Rhinolithiasis is considered to be a rare entity in clinical practice and describes the formation of rhinoliths (or nasal calculi) in the nasal cavity [1] [2] [3] [4]. Rhinoliths are mineralized masses composed of calcium, phosphate, magnesium, iron, and other organic/inorganic materials, together with secretions and mucus from local tissue [1] [4]. They arise in the presence of a foreign body (authors have detected grains, stones, plastic, fruit seeds, insects, buttons, beads, pebbles etc. as objects that contribute to rhinolith formation) or are due to endogenous factors, such as blood clots, necrotic processes, or even teeth that behave as foreign bodies [1] [2] [5]. Insertion of foreign bodies is typical during childhood, which is why the majority of cases belong to pediatric and young adult population [2]. The pathogenesis of rhinolithiasis is incompletely understood but seems to involve local inflammatory changes and progressive accumulation of minerals and salts around the mass that might eventually produce symptoms [2]. Purulent discharge is the most commonly reported symptom by patients [5], whereas unilateral nasal obstruction, cacosmia (persistent sensation of a bad smell) or sometimes even anosmia (loss of smell), recurrent epistaxis, and headaches are other accompanying features [1] [2] [3] [5]. In addition, nasal swelling and deviation of the nasal septum, as well as epiphora may also be documented [3]. Studies have confirmed a very long clinical course of the illness, presumably because the initial event that led to the development of rhinolithiasis was either asymptomatic or gave rise to minimal complaints [3] [5]. As a result, symptoms last for months or even years before a diagnosis is made [3] [5]. Complications include the formation of an oroantral or oronasal fistula, anatomic disruption of the nasal wall or the palate, and chronic sinusitis [2] [6].

• Asymptomatic

  Rhinoliths are uncommon and often an asymptomatic condition diagnosed accidentally during a routine examination; but sometimes they may cause complications such as unilateral nasal obstruction, fetid rhinorrhea, or epistaxis. [ncbi.nlm.nih.gov]

  Studies have confirmed a very long clinical course of the illness, presumably because the initial event that led to the development of rhinolithiasis was either asymptomatic or gave rise to minimal complaints. [symptoma.com]

  This pathology is rarely asymptomatic. It comprises mainly a unilateral chronic rhinitis sometimes stinking and bloody. The diagnosis is made with nasal endoscopy which is characteristic. [read.qxmd.com]

• Dentist

  A 26-year old male patient with a history of long standing halitosis consultation by a dentist with an otolaryngologist had an operation for rhinolith seven years ago. [mona.uwi.edu]

• Nasal Discharge

  The first was 23 years old female having unilateral nasal obstruction, cacosmia and occasional blood stained nasal discharge. [ncbi.nlm.nih.gov]

  Our patients presented with foul-smelling nasal discharge and breath, halitosis, nasal congestion and facial pain. [entcase.net]

• Nasal Congestion

  A unilateral rhinorrhea, nasal congestion and a bad smell is the most common symptoms. In this study, the 39-year-old female patient was operated on for rhinolithiasis with the review of the literature is presented. [agris.fao.org]

  Our patients presented with foul-smelling nasal discharge and breath, halitosis, nasal congestion and facial pain. [entcase.net]

  It is very important to always consider it in patients with unilateral purulent nasal discharge, nasal congestion, oral malodor, chronic headaches, and recurrent epistaxis. [slideplayer.com]

• Postnasal Drip

  The first suggested mechanism is the persistent inflammation and chronic postnasal drip, which cause chronic low-grade inflammation and interfere with the physiologic regression of adenoid tissue. [academic.oup.com]

• Snoring

  […] f(- d aril- liiiiii he snore. A puny iifl I'ichieeu niarKct vkoi'iC vturv ehieeu marKct in'opie Wviv .i.. ... ... ,'..'. -i nooniu mi -ravauimu. inn uiuil ui.i-. ami jiiiik within a very fow ininuteiv.. mid twelve people wcru iirawn.nl. [newspapers.com]

• Nasal Pruritus

  26-year-old female patient, was seen in the service of ORL-HUAP manifesting chronic nasal obstruction, purulent and fetid rhinorrhea, facial pain, especially on the interorbicular region, marked nasal pruritus, sneezing and anosmia for 16 years. [oldfiles.bjorl.org]

• Dental Caries

  Salient Features Extensively revised and updated chapters Temporomandibular Joint Diseases section completely rewritten Physical and Chemical Injuries of the Oral Cavity chapter updated Extensive revision of Dental Caries and Forensic Odontology chapters [books.google.com]

• Facial Pain

  The most common manifestations of rhinolithiasis are unilateral nasal discharge, nasal obstruction, and facial pain. The diagnosis is made by nasal endoscopy and computed tomography. [ncbi.nlm.nih.gov]

• Confusion

  The rhinolith was initially confused with a lesion of the palate. Precise localization of lesions is mandatory before transoral exploration is attempted. [ncbi.nlm.nih.gov]

  It is an uncommon medical phenomenon, not to be confused with dried nasal mucus. A rhinolith usually forms around the nucleus of a small exogenous foreign body, blood clot or secretion by slow deposition of calcium and magnesium salts. [en.wikipedia.org]

  Félix3, Márcia Defaveri4 Abstract: Rhinoliths are calcareous formations found inside the nose, have rare occurrence and are easily confused with infection or obstruction of superior airways. [oldfiles.bjorl.org]

• Neglect

  Rhinolithiasis is a rare condition often neglected or unknown that tends to disappear in developed countries and corresponds to a solid calcification by gradual deposition of calcareous salts around a central resorbable or non-resorbable foundation of [ncbi.nlm.nih.gov]

  Rhinoliths result from neglected nasal foreign bodies that gradually increase in size. [entcase.net]

Because of the rather wide differential diagnosis (chronic inflammatory disorders and both benign and malignant tumors), the physician must obtain a detailed patient history and conduct a thorough physical examination [2] [4], perhaps the two most important steps for gaining sufficient evidence to make a presumptive diagnosis of rhinolithiasis. Patients (or parents in the pediatric setting) should be asked about a history of foreign body insertion into the nose [2], but they may not always recall the event [5]. Some studies have established that trauma, surgery, and dental work potentially promote the formation of rhinoliths [4], thus a comprehensive personal history is equally important. In the presence of persistent unilateral nasal obstruction and purulent rhinorrhea, however, clinical suspicion of rhinolithiasis must be raised [1]. After a complete nasal examination (through anterior rhinoscopy), imaging studies should be ordered. Although plain radiography might be of benefit in the assessment of the nasal cavity by being able to detect a dense, calcified mass, more advanced studies, such as computed tomography (CT), are favored [2] [3] [5]. Supplementary to CT and X-rays, nasal endoscopy has emerged as an important tool for diagnosing intranasal lesions [1] [2] [4] [5].

1. Ozdemir S, Akbas Y, Görgülü O, Selçuk T, Sayar C. Rhinolithiasis: review of 21 cases. Am J Rhinol Allergy. 2010;24(6):136-139.
2. Dib GC, Tangerina RP, Abreu CE, Santos Rde P, Gregório LC. Rhinolithiasis as cause of oronasal fistula. Braz J Otorhinolaryngol. 2005;71(1):101-103.
3. Price HI, Batnitzky S, Karlin CA, Norris CW. Giant nasal rhinolith. Am J Neuroradiol. 1981;2:371-373.
4. Brehmer D, Riemann R. The Rhinolith—A Possible Differential Diagnosis of a Unilateral Nasal Obstruction. Case Rep Med. 2010;2010:845671.
5. Hadi U, Ghossaini S, Zaytoun G. Rhinolithiasis: a forgotten entity. Otolaryngol Head Neck Surg. 2002;126(1):48-51.
6. Ozcan I, Ozcan KM, Ensari S, Dere H. Rhinolithiasis with a nasal polyp: a case report. Ear Nose Throat J. 2008;87(3):150-151.