<div>Accidental Finding Prior to Rhinoplasty: Rhinolith- A Rare Case Report</div><div>Key Clinical Message</div><div>Through this case report, we review a rare radiopacity finding within
the nasal cavity and its histopathological findings in order to
emphasize the importance of familiarizing oneself with all radiographic
findings, regardless of their rarity.</div><div>Keywords: Rhinoplasty; Nasal Cavity; Nasal Obstruction; Rhinolith</div><div>Introduction</div><div>A rhinolith, also known as a nasal calculus, is a densely calcified
mass, possibly formed around either external substances such as stones,
batteries and plastic, or internal materials including dental epithelium
and dried blood clots, within the nasal cavity (1-4). However, its exact
etiology remains unknown (2). Typically, it is found either between the
maxillary sinus wall and the inferior turbinate or between the nasal
septum and inferior turbinate (1). Rhinoliths are generally single,
unilateral and have an irregular shape (5). Various sizes and internal
structures have been reported based on the nature of the rhinolith’s
core, including homogeneous or heterogeneous radiopacities (6). The
occurrence of rhinoliths in the oral and maxillofacial structures is
rare (1). However, they are more commonly observed in young adults,
females, and individuals with a low socioeconomic status (2). Symptoms
such as headache, anosmia, nasal obstruction, discharge, swelling,
unpleasant nasal odor, halitosis, epistaxis, localized pain, and fever
have been reported in approximately 1 out of 10,000 patients visiting
ear, nose, and throat (ENT) specialists in relation to rhinoliths, which
may persist for months or even years (4, 6). Although rhinoliths are
often asymptomatic (7) and may be detected incidentally through routine
radiographic imaging (5). Conventional radiographs are useful in
differentiating rhinoliths from other lesions and detecting their
location, especially in cases where the foreign body has high
radiodensity (5, 7). However, computed tomography (CT) is more effective
in localizing rhinoliths with lower radiodensity in the core (3).</div><div>In this case report, we present the incidental detection of a rhinolith
through radiographic imaging in a 20-year-old patient who was a
candidate for aesthetic rhinoplasty.</div><div>Case presentation</div><div>A 20-year-old female came to the outpatient department as a candidate
for rhinoplasty. The patient’s general medical history and the head and
neck examinations were unremarkable. There were no complaints of nasal
obstruction or discharge. On extraoral examination, there was no sensory
disturbance and the face was symmetrical except for the nasal septum
deviation. Cone beam computed tomography (CBCT) was prescribed to the
septum deviation. The CBCT revealed an s-type deviation of the nasal
septum, open ostia, and clear maxillary sinus cavity. Additionally, a
solitary, densely heterogenic calcified mass measuring 9.3 mm in width,
14.4 mm in height, and 8.7 mm in anteroposterior size was noted in the
right nasal fossa between inferior turbinate and nasal septum. The mass
was attached to the septum and the superomedial portion of inferior
nasal concha and the inferomedial part of the middle nasal concha. The
mass was well defined with mix, mostly opaque, and laminated internal
view. (fig. 1)</div><div>Based on the radiographic findings, three differential diagnoses were
rhinoliths, paranasal osteoma, and nasal foreign body.</div><div>The procedure entailed the removal of the lesion under general
anesthesia. The lesion, which was attached to the perichondrium, was
successfully excised using a nostril approach. Unilateral perforations
on the mucosa of the septum and inferior and middle conchae, resulting
from the lesion removal, were left unsutured due to their size, allowing
them to heal through secondary intention. The excised lesion was sent
for histopathological evaluation, and a routine septorhinoplasty was
performed. For this purpose, a septal graft was harvested. However, the
preserved L-strut proved inadequate in supporting the septal mucosa
perforation due to its location and the amount of cartilage graft
required. Turbinate outfracture or cauterization were not carried out,
although turbinectomy was performed. An internal splint was applied as a
routine measure, and follow-up sessions were scheduled for 1 week, 1
month, 3 months, and 6 months after the operation.</div><div>The histological examination revealed the presence of vascular
respiratory epithelium, with subepithelial glands displaying a bland
appearance and mild chronic inflammation. Calcified foreign body
fragments were also identified. No atypical cells or conclusive evidence
of malignancy were detected. The histological findings were consistent
with a diagnosis of rhinolith. (fig.2)</div><div>The patient expressed satisfaction with the results and reported no
nasal obstruction. Additionally, the patient noted improved breathing,
despite having had no difficulties in breathing prior to the operation.
No asymmetry was detected.</div><div>A CBCT scan was ordered 3 months post-surgery to validate the
histopathologic outcomes and confirm the complete removal of the lesion.
The CBCT evaluation confirmed the successful and complete excision of
the lesion, thus supporting the rhinolith diagnosis. Synechia was found
to be limited. (fig.3)</div><div>Discussion</div><div>Rhinoliths are uncommon findings, likely caused by the deposition of
mineral salts around a nidus, such as a foreign body (8). A high level
of suspicion is necessary, and differential causative factors, including
osteoma, calcified nasal polyps, and ossifying fibroma should be
considered to choose the best treatment approach (9). A variety of
symptoms may be reported, depending on the localization and size of the
lesion, such as unilateral nasal obstruction, epistaxis, headache,
anosmia, epiphora, and purulent rhinorrhea (2, 9). However, rhinoliths
can also be asymptomatic (6). Therefore, in cases with no symptoms,
radiographic scans can lead to a diagnosis of rhinolith (4). A
radiopaque lesion with lesser radiopacity in the center, located in
either the nasal cavity or maxillary sinus, is a good predictor for
rhinolith (5). However, rhinoliths may also appear as a homogeneous
radiopaque view due to the presence of a radiopaque nidus (2).</div><div>In the present case, CBCT evaluations revealed a mixture of radiopaque
and radiolucent radiographic findings. Furthermore, in the absence of
any symptoms, a histopathological examination was conducted to establish
a definitive diagnosis.</div><div>In cases where there is a coexistence of septal deviation and
rhinoliths, the septum is typically deviated towards the opposite side
of the rhinolith (2). This is likely due to the influence of the
rhinolith on the cartilaginous septum during mass growth (2). This
finding is consistent with our case.</div><div>Although previous studies have reported the concurrent performance of
septoplasty or septorhinoplasty and removing rhinolith (2), the specific
details of the septoplasty procedures used are unclear. In this case
presentation, we have provided a detailed description of the
septorhinoplasty procedure to assist surgeons in surgical planning.</div><div>The defects in the intranasal mucosal lining may be asymptomatic and do
not require additional treatment procedures (10). However, the
intranasal exposure of the spreader grafts may occur due to the presence
of a defect in the mucosa. Therefore, large defects may require covering
the grafts using various techniques to protect them from intranasal
exposure (11).</div><div>A variety of surgical interventions have been introduced to manage
perforations of the septal mucosa in cases where the underlying septum
is also perforated. These procedures are categorized into local flaps
only or incorporation of interposition grafts (10). The local flap may
be used unilaterally or bilaterally, unipedicled or bipedicled, and with
an anterior or posterior base (12). The interposition graft can also be
harvested from various sites including temporalis fascia, conchal
cartilage, and tragal cartilage (10). In the present case, despite the
absence of supporting septal cartilage, the unilateral perforation of
septal mucoperichondrial tissue was left unsutured because of the intact
contralateral mucoperichondrial tissue of the septum. Moreover, the
internasal splint was used to prevent synechia following the unsutured
perforation of the mucosa of the septum and inferior and middle conchae.
Favorable outcomes revealed the secondary intention was successfully
performed.</div><div>However, there is insufficient evidence regarding the critical limit of
septal mucosa perforation that prevents synechiae and ensures secondary
intention. This may also be influenced by many other factors, including
the cite of the perforation. Therefore, further researches should be
conducted in this matter.</div><div>Based on the favorable outcomes and absence of complications, the
introduced procedure may be useful for assisting surgeons in carrying
out septorhinoplasty and successfully removing the rhinolith without
concerns about synechia.</div><div>Conflict of interest statement</div><div>The authors have no conflict of interest to declare.</div><div>Consent</div><div>Written informed consent was obtained from the patient to publish this
report in accordance with the journal’s patient consent policy.</div><div>References</div><div>1. Orhan K, Kocyigit D, Kisnisci R, Paksoy CS. Rhinolithiasis: an
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Otolaryngologic clinics of North America. 2009;42(3):483-93.</div><div>Figure legends:</div><div>Fig.1: pre-operative CBCT. (a) sagittal view; (b) coronal aspect; (c)
axial section.</div><div>Fig.2: histopathological micrograph. Note the fragments of calcified
foreign bodies.</div><div>Fig.3: post-operative CBCT. (a) sagittal aspect; (b) coronal view; (c)
axial section. Note the limited synechiae in comparison with
pre-operative CBCT.</div>