Rev Bras Otorrinolaringol.

ARTIGO ORIGINAL
V.71, n.1, 101-3, jan./feb. 2005
C ASE REPORT

Rhinolithiasis as cause of
oronasal fistula

Ga br iel Ces a r Dib1, R odr igo P . Ta nger ina 2,

Ca r los E.C.Abr eu 3, R odr igo de P a ula Sa ntos 4, Key words: rhinolithiasis, rhinolith,
Luiz Ca r los Gr egr io 5 oronasal fistula, nasal obstruction.

Summary

R hinolithiasis is a disease caused by deposition of

organic and inorganic compounds in the nasal cavity,
leading to unilateral nasal obstruction, fetid rhinorrhea,
epistaxis, and it may cause complications. The authors
present a case of rhinolithiasis with oronasal fistula and
literature review.

1
Specialization in Otorhinolaryngology under course, Federal University of Sao Paulo Escola Paulista de Medicina.
2
Resident Physician in Otorhinolaryngology, Federal University of Sao Paulo Escola Paulista de Medicina.
3
Master studies in Otorhinolaryngology under course, Federal University of Sao Paulo Escola Paulista de Medicina.
4
Master; Ph.D. studies in Otorhinolaryngology under course, Federal University of Sao Paulo Escola Paulista de Medicina.
5
Head of the Discipline of Otorhinolaryngology, Sector of Rhinology, Federal University of Sao Paulo Escola Paulista de Medicina.
Address correspondence to: Dr. Gabriel Cesar Dib Rua Borges Lagoa 980 apt 12 Vila Clementino 04038-002 Sao Paulo SP
Tel (55 11) 9677-1212 E-mail: [email protected]
Study conducted at the Discipline of Otorhinolaryngology, Department of Otorhinolaryngology and Human Communication Disorders, Unifesp-EPM.
Article submited on April 07, 2003. Article accepted on April 24, 2003.

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 INTRODUCTION inflammatory process with granulation tissue and presence
of filament bacteria suggestive of Actinomices sp. It was
Rhinolithiasis is an uncommon disease that may necessary to fragment the rhinolith so that it could be
present asymptomatically, characterized by presence of removed, owing to its extremely irregular shape and
mineralized tumor in the nasal cavity, which may be large extension (Figure 3).
and deviate neighboring structures 1.
The presence of deviation and nasal septum
perforation, destruction of nasal cavity lateral wall,
involvement of maxillary sinus and production of oroantral
or oronasal fistula are rare complications.
We report one case of rhinolithiasis with presence of
oronasal fistula and present literature review on the condition.

CASE REPORT

Female 43-year-old patient, Caucasian, single,

housewife, born in Jacana-CE, living in Sao Paulo-SP,
complained of left nasal obstruction for 11 years. She was
seen in the outpatient clinic of Otorhinolaryngology, Hospital
Sao Paulo, Federal University of Sao Paulo Escola Paulista
de Medicina.
She reported progressive nasal obstruction, only on
the left nasal fossa, intermittent, that progressed to continuous Figure 1. Oronasal fistula in the anterior region of hard palate on the
obstruction, with anterior and posterior purulent discharge left.
and cacosmia.
Six months before she had had perforation of hard
palate, with drainage of nasal secretion into the oral cavity
and regurgitation of liquids into the left nasal cavity. She did
not report pain, nasal bleeding, headache, fever, loss of
weight or allergic symptoms.
She reported that at the age of 2 years she introduced
a bean seed into the left nostril, which was removed the
next day, and she had remained without complaints up to
the current presentation.
Rhinoscopy showed presence of purulent secretion Figure 2. Coronal and axial CT scan sections showing large rhinolith
and irregular surface tumor, which was gray and recovered in the left nasal fossa.
by granulation tissue, stone-hard upon touch with scalpel,
immovable, obstructing the left nasal fossa and affecting the
floor, nasal septum, inferior and middle conchae, with nasal
septum deviation to the right. The examination revealed
extremely fetid odor from the nose.
Oroscopy presented perforation in the left anterior
region of hard palate, measuring 3 x 2 mm in diameter, with
irregular margins, and drainage of purulent secretion into
the oral cavity (Figure 1).
Paranasal sinuses CT scan revealed bone density
tumor occupying the left nasal fossa (Figure 2).
It was not possible to perform nasofibroscopy because
the tumor did not allow the passage of the instrument through
the left nasal fossa.
Based on the diagnostic hypothesis of rhinolithiasis,
the patient was submitted to nasal endoscopic surgery and
we removed a rhinolith measuring 4.5 x 2.5 x 1.5 cm, sent Figure 3. Surgical piece after fragmentation of rhinolith for its
to clinical pathology analysis that evidenced chronic removal.

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 We decided not to close the oronasal fistula in the tumors (osteomas), bone sequestration and malignant tumors
same surgical act owing to presence of marked local (chondrosarcoma, osteosarcoma, among others) 2, 11.
inflammatory process. Treatment consists of removal of rhinolith and the
surgical approach chosen depends on location and size of
DISCUSSION the rhinolith and presence or not of complications, but most
of them may be removed endonasally. External approaches
Rhinolithiasis was first described by Bartholin in 1654. may be necessary in cases of giant rhinoliths, and endoscopes
It is an uncommon affection that is many things left are extremely helpful in both approaches9.
undetected by patients. Treatment of complications can be performed in the
Etiology is not always detected, and it may be same or in another surgical act 8.
exogenous (such as grains, small stone fragments, plastic In the case of oronasal fistulas, there is a tendency in
parts, seeds, insects, glass, wood and others), or endogenous, the literature to leave the correction to second intervention,
resulting from dry secretion, clots, cell lysis products, mucosa which should be performed by rotation of palate and nasal
necrosis and tooth fragments, which operate as foreign body flap, promoting two-layer closing 2,11.
2, 4
.
Foreign bodies normally access the site anteriorly, but CLOSING REMARKS
they may occasionally reach into the nasal cavity through
the choana owing to cough or vomiting 5. Rhinolithiasis is an uncommon disease that may be
Foreign bodies are normally introduced during left undiagnosed for many years and present complications.
childhood, occupying the nasal floor in most situations 6. Its The diagnosis is normally made by clinical history and physical
presence causes local inflammatory reaction, leading to examination, and it should be considered in cases of unilateral
deposits of carbonate and calcium phosphate, magnesium, nasal obstruction. Treatment consists of removing the rhinolith
iron and aluminum, in addition to organic substances such as and correcting occasional complications.
glutamic acid and glycin, leading to slow and progressive
increase in size 4,7. REFERENCES
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