a rhinolith presenting in the palate

A RHINOLITH PRESENTING IN THE PALATE

S. G. ALLEN, F.D.S., M.R.C.S., L.R.C.P. Consultant Dental Surgeon, London Hospital

IN a comprehensive survey of the literature, Polson (1943) pointed out that rhinoliths are relatively uncommon. The first authentic cases which this author noted were two reported by Bartholin in I654, although an account of what might have been a rhinolith was given as long ago as I5O2 by Mathias di Gardi.

These nasal stones, usually unilateral, are hard calcareous bodies found in the nasal passages. They are formed by the gradual accretion of calcium and other mineral salts around a central nucleus which fails to be expelled by the normal practice of blowing the nose or sneezing. The salts are deposited from the nasal

FIG. I FIG. 2

Figure I~X-ray of a boy's incisor region showing foreign body in the nasal fossa. Figure 2--Mirror view of rhinolith ulcerating through the palate.

and lacrimal secretions and from pus in the nasal fossae. The central nucleus may be of exogenous origin, and a variety of objects have been found ranging from signet rings to marbles. There is frequent mention of cherry stones forming the basis of a rhinolith. The patients are usually completely unaware that a foreign body has been lodged in the nasal cavity. Fig. I shows a potential rhinolith which was found fortuitously after a radiograph had been taken of a boy's incisor region. It is a portion of a tyre-valve assembly and was easily removed from the nasal fossa by using a pair of college tweezers. The patient did not know how long it had remained in that position, but a deposit had already formed upon its surface.

Endogenous nuclei are also described, such as portions of teeth and sequestra, while blood clot, inspissated pus and epithelial debris are believed to be the basis of those for which no obvious focus is discovered.

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A R H I N O L I T H P R E S E N T I N G IN THE PALATE 241

Rhinoliths develop slowly and are usually found during an investigation of the cause of symptoms which they have produced. The most constant of these are the gradual onset of nasal obstruction and a nasal discharge due to the accom- panying rhinitis, often of a very offensive nature. Pain is not a prominent symptom but may be severe, particularly when infection of the neighbouring sinuses occurs.

Ulceration of the nasal mucous membrane and destruction of the septal and antral walls have been described, but probably because of the thickness of the bone at the base of the nasal fossa perforation of the palate is a rare occurrence. A case, however, was reported by Gilbert in 1952 .

The present case concerns a large rhinolith which caused perforation of both the nasal septum and the hard palate.

FIG. 3 FIG. 4 Figure 3--Occipito- mental X-ray showing extension through the nasal septum. Figure 4--Lateral X-ray showing extension through the palate.

Miss M. attended her doctor complaining of discomfort under her full upper denture. A diagnosis of ulceration of the palate was made and she was referred to the London Hospital for investigation and treatment. The patient, a pleasant little woman of 59, was edentulous and had worn her present dentures since 1941. They had always been comfortable but were now gradually becoming looser. About three weeks before consulting her doctor she had noticed that her upper denture was less comfortable than usual and had appeared to grate against something hard in her palate. She had thought that this was a piece of exfoliating bone or tooth.

For about five years she had suffered from nasal catarrh and had been unable to breathe freely through her left nostril, which had finally become completely blocked. She had also noticed an unpleasant taste and smell which she assumed was due to her catarrh. She was otherwise in good health and had suffered from no serious diseases in the past.

On examining the patient one immediately became aware of a foul and nau- seating odour. After removing the upper denture what appeared to be an oval, clear-cut ulcer about i.o × 1. 5 cm. was seen to the left of the midline of the palate,

242 BRITISH JOURNAL OF ORAL SURGERY

opposite the premolar region (Fig. 2). The base was grey, bony hard and mobile, and the medial edge slightly raised and inflamed.

A few crusts were present around the anterior nares and the skin was red- dened, particularly on the left side. On further examination the left nasal fossa was seen to be filled by a whitish-grey mass, which was hard to touch and moved simultaneously with the hard lesion in the palate.

Radiographs revealed a large radio-opaque area of woolly appearance occupy- ing the left nasal fossa with extensions through the palate and nasal septum. There was a loss of the normal translucency of the left antrum and left frontal sinus (Figs. 3 and 4).

The shape and position of the mass, together with the marked ozoena, sug- gested that this was a large rhinolith which had ulcerated through the palate, becoming smooth and contoured where it was in contact with the upper denture.

The patient was referred to the Ear, Nose and Throat Department where she was examined by Mr. J. W. S. Lindahl, who confirmed the diagnosis and sub- sequently removed the rhinolith after having crushed it into small fragments. About ten pieces were recovered, the largest being 2 cm. in diameter. At the same time a perforation about I cm. in diameter was found to be present in the nasal septum. A chemical analysis of the specimen was not made, and no obvious nucleus was found.

With the removal of the rhinolith the stagnation and infection in the nose rapidly cleared up. The patient, who for a long time must have been a source of great embarassment to her friends and contacts, has become once again socially acceptable. The palatal perforation remains, but this is satisfactorily covered by a new denture which controls all fluids and solid foods and corrects the speech defect which had developed as soon as the oro-nasal fistula became patent.

ACKNOWLED GEMENT S

I am indebted to Mr. G. R. Seward for permission to use his slide showing the foreign body in the nose and to Mr. Broadberry of the Photographic Department, London Hospital, for preparing the photographs.

REFERENCES

GILBERT, R. K. (1952). Brit. dent. J. 93, 75. POLSON, C. J. (1943). ft. Laryng. 58, 79.