ORIGINAL ARTICLE
Rhinolithiasis with a nasal polyp:
A case report
Ibrahim Ozcan, MD; K. Murat Ozcan, MD; Serdar Ensari, MD; Huseyin Dere, MD
Abstract
Rhinoliths are uncommon mineralized masses that form
as a result of calcification of an endogenous or exogenous
nidus. The most common manifestations ofrhinolithiasis
are unilateral nasal discharge, nasal obstruction, and fa-
cial pain. The diagnosis is made by nasal endoscopy and
computed tomography. Thedifferential diagnosisincludes
chronic inflamm ation, osteomyelitis, benign tumors (e.g.,
calcified nasal polyps, ossifying fibromas, osteomas, and
chondromas), and malignant tumors (e.g., osteosarcomas,
chondrosarcomas,and squamouscellcarcinomas). Rhino-
liths may cause rhinosinusitis, erosion ofthe nasalseptum
and medial wall of the maxillary sinus, and perforations
of thepalate. To the best of our knowledge, the occurrence
ofa nasalpolyp associatedwith rhinolithiasishasnot been
previously reported in the English-language literature. In
this article, we describe such a case.
Introduction
Rhinolithiasis occurs as a result of the calcification ofan
endogenous or exogenous nidus. According to Polson,'
the first case reported in the literature was publ ished by
Bartholin in 1654. Rhinoliths are un common clinical
entities.' The y may cause symptoms of unil ateral nasal
discharge , nasal obstruction, and facial pain. Rhinosi-
nu sitis, erosion of th e nasal septum and medial wall of
th e maxillary sinus, and perforations of the palate have
been reported to occur in association with a rhinolith. P
but until now, no case of a nasal polyp associated with
a rhinolith has been reported in the English-language
literature.
From the 4th ENT Clinic, Ankar a Num une Research and Education
Hospital, Ankara, Turke y.
Corrcspo nding author: Ibrah im Ozcan,M D,Aydinlar Mh. FehmiTacerSk.,
No: 15/ 8 06460 Dik me n/Ankara, Turke y. Phone: 90-532-37 1-7 192;
fax: 90-3 12-311-112 1; e-ma il: ibrozcan@ho tmail.com
Th e informa tion in thi s article was originally present ed at the 23rd In-
tern ationa l Symposium on Infection an d Allergy of the Nose; June
18-25, 2004; Istanbul.
150· www.entjournal.com
Case report
A 55-year-old woman with left-sided nasal disch arge,
nasal obstruction, and epistaxis of 2 months' duration
was admitted to our ENT clinic. She was not aware of
any foreign mass in her nose.
Anterior rhinoscopic examination of th e left nasal
vestibule revealed the presence of a soft,whitish polypoid
mass and deviation of th e nasal septum to th e right.
X-rays detected a calcification in the left nasal cavity.
Computed tomograph y (CT) revealed that the calcified
mass extended from the vestibule to the choana (figure
1). CT also confirmed the deviation ofthe nasal septum ,
and it demonstrated opacific ation of th e left maxillary
sinus and th e anterior and posterior ethmoid sinuses .
Endoscopic sinus surgery was performed, and a large
amount of polypoid tissue, including a 7 x 2-cm rhino-
lith , was removed (figure 2). Mineralogic analysis of the
mass revealed that it was made up of calcium phosphate
and calcium carbonate. Histologic analysis of the soft
tissue identified it as a nasal polyp. No postoperative
complications occurred, and the patient was discharged
on the second po stoperative day.
Discussion
A rhinolith is a calcareou s concretion that form s as a
result of th e deposition of salts on an intranasal nidus.
Exogenous nidi include buttons, erasers, stones, bean s,
seeds, parasites , and pieces of pap er, wood, cloth, or
sponge-in short, just about any material that can pass
through the anterior (or in rare cases the po sterior)
nares.f Endogenous nidi include sequestra, clotted
blood, dried pus, teeth , and leukocytes.'
The pathogenesis of rhinolithiasis is not fully und er-
stood, but it is thought th at the pr esence of a foreign
bodypredisposes to a chronic inflammatory reaction and
the precipitation ofsalts.Air probably promotes concen-
tr ation and crystallization.':' X-ray powder diffract ion
analysis, electron microprobe analysis, and infrared
spectroscopy have been used to study th e mineralogic
content of rh inoliths. Calcium phosphate, calcium car-
bon ate, magnesium phosph ate, and ionized iron (Pe")
ENT-Ear, Nose & Throat Journal· March 2008
 RHI NOLITHIASIS W ITH A NASAL POLYP: A CAS E REPORT

have been found .' :' In our

patient ,calcium ph osph ate
an d calcium carb onat e
were found.
Typi cal symptom s of
rhinolithiasis are un ilat-
eral fetid nasal discharge,
nasal ob struction, facial
pain , epistax is, ano smi a,
purulent discha rge from
th e punctum lacrimale, Figure 1. A: Coronal CT of the paranasal sinli S shows the polypoid tissue and the calcified massin the
and swelling of the face left nasalcavity. B:Anothersliceshowsmore calcification and polypoid tissueat thelevelof theposterior
part of the nasal cavity and choana.
or nose. ':" Our patient
had symptoms of nasal
discharge, nasal obstruction, and epistaxis for only 2 nasal gliomas, and sept al desm oid tumors; malignant
months.The sho rt duration of her symptoms suggested tumors include osteosarcom as, chondrosarcom as, and
an in tra nasa l neopl asm . squamo us cell carcinomas.F
Rhinol ithi asis may be suspected if the patient has a Th e preferr ed treatm ent for rh inolith iasis is extrac-
history ofa foreign bodyor tr auma,altho ugh our patient tion .' Most rhinoliths can be rem oved endoscopically,
had a history of neither. In our case, conventional x-rays as was don e in our case, but some times more extensive
showed calcification bu t provided little else in the way of surge ry is necessary.
inform ation. The current radiologic modality of choiceis Pot ential complication s of rhino lithiasis include rhi -
CT,which is useful for identifying not onlycalcifications, nosinu sitis, erosion of the nasal septum and med ial wall
but also surrounding tissue pattern s and erosions. In our of th e max illary sinus, and perforations of the palate. ' ,2
patient ,CT showed thatthe calcified nasal massextended A rhinolith th at mimicked a benign nasal mass has also
from the vestibule to th e choa na; it also demonstrated been repor ted.' In that case, th e rhino lith was found to
op acification of the maxillary and ethmoid sinuses. But be surro unded by chronic inflammation.
CT only help s in the differenti al diagnosis; it alone may In our case, the rhinolith and nasal polyp were found
not distinguish a rhinolith from any oth er type of calci- togeth er. To the best of our knowl edge, the occurrence
fied nasal mass. Clinical findin gs and nasal endoscopy of a rhinolith surrounded by a nasal polyp has not been
are necessary for a definitive diagnosis. pr eviously reported in the English-language literatur e.
The differential diagnosis of rhinolithiasis includes Th e nasal polyp in our patient might have develop ed
chronic inflammation, osteomyelitis, benign tumors, secondary to the rhinolith or it might have existed
and malignant tumors. Among the benign tumors are coincidentally. Th e polyp also m ight have developed
calcified nasal polyps, ossifying fibromas , osteomas, in response to longstanding mucosal irritation by th e
chondromas, odontomas, calcifying angi ofibromas, rh inolith.

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Figure 2. Following extraction, photograph shows the rhinolith
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(top) and the polyp.

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