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ABSTRACT NO:EP-94

SUBMİSSİON NUMBER:1020 

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The authors declare

no conflicts of interest

No financial support was taken for this retrospective

study

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ASNR 2015 Annual Meeting

Abstract No: EP-94

Submission Number: 1020

Clinical and radiological presentation of rhinolithiasis; Analysis of 16 cases and

review of the literature

Ramazan Buyukkaya1, Ayla Buyukkaya 2, Mehmet Memiş 3, Beyhan Öztürk1, F.Halit

Beşir1

  1-Duzce University, School of Medicine, Department of Radiology

2-Duzce Ataturk Government Hospital, Department of Radiology

3-Duzce University, School of Medicine, Department of Ear Nose Throat

 

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Purpose

Rhinoliths are mineralized mass lesions due to calcification of an

endogenous or exogenous nidus in the nasal cavity 1

Rhinoliths are usually unilateral; they are rare lesions that are

predominantly found in females2. A history of purulent rhinorrhea,

nasal obstruction and pain suggest the presence of rhinoliths3. In

CT, the specificity and sensitivity of the calcification and the

foreign body are high, and both are essential in the diagnosis of

rhinolithiasis.

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Purpose

In CT, the specificity and sensitivity of the calcification and the foreign body are high, and both are essential in the diagnosis of rhinolithiasis. In CT, a rhinolith is typically seen as a relatively homogenous, high density lesion. The nidus can have low density at the central region of the lesion2-4

We aimed to present 16 symptomatic cases of rhinolithiasis along with the clinical imaging findings

and a literature review.

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Methods and Materials

A total of 16 patients, who were diagnosed with rhinolithiasis at the University Medical School Department of Otorhinolaryngology between January 2006 and June 2013, were included in the study.

Patients were recorded according to their age, gender, symptoms on presentation, duration of the complaint, location of the rhinolithiasis, and concomitant diseases.

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Materials and Methods

The presenting symptoms of the patients were: purulent rhinorrhea, nasal obstruction, headache, epistaxis, and halitosis. Nasal endoscopy was used in the diagnosis and treatment of the patients.

In 10 of the patients with CT examination, CT was used to assess the boundaries of the rhinolith and its relation to adjacent structures or CT was used before endoscopic evaluation was conducted.

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Materials and Methods

Images were evaluated using bone and soft tissue algorithms in all patients that underwent CT examination.

The sizes of the rhinoliths were obtained using bone algorithms resulting in three-dimensional measurements.

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Materials and Methods

Statistical analyses of intracranial total grey matter, total

cortical white matter, white matter hypointensity, total

intraventricular and subcortical grey matter volumes that

were assessed in FreeSurfer version 4.5.0 were

performed in SPSS 22.0 statistical package program.

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Materials and Methods

Whether the data demonstrated a normal distribution

or not was determined using Shapiro-Wilk test.

Dependent groups were compared using Wilcoxon

signed rank test and matched pairs t-test. Level of

significance was set at α= .05.

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Results

A total of 16 patients (7 males and 9 females; median age, 32 years; age range, 8-74 years) diagnosed with rhinolithiasis were reviewed in this study.

Duration of symptoms ranged from 2 months to 5 years. According to localization, the rhinoliths were seen on the left side in 10 patients and on the right side in 6 patients.

With respect to conchal meatus, ten of the rhinoliths were located in the middle concha (62,5 %) and six were located in the inferior concha (37,5 %).

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Results

All patients had purulent rhinorhea and nasal obstruction (100%). Seven patients had headache (43,8 %), 4 patients had epistaxis (25%), 3 patients had oral malodor (18,8 %) complaints. Clinical and radiological features of rhinoliths (Table 1).

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PatientSex/Age

Major Symptomps DiagnosisRinolithiasis Characteristics

Treatment

No. (Year) Size, mm Location

1 F/35

Purulent rhinorrhea, nasal obstruction NE Left inferior meatus Removed/LA

2 F/9Purulent rhinorrhea,

nasal obstruction, epistaxis

NE Right midle meatus Removed/GA

3 M/39Purulent rhinorrhea,

nasal obstruction, Headache

NE Left midle meatus Removed/LA

4 M/74Purulent rhinorrhea,

nasal obstruction, Headache

NE Left midle meatus Removed/LA

5 F/8Purulent rhinorrhea,

nasal obstruction, epistaxis

NE Right inferior meatus Removed/GA

6 M/32Purulent rhinorrhea,

nasal obstruction, Headache

NE Left midle meatus Removed/LA

7 M/41Purulent rhinorrhea, nasal obstruction,

oral malodor NE + CT 26 x 15 x 12 Left midle meatus Removed/GA

8 F/33Purulent rhinorrhea, nasal obstruction,

oral malodor NE + CT 14 x 12 x 11 Left inferior meatus Removed/LA

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Patient Sex/AgeMajor Symptomps Diagnosis

Rinolithiasis CharacteristicsTreatment

No. (Year) Size, mm Location

9 M/52

Purulent rhinorrhea,

nasal obstruction, Headache

NE + CT 19 x 14 x 11 Left inferior

meatusRemoved/

LA

10 F/35 Purulent rhinorrhea, nasal obstruction, Headache NE + CT 20 X 17 x12 Left inferior meatus Removed/LA

11 F/32 Purulent rhinorrhea, nasal obstruction epistaxis NE + CT 15 x 11 x 10 Right midle meatus Removed/LA

12 M/8 Purulent rhinorrhea, nasal obstruction, epistaxis NE + CT 10 x 9 x 7 Left midle meatus Removed/GA

13 F/17 Purulent rhinorrhea, nasal obstruction, oral malodor NE + CT 19 X 15 x 11 Left midle meatus Removed/LA

14 F/29 Purulent rhinorrhea, nasal obstruction, Headache NE + CT 14 X 11 x 8 Right midle meatus Removed/LA

15 F/34 Purulent rhinorrhea, nasal obstruction, Headache NE + CT 16 x 12 x 10 Right inferior meatus Removed/LA

16 M/29 Purulent rhinorrhea, nasal obstruction NE + CT 15 X 12 x 11 Right midle meatus Removed/LA

F; Female, M ; Male, LA ; Local anesthesia, GA; General anesthesia, CT; Computed tomography, NE; Nasal endoscopy

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Results

CT and endoscopic procedures were used in the diagnosis of ten patients and only endoscopic examination was used in six patients, without the need for CT images. Of the patients that underwent CT, a 26x15x12 mm rhinolith, located in the left inferior concha, was found to be the largest in the series.

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(A) Coronal CT scan of the sinuses demonstrates the densely calcified mass in the right nasal cavity between the left inferior turbinate and nasal septum. Well-defined hypodense nidus and irregular calcified mass extending to adjacent structures (B) Rigid nasal endoscopy shows the rhinolith in the left nasal cavity. (C) A button as core material of rhinolith is seen macroscopically, which appears as hypodense nidus on the CT.

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(A) High density rhinolith was apparent in the nasal cavity between the deviated nasal septum and left inferior turbinate on the coronal CT scan. (B) Gross appearance of the broken rhinolith.

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Conclusion

As a result, rhinolithiasis is a rare condition. It is very important to always consider it in patients with unilateral purulent nasal discharge, nasal congestion, oral malodor, chronic headaches, and recurrent epistaxis. CT should be used for radiological diagnosis.

CT is a valuable method for the identification of lesion size and it can be used to ascertain information about the position of the lesion, showing the nidus.

CT can also aid in the assessment of the bony structures and in the detection of other possible accompanying pathologies.

References1. Aksungur EH, Binokay FB, Bicakci K, Apaydin D, Oguz M, Aydogan B. A rhinolith which is mimicking a nasal benign tumor. Eur J Radiol 1999; 31: 53-55.

2. Royal SA, Gardner RE. Rhinolithiasis: an unusual pediatric nasal mass. Pediatr Radiol 1998; 28: 54-55.

3. Hadi U, Ghossaini S, Zaytoun G. Rhinolithiasis: a forgotten entity. Otolaryngol Head Neck Surg 2002; 126: 48–51.

4. Ozdemir S, Akbas Y, Görgülü O, Selçuk T, Sayar C. Rhinolithiasis: review of 21 cases. Am J Rhinol Allergy. 2010; 24(6): 136-139.

5. Appleton SS, Kimbrough RE, Engstrom HI. Rhinolithiasis: areview. Oral Surg Oral Med Oral Pathol Oral Radiol Endod 1988; 65: 693-698

6. Price HI, Batnitzky S, Karlin CA, Norris CW. Giant nasal rhinolith. AJNR 1981; 2: 371-373.

7.Ezsias A, Sugar AW. Rhinolith: an unusual case and an update. Ann Otol Rhinol Laryngol. 1997; 106: 135-138.

8.Pitt SKJ, Routt PGJ. Rhinoliths presenting during routine radiography: two cases. Dent Update. 2000; 29: 505-507.

9.Demirturk Kocasarac H, Celenk P, Erzurumlu Z, Kutlar G. Clinical and radiological aspects of rhinoliths: report of five cases. Oral Surg Oral Med Oral Pathol Oral Radiol. 2013 Aug;116(2):232-7.

10.Kermanshahi MS, Jassar P. A bolt from the blew: Rhinolith in the nose for more than 80 years. BMJ Case Rep. 2012; Epub. doi: 10.1136/bcr-2012-007322.

11.Orhan K, Kocyigit D, Kisnisci R, Paksoy CS. Rhinolithiasis: an uncommon entity of the nasal cavity. Oral Surg Oral Med Oral Pathol Oral Radiol Endod. 2006; 101: 28-32.

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20

12.Stoney P, Bingham B, Okuda I, and Hawke M. Diagnosis of rhinoliths with rigid endoscopy. J Otolaryngol 1991; 20: 408–411.

13.Yuca K, Caksen H, Etlik O, Bayram I, Sakin YF, Dülger H et al. The importance of rigid nasal endoscopy in the diagnosis and treatment of rhinolithiasis. Auris Nasus Larynx. 2006; 33: 19–22,

14.Genc S, Kahraman E, Ozel HE, Genc MG. Bilateral rhinolithiasis. J Craniofac Surg. 2011; 22(6): 2429.

15.Dib GC, Tangerina PR, Abreu EC, Santos PR, Gregório LC. Rhinolithiasis as cause of oronasal fistula. Rev Bras Otorrinolaringol. 2005; 71: 101-103.

16.Gill RS, Lal M. Perforation of the hard palate by a rhinolith and its repair. J Laryngol Otol. 1977; 91: 85-89.

17.Sumbullu MA, Tozoglu U, Yoruk O, Yilmaz AB, Ucuncu H. Rhinolithiasis: the importance of flat panel detector-based cone beam computed tomography in diagnosis and treatment. Oral Surg Oral Med Oral Pathol Oral Radiol Endod. 2009; 107: 65-67.

18.Munoz A, Pedrosa I, Villafruela M. ‘‘Eraseroma’’ as a cause of rhinolith: CT and MRI in a child. Neuroradiology. 1997; 39: 824-826.

19.Meyer JR, and Quint DJ. Posttraumatic rhinolith. Am J Neuroradiol. 1993;14:1181–1182.