Case Report

A 47 year old gentleman presented to the Otorhinolaryngology clinic with the complaint of recurrent episodes of epistaxis for the past three years. The bleeding occurred from the left side of the nose. It was associated with foul smelly nasal discharge and left sided nasal blockage. There was no history of nasal foreign body or trauma to the face.

Examination of the nose revealed a calcified mass with irregular surface located on the floor of the left nasal cavity. It was hard and fixed to the floor. No other mass seen. Oral examination was unremarkable with complete set of dentition. The palate was intact and presence of torus palatinus was noted.

The diagnosis of left rhinolith was made. As the attempt to remove the mass under local anaesthesia failed, he was planned for examination under general anaesthesia. Intraoperative finding was almost similar to the clinical diagnosis. The mass was situated parallel to the nasal septum and below the inferior turbinate. Freer elevator was used to mobilize the rhinolith from the floor. Later, it was successfully removed in total with the Tilley-Henckel forceps.

After cleaning the overlying calcified material, the mass was found to be a canine tooth with intact crown and root. Clinically considering the size, it was a deciduous canine. Specimen was sent for histopathological examination.

Figure 1

Figure 1: Tooth removed from the floor of the left nostril

Oral surgeon and maxillofacial consultation were made. Intraoral anterior upper occlusal view radiograph was not consistent with supernumerary tooth. Laboratory report confirmed the tooth as a deciduous type.

Discussion

Rhinoliths or rhinolithiasis are benign calcareous concretions that are formed by the deposition of salts on an intranasal foreign body. They are commonly found in children or mentally disabled individuals. The foreign body can be exogenous or endogenous. Endogenous rhinolith includes blood clots, bone fragments and ectopic teeth. Other foreign bodies such as seeds, fruit pits, food material, pebbles, dirt, buttons, button batteries and crumpled pieces of paper are the exogenous material that can stimulate the rhinolith formation. The exogenous sources are more common.

Removal of rhinolith can be performed under local or general anaesthesia. In view of the concretion's size, irregular surface, and impingement on the left inferior turbinate, the patient was scheduled to undergo removal of the mass under general anaesthesia. Lithotripsy has also been used to debulk large stones. If access remains restricted, a submucosal resection of the nasal septum and a bony turbinoplasty will allow for further exposure and will facilitate extraction₁.

Tooth as a core for the rhinolith formation is rare. Moreover, if the tooth is deciduous type and found in an adult with no history of trauma or mental illness. Paediatric dental records for this patient could not be traced as he was not under a proper dental follow-up during childhood. Otherwise, the current adult set of dentition in this patient was complete.

The other possibility is the supernumerary tooth which erupted in the nose. However, the radiograph taken was not suggestive of it. The incidence of supernumerary tooth in population ranges from 0.1 to 1 % and the most commonly affected area is the upper central incisor area₂. A tooth existing in the nasal cavity is an unusual phenomenon and a rare form of supernumerary teeth₃.