential diagnosis should take into account benign tumors (osteomas), bone sequestration and malignant tumors (chondrosarcoma, osteosarcoma, among others)<a class="elsevierStyleCrossRefs" href="#bib2"><span class="elsevierStyleSup">2,11</span></a>.</p><p id="para240" class="elsevierStylePara elsevierViewall">Treatment consists of removal of rhinolith and the surgical approach chosen depends on location and size of the rhinolith and presence or not of complications, but most of them may be removed endonasally. External approaches may be necessary in cases of giant rhinoliths, and endoscopes are extremely helpful in both approaches<a class="elsevierStyleCrossRef" href="#bib9"><span class="elsevierStyleSup">9</span></a>.</p><p id="para250" class="elsevierStylePara elsevierViewall">Treatment of complications can be performed in the same or in another surgical act<a class="elsevierStyleCrossRef" href="#bib8"><span class="elsevierStyleSup">8</span></a>.</p><p id="para260" class="elsevierStylePara elsevierViewall">In the case of oronasal fistulas, there is a tendency in the literature to leave the correction to second intervention, which should be performed by rotation of palate and nasal flap, promoting two-layer closing<a class="elsevierStyleCrossRefs" href="#bib2"><span class="elsevierStyleSup">2,11</span></a>.</p></span><span id="cesec40" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="cestitle60">CLOSING REMARKS</span><p id="para270" class="elsevierStylePara elsevierViewall">Rhinolithiasis is an uncommon disease that may be left undiagnosed for many years and present complications. The diagnosis is normally made by clinical history and physical examination, and it should be considered in cases of unilateral nasal obstruction. Treatment consists of removing the rhinolith and correcting occasional complications.</p></span></span>" "textoCompletoSecciones" => array:1 [ "secciones" => array:7 [ 0 => array:3 [ "identificador" => "xres572507" "titulo" => "Summary" "secciones" => array:1 [ 0 => array:1 [ "identificador" => "ceabs10" ] ] ] 1 => array:2 [ "identificador" => "xpalclavsec589566" "titulo" => "Key words" ] 2 => array:2 [ "identificador" => "cesec10" "titulo" => "INTRODUCTION" ] 3 => array:2 [ "identificador" => "cesec20" "titulo" => "CASE REPORT" ] 4 => array:2 [ "identificador" => "cesec30" "titulo" => "DISCUSSION" ] 5 => array:2 [ "identificador" => "cesec40" "titulo" => "CLOSING REMARKS" ] 6 => array:1 [ "titulo" => "REFERENCES" ] ] ] "pdfFichero" => "main.pdf" "tienePdf" => true "PalabrasClave" => array:1 [ "en" => array:1 [ 0 => array:4 [ "clase" => "keyword" "titulo" => "Key words" "identificador" => "xpalclavsec589566" "palabras" => array:4 [ 0 => "rhinolithiasis" 1 => "rhinolith" 2 => "oronasal fistula" 3 => "nasal obstruction" ] ] ] ] "tieneResumen" => true "resumen" => array:1 [ "en" => array:2 [ "titulo" => "Summary" "resumen" => "<span id="ceabs10" class="elsevierStyleSection elsevierViewall"><p id="spara40" class="elsevierStyleSimplePara elsevierViewall">Rhinolithiasis is a disease caused by deposition of organic and inorganic compounds in the nasal cavity, leading to unilateral nasal obstruction, fetid rhinorrhea, epistaxis, and it may cause complications. The authors present a case of rhinolithiasis with oronasal fistula and literature review.</p></span>" ] ] "NotaPie" => array:1 [ 0 => array:1 [ "nota" => "<p class="elsevierStyleNotepara" id="cenpara10">Study conducted at the Discipline of Otorhinolaryngology, Department of Otorhinolaryngology and Human Communication Disorders, Unifesp-EPM.</p> <p class="elsevierStyleNotepara" id="cenpara20">Article submited on April 07, 2003. Article accepted on April 24, 2003.</p>" ] ] "multimedia" => array:3 [ 0 => array:7 [ "identificador" => "fig1" "etiqueta" => "Figure 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 689 "Ancho" => 1022 "Tamanyo" => 100793 ] ] "descripcion" => array:1 [ "en" => "<p id="spara10" class="elsevierStyleSimplePara elsevierViewall">Oronasal fistula in the anterior region of hard palate on the left.</p>" ] ] 1 => array:7 [ "identificador" => "fig2" "etiqueta" => "Figure 2" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr2.jpeg" "Alto" => 419 "Ancho" => 1024 "Tamanyo" => 62190 ] ] "descripcion" => array:1 [ "en" => "<p id="spara20" class="elsevierStyleSimplePara elsevierViewall">Coronal and axial CT scan sections showing large rhinolith in the left nasal fossa.</p>" ] ] 2 => array:7 [ "identificador" => "fig3" "etiqueta" => "Figure 3" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr3.jpeg" "Alto" => 689 "Ancho" => 1022 "Tamanyo" => 164675 ] ] "descripcion" => array:1 [ "en" => "<p id="spara30" class="elsevierStyleSimplePara elsevierViewall">Surgical piece after fragmentation of rhinolith for its removal.</p>" ] ] ] "bibliografia" => array:2 [ "titulo" => "REFERENCES" "seccion" => array:1 [ 0 => array:2 [ "identificador" => "cebibsec10" "bibliografiaReferencia" => array:10 [ 0 => array:3 [ "identificador" => "bib1" "etiqueta" => "1" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Unilateral rhinolithiasis." "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:2 [ 0 => """ Sharma BG \n \t\t\t\t\t\t\t\t """ 1 => """ Sahni RC. \n \t\t\t\t\t\t\t\t """ ] ] ] ] ] "host" => array:1 [ 0 => array:1 [ "Revista" => array:6 [ "tituloSerie" => "Australasian Radiol" "fecha" => "1981" "volumen" => "25" "paginaInicial" => "132" "paginaFinal" => "134" "itemHostRev" => array:3 [ "pii" => "S0002914912025507" "estado" => "S300" "issn" => "00029149" ] ] ] ] ] ] ] 1 => array:3 [ "identificador" => "bib2" "etiqueta" => "2" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "A rhinolith which is mimicking a nasal benign tumor." 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| Year/Month | Html | Total | |
|---|---|---|---|
| 2024 October | 46 | 8 | 54 |
| 2024 September | 79 | 18 | 97 |
| 2024 August | 98 | 24 | 122 |
| 2024 July | 80 | 52 | 132 |
| 2024 June | 70 | 55 | 125 |
| 2024 May | 68 | 45 | 113 |
| 2024 April | 62 | 45 | 107 |
| 2024 March | 96 | 32 | 128 |
| 2024 February | 100 | 30 | 130 |
| 2024 January | 115 | 40 | 155 |
| 2023 December | 92 | 32 | 124 |
| 2023 November | 88 | 51 | 139 |
| 2023 October | 96 | 44 | 140 |
| 2023 September | 85 | 58 | 143 |
| 2023 August | 57 | 19 | 76 |
| 2023 July | 74 | 25 | 99 |
| 2023 June | 51 | 12 | 63 |
| 2023 May | 41 | 23 | 64 |
| 2023 April | 49 | 14 | 63 |
| 2023 March | 76 | 25 | 101 |
| 2023 February | 47 | 18 | 65 |
| 2023 January | 43 | 15 | 58 |
| 2022 December | 61 | 29 | 90 |
| 2022 November | 44 | 35 | 79 |
| 2022 October | 44 | 31 | 75 |
| 2022 September | 56 | 63 | 119 |
| 2022 August | 40 | 45 | 85 |
| 2022 July | 45 | 27 | 72 |
| 2022 June | 66 | 30 | 96 |
| 2022 May | 131 | 40 | 171 |
| 2022 April | 97 | 41 | 138 |
| 2022 March | 65 | 41 | 106 |
| 2022 February | 95 | 20 | 115 |
| 2022 January | 140 | 20 | 160 |
| 2021 December | 85 | 41 | 126 |
| 2021 November | 67 | 36 | 103 |
| 2021 October | 49 | 32 | 81 |
| 2021 September | 71 | 27 | 98 |
| 2021 August | 51 | 25 | 76 |
| 2021 July | 75 | 25 | 100 |
| 2021 June | 54 | 15 | 69 |
| 2021 May | 39 | 48 | 87 |
| 2021 April | 98 | 45 | 143 |
| 2021 March | 40 | 17 | 57 |
| 2021 February | 49 | 22 | 71 |
| 2021 January | 48 | 17 | 65 |
| 2020 December | 68 | 20 | 88 |
| 2020 November | 83 | 14 | 97 |
| 2020 October | 33 | 20 | 53 |
| 2020 September | 78 | 20 | 98 |
| 2020 August | 64 | 22 | 86 |
| 2020 July | 57 | 13 | 70 |
| 2020 June | 37 | 17 | 54 |
| 2020 May | 11 | 10 | 21 |
| 2020 April | 16 | 12 | 28 |
| 2020 March | 24 | 18 | 42 |
| 2020 February | 16 | 18 | 34 |
| 2020 January | 16 | 11 | 27 |
| 2019 December | 17 | 15 | 32 |
| 2019 November | 10 | 9 | 19 |
| 2019 October | 14 | 10 | 24 |
| 2019 September | 13 | 17 | 30 |
| 2019 August | 25 | 8 | 33 |
| 2019 July | 60 | 7 | 67 |
| 2019 June | 59 | 5 | 64 |
| 2019 May | 87 | 9 | 96 |
| 2019 April | 38 | 10 | 48 |
| 2019 March | 7 | 14 | 21 |
| 2019 February | 13 | 9 | 22 |
| 2019 January | 4 | 4 | 8 |
| 2018 December | 67 | 16 | 83 |
| 2018 November | 26 | 11 | 37 |
| 2018 October | 26 | 11 | 37 |
| 2018 September | 34 | 14 | 48 |
| 2018 August | 54 | 23 | 77 |
| 2018 July | 47 | 20 | 67 |
| 2018 June | 32 | 17 | 49 |
| 2018 May | 58 | 23 | 81 |
| 2018 April | 49 | 14 | 63 |
| 2018 March | 74 | 29 | 103 |
| 2018 February | 52 | 21 | 73 |
| 2018 January | 32 | 19 | 51 |
| 2017 December | 43 | 15 | 58 |
| 2017 November | 41 | 19 | 60 |
| 2017 October | 35 | 24 | 59 |
| 2017 September | 57 | 26 | 83 |
| 2017 August | 78 | 49 | 127 |
| 2017 July | 70 | 34 | 104 |
| 2017 June | 68 | 37 | 105 |
| 2017 May | 67 | 24 | 91 |
| 2017 April | 71 | 16 | 87 |
| 2017 March | 48 | 21 | 69 |
| 2017 February | 28 | 16 | 44 |
| 2017 January | 28 | 14 | 42 |
| 2016 December | 29 | 14 | 43 |
| 2016 November | 26 | 11 | 37 |
| 2016 October | 29 | 21 | 50 |
| 2016 September | 37 | 6 | 43 |
| 2016 August | 55 | 25 | 80 |
| 2016 July | 23 | 12 | 35 |
| 2016 May | 1 | 0 | 1 |
| 2016 April | 1 | 0 | 1 |
| 2016 February | 4 | 0 | 4 |
| 2015 December | 2 | 0 | 2 |
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