Clinical and radiological aspects of rhinoliths: report of five cases Husniye Demirturk Kocasarac, DDS, a Peruze Celenk, DDS, PhD, b Zerrin Erzurumlu, DDS, a and Gökhan Kutlar, MD c Faculty of Dentistry, University of Ondokuz Mayis, Samsun, Turkey and Gazi State Hospital, Samsun, Turkey Rhinoliths are calcified masses in the nasal cavity caused by the deposition of nasal, lacrimal, and inflammatory mineral salts by accretion around an endogenous or exogenous nidus. Rhinoliths can be seen as incidental findings on panoramic radiography, although they typically appear blurred due to remaining outside the focus. Therefore, rhinoliths may be difficult to recognize; this difficulty can lead to misdiagnosis. Computed tomography (CT)/cone beam CT (CBCT) scans are generally necessary to define the precise location and to make a differential diagnosis. This article describes radiologic features of five cases of rhinoliths that were detected incidentally on panoramic radiographs. CT or CBCT images were obtained before removing the rhinoliths. (Oral Surg Oral Med Oral Pathol Oral Radiol 2013;116:232-237) Rhinoliths are hard, dense, calcified masses in the nasal cavity caused by the deposition of nasal, lacrimal, and inflammatory mineral salts by accretion around an endogenous (i.e., tooth, bone fragment, blood clot, mucus, bacteria) or exogenous (i.e., fruit seed, bead, button, pebble or gauze) nidus. 1-3 Although foreign objects in the nose are common, rhinolith formation is rare, 4 and is seen in 0.01% patients in otolaryngology clinics. 5 Rhinoliths are mostly asymptomatic; however, sometimes they can have symptoms such as nasal obstruction, purulent nasal discharge, sinusitis, head- ache, epistaxis, fetor, fever, and anosmia. 2,6,7 Signs such as nasal septum deviation and perforation, destruction of the nasal cavity lateral wall, erosion of the maxillary sinus and production of an oroantral or oronasal fistula can indicate the presence of rhino- liths. 2,8 They are usually irregular masses with bony, hard and gritty features on probing and grayish or brownish-black in color. 9,10 Radiographic features of rhinoliths represent heterogeneous density with an irregular border in the anterior maxillary region. Computed tomography (CT)/cone beam CT (CBCT) are useful in determining the internal features, exact localization and dimensions of rhinoliths that cannot be seen clearly in conventional radiographs. 1,11,12 This article describes radiologic features in five cases of rhinoliths that were identified incidentally in pano- ramic radiographs. CT or CBCT images were obtained before removing the rhinoliths. Histopathological examination was performed in three of the cases. CASE REPORTS Case 1 An 18-year-old female was referred to our clinic for a routine examination. Panoramic radiography showed a prominent heterogeneous calcified mass with irregular borders in her nasal cavity (Figure 1A). The patient reported having inserted beans into her nose when she was five years of age and that sometimes she had nasal congestion. An axial CT scan (bone window) showed a calcified mass measuring 25 13 mm that was hypodense in the center and hyperdense in the periphery and located on the floor of the left nasal cavity (Figure 1B). Expansion of the left nasal passage was noted, but no septal deviation. The calcified mass was removed using nasal forceps with rigid nasal endoscopy under topical anesthesia in the otorhinolaryngology clinic. The specimen was identified as a dark green, stony-hard mass. The microscopic evaluation showed calcification and necrotic epithelium between the necrotic tissues (Figure 1C). The nidus was not distinguish- able. The postoperative follow-up was uncomplicated for two years, and the patient was grateful for being able to breathe easily. Case 2 A 24-year-old mentally retarded female presented to our clinic complaining of a toothache. Extra-oral examination revealed purulent nasal discharge in the right nasal aperture. Panoramic radiography (maxillary sinus program) showed a roughly ovoid, radiopaque mass measuring approximately 10 10 mm in the right nasal cavity (Figure 2). There was no history of foreign body insertion but her mother said that the patient suffered from nasal congestion. The mass was removed under general anesthesia in the otorhinolaryngology clinic. The specimen was a brown-green hard mass. The microscopic evaluation revealed an amorphous material that showed lamellar calcifications. The postoperative follow-up was unremarkable. Case 3 A 29-year-old female was referred to our clinic for pain in the maxillary anterior region and orthodontic treatment. Pano- ramic and cephalometric radiographs showed a heteroge- neous, diffuse calcified mass in the right nasal cavity a Department of Maxillofacial Radiology, Faculty of Dentistry, University of Ondokuz Mayis. b Professor, Department of Maxillofacial Radiology, Faculty of Dentistry, University of Ondokuz Mayis. c Department of Otorhinolaryngology, Gazi State Hospital. Received for publication Mar 15, 2013; returned for revision May 8, 2013; accepted for publication May 25, 2013. Ó 2013 Elsevier Inc. All rights reserved. 2212-4403/$ - see front matter http://dx.doi.org/10.1016/j.oooo.2013.05.019 232 Vol. 116 No. 2 August 2013