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Rhinolith: an unusual cause of palatal perforation
British Journal of Oral and Maxillofacial Surgery (1988) 26, 486-490 0 1988 The British Association of Oral and Maxillofacial Surgeons
RHINOLITH:
AN UNUSUAL
CAUSE
T. R. FLOOD, M.B., B.S., Department
of Oral and Maxillofacial School, 378 Sauchiehall
OF PALATAL B.D.s.,
PERFORATION
F.D.S.R.C.S.
Surgery, Glasgow Dental Street, Glasgow G2 3JZ
Summary. An unusual case of a large rhinolith, which initially presented reported. The surgical removal of the rhinolith through a maxillary osteotomy immediate direct fixation using ‘Champy’ plates is described. This approach for removal of the mass and repair of the oronasal fistula.
Hospital
and
as an oronasal fistula, is at the Le Fort 1 level with provided excellent access
Introduction
Rhinolithiasis is an uncommon and often asymptomatic condition (Carder & Hill, 1966; Sharma & Sahni, 1981) which may be encountered during the course of a routine examination, or noticed incidentally on radiographs (Jain & Frommer, 1982; Varley, 1964). If undetected for many years rhinoliths may grow large enough to cause nasal obstruction and distortion or destruction of surrounding structures (Price et al., 1981). There have been various reports of septal deviation (Ishrat-Husain, 1967; Deyasi, 1985), septal perforation (Teachey & Smith, 1973), and destruction of the lateral wall of the nasal cavity with growth of the calculus to involve the maxillary sinus (Eliachar & Schalit, 1970). Rarely a large calculus may produce an oro-antral fistual (Dutta, 1973) or an oronasal fistula (Allen, 1966; Conrad, 1968; Bicknell, 1970; Gill & Lal, 1977; O’Dowling, 1984). Successful repair of an oronasal fistula can prove difficult as experience has shown that the bony defect is often larger than the soft tissue defect. Two layer closure is therefore desirable in order to reduce wound contracture and the likelihood of wound breakdown due to infection with recurrence of the fistula (Quayle, 1981).
Case report
A 24-year-old lady presented to the Oral Surgery clinic complaining of a ‘hole in her palate’ which had been present for 7 months. This had been associated with an unpleasant discharge from her nose into her mouth and occasionally small pieces of ‘gravel’ also had extruded from the hole. On further questioning she admitted that she had suffered from recurrent headaches and had had a persistent nasal discharge over the previous 2 years but no epistaxis nor pain from the area. Intra-oral examination revealed an inflammed oronasal fistual posteriorly in the midline of the hard palate (Fig. 1) and no other abnormality. Mirror examination of the post nasal space disclosed a mass obstructing the right posterior choanae. Radiographs (Fig. 2) showed the presence of a large calcified mass which appeared to occupy the posterior part of the right nasal cavity and extended into the maxillary antrum on the right. A CT scan showed an irregular mass 3x2 cm in dimension, composed mainly of calcified tissue confined to the posterior choanae (Received
8 July
1987; accepted 6 December
486
1987)
487
RHINOLITH
but distorting the lateral wall of the nasal cavity and the inferior turbinate bone (Fig. 3). A differential diagnosis of infected rhinolith or osteochondroma was considered. As the patient was concerned by the unpleasant discharge from the oro-nasal fistual it was decided to repair the fistula as part of the surgical procedure to remove the mass.
Fig. 1
Fig. 2 Figure l-Photograph
Fig. 3 showing the palatal perforation
preoperatively.
Figure 2-The lateral radiograph of the facial bones showing the extent of the mass and its irregular opacification. A differential diagnosis of rhinolith or osteochondroma was considered.
Figure 3-A CT scan showing clearly that the mass occupies the nasal cavity and does not invade the maxillary antrum. The gross distortion of the right lateral nasal wall is clearly shown.
488
BRITISH
JOURNAL
OF ORAL
& MAXILLOFACIAL
SURGERY
Surgical technique Under general anaesthesia the mass was approached via a Le Fort I maxillary osteotomy. Prior to making the osteotomy cuts the osteotomy site was marked out and Champy bone plates were positioned across the proposed osteotomy site and the screw holes drilled. The plates were then removed and the osteotomy cuts were completed in the usual manner followed by the maxilla being fractured downwards, so as to provide good access for removal of the mass lying within the nasal cavity which was ulcerating through the nasal mucosa. This approach also gave excellent access for primary closure of the nasal mucosa. The palatal mucosa was repaired by suturing from the oral aspect. The maxilla was then replaced and fixed using the Champy plates in their pre-determined positions. No intermaxillary fixation was necessary and the patient made an uneventful postoperative recovery. Discussion
Rhinoliths are irregular hard calcareous bodies, grey or brown in colour, found in the nasal passages and are relatively uncommon (Polson, 1943). These stones usually occur unilaterally in the lower half of the nasal cavity (Marfatia, 1968) and are thought to be formed by the gradual accretion of calcium and mineral salts around a nidus within the nasal lumen which may be either endogenous or exogenous in origin. Exogenous calculi appear to be more common (Davis & Wolff, 1985) and these are usually foreign bodies, often introduced many years previously during childhood, which have become chronically infected (Chaker et al., 1978) and subsequently encrusted with calcified tissue. Occasionally rhinoliths may develop in association with occupational factors such as sawdust (Hunt et al., 1966), coal dust and cement dust (Polson, 1943). Rhinoliths developing from endogenous nuclei, such as misplaced teeth or sequestrae, are more rare and sometimes rhinoliths form without any identifiable nucleus. Although the mechanism by which mineralisation of calculi is initiated is not yet fully understood, organic components are believed to play a part (Osuoji & Rowles, 1974) and it has been postulated that blood clot, epithelial debris and inspissated pus may form the initial endogenous nidus in these cases (McNab-Jones, 1971). This is further supported by reports of endogenous rhinoliths occurring in cases of choanal atresia (Ali, 1967; Worgan, 1966) where stasis of nasal and lacrymal secretions promote infection and stone formation. Rhinoliths tend to increase in size over a number of years and usually first present in early adult life with symptoms of chronic nasal discharge or obstruction (Hunt et al., 1966). Occasionally patients may complain of symptoms associated with local tissue destruction such as facial pain, swelling or epistaxis, giving rise to the suspicion of a malignant growth (Abu-Jaudeh, 1951; Price et al., 1981). However the true diagnosis may be suspected if there is a past history of a foreign body having been introduced into the nose. Radiographic findings are usually the most helpful, A densely calcified mass is suggestive of a rhinolith which may have an annular appearance, the centre of which may have a greater or lesser density depending on the nature of the nidus. Occasionally it is possible to identify the nature of the foreign body which forms the nidus from its radiographic appearance. The differential diagnosis should include calcified polyps, odontomes, granulomas, granulomatous diseases, sequestration following local osteomyelitis, osteomas, calcified odontogenic cysts, chondrosarcoma and osteosarcoma. Tomography and CT, scanning demonstrate the full extent of distortion and destruction of the
RHINOLITH
489
surrounding structures (Price et al., 1981) and are helpful when deciding on the most appropriate surgical approach. Small, soft calculi can often be crushed and removed in a piecemeal fashion through an anterior transnasal approach (Hunt et al., 1966) or, if bulky, displaced posteriorally into the nasopharynx (Marano et al., 1970) taking care to avoid aspiration. In some cases a formal submucous resection may be required to provide sufficient space for transnasal removal (Ishrat-Husain, 1967). Larger calculi may be impacted and difficult to remove especially if the lateral nasal wall has been eroded or displaced and in these cases a Caudwell-Luc approach has been advocated (McNab-Jones, 1952 & 1971) although troublesome haemorrhage may be a problem in these cases (Dutta, 1973). Extremely large rhinoliths however may require an external exposure through a lateral rhinotomy incision (Abu-Jaudeh, 1951; Perrone, 1968) and Price et al. (1981) have reported a case where a rhinolith was removed through a palatal osteotomy although the operative details of this case are not described. There have only been a few reports of large rhinoliths causing oro-nasal fistulae (Allen, 1966; Conrad, 1968; Bicknell, 1970; Gill & Lal, 1977; O’Dowling, 1984). These were not repaired except in the case reported by Gill & La1 (1977) in which bilateral Veau flaps were used in conjunction with nasal flaps to provide a two layer. closure of a mid-line palatal perforation. In the case reported the patient presented with a troublesome oro-nasal fistula. It was therefore decided that the fistula should be repaired as part of the initial surgical procedure. This was easily achieved through the Le Fort I maxillary osteotomy which allowed the nasal mucosa to be repaired directly and palatal fistula repaired from within the mouth. The defect was not bone grafted as this was considered to be unnecessary. Had the defect been larger, however, then this could have easily been achieved through the access provided by this downfracture technique. Acknowledgements I would like to thank Mr D. Russell for his kind permission to report his case and the Departments Medical Illustration at the Glasgow Dental Hospital and the Western Infirmary, Glasgow preparation of the illustrations.
of for
References Abu-Jaudeh, C. N. (1951). A giant rhinolith. Laryngoscope 61, 271. Ali, D. S. (1967). Congenital unilateral choanal atresia associated with a rhinolith. Jourruzl of Laryngology and Otology, 81, 359. Allen, S. G. (1966). A rhinolith presenting in the palate. British Journal of Oral Surgery, 4, 240. Bicknell, P G. (1970). Rhinolith perforating the hard palate. Journal of Laryngology and Otology, 84, 1161. Carder, H. M. & Hill, J. J. (1966). Asymptomatic rhinolith. Laryngoscope, 76, 524. Chaker. A. C.. Schwarz. G. S. & Kole. G. L. (1978). Ear, Nose and Throat \ , Bilateral rhinolithiasis. Jo&zal, S?, 50. Conrad, G. J. (1968). Rhinolith perforating the hard palate. Journal of Laryngology and Otology, 82, 1155. Davis, 0. & Wolff, A. (1985). Rhinolithiasis and maxillarv antrolithiasis. Ear, Nose and Throat Journal, i 64, 421. Deyasi, S. (1968). Rhinolith. Journal of Laryngology and Otology, 82, 481 Dutta, A. (1973). Rhinolith. Journal of Oral Surnerv, 31, 876. Eliachar, I.‘ & Schalit, M. (1970). Rhinolithiasis. Akhive~ of Otolaryngology, 91, 88. Gill, R. S. & Lal, M. (1977). Perforation of the hard palate by a rhinolith and its repair. Journal of Laryngology and Otology, 91, 85. Hunt, M. J., Cotton, B. P. & Joseph, D. J. (1966). Rhinoliths. Archives of Otolaryngology, 83, 256. I
BRITISH
490 Ishrat-Husain, Journal,
JOURNAL
OF ORAL
S. (1967). Rhinolith:
& MAXILLOFACIAL
SURGERY
a rare cause of chronic cough. Canadian Medical Association
91, 540.
Jain, R. K. & Frommer, H. H. (1982). Incidental finding of rhinoliths in panoramic radiography. New York State Dental Journal, 48, 530. Marano, P. D., Smart, E. A. & Kolodny, S. C. (1970). Rhinolith simulating osseous lesion: report of a case. Journal of Oral Surgery, 28, 615. Marfatia, P. T. (1968). Rhinolith: a brief review of the literature and a case report. Postgraduate Medical Journal,
44, 478.
R. F. (1952). Rhinoliths. Journal of Laryngology and Otology, 66, 462. R. F. (1971). Affections of the external nose and nasal cavities. In: Scott-Brown’s Diseases of the Ear, Nose and Throat. 3rd Ed. Volume 3, pp. 39-42. London: Butterworth and Co. O’Dowling, I. B. (1984). A rhinolith perforating the hard palate. Journal of the Irish DentalAssociation, McNab-Jones, McNab-Jones, 30, 2.
Osuoji, C. I. & Rowles, S. L. (1974). Studies on the organic composition of dental calculus and related calculi. Calcified Tissue Reserve, 16, 193. Perrone, J. A. (1968). An unusual rhinolith. Laryngoscope, 78, 279. Polson, C. J. (1943). On rhinoliths. Journal of Laryngology and Otology, 58, 79. Price, H. I., Batnitzky, S., Karlin, C. A. & Norris, C. W. (1981). Giant nasal rhinolith. American Journal
of Neuroradiology,
2, 371.
Quayle, A. A. (1981). A double flap technique for the closure of oro-nasal and oro-antral fistulae. British Journal
of Oral Surgery,
19, 132.
Sharma, B. G. & Sahni, R. C. (1981). Unilateral rhinolithiasis. Australasian Radiology, 25, 132. Teachey, W. S. & Smith, R. 0. (1973). Rhinolith: an unusual cause of septal perforation. Journal of the Florida Medical Association,
60, 24.
Varley, E. W. B. (1964). Rhinolith: an incidental finding. British Journal of Oral Surgery, 2, 40. Worgan, D. (1966). Unilateral choanal atresia associated with a rhinolith. Journal of Laryngology and Otology, 80, 418.
RHINOLITH:
AN UNUSUAL
CAUSE
T. R. FLOOD, M.B., B.S., Department
of Oral and Maxillofacial School, 378 Sauchiehall
OF PALATAL B.D.s.,
PERFORATION
F.D.S.R.C.S.
Surgery, Glasgow Dental Street, Glasgow G2 3JZ
Summary. An unusual case of a large rhinolith, which initially presented reported. The surgical removal of the rhinolith through a maxillary osteotomy immediate direct fixation using ‘Champy’ plates is described. This approach for removal of the mass and repair of the oronasal fistula.
Hospital
and
as an oronasal fistula, is at the Le Fort 1 level with provided excellent access
Introduction
Rhinolithiasis is an uncommon and often asymptomatic condition (Carder & Hill, 1966; Sharma & Sahni, 1981) which may be encountered during the course of a routine examination, or noticed incidentally on radiographs (Jain & Frommer, 1982; Varley, 1964). If undetected for many years rhinoliths may grow large enough to cause nasal obstruction and distortion or destruction of surrounding structures (Price et al., 1981). There have been various reports of septal deviation (Ishrat-Husain, 1967; Deyasi, 1985), septal perforation (Teachey & Smith, 1973), and destruction of the lateral wall of the nasal cavity with growth of the calculus to involve the maxillary sinus (Eliachar & Schalit, 1970). Rarely a large calculus may produce an oro-antral fistual (Dutta, 1973) or an oronasal fistula (Allen, 1966; Conrad, 1968; Bicknell, 1970; Gill & Lal, 1977; O’Dowling, 1984). Successful repair of an oronasal fistula can prove difficult as experience has shown that the bony defect is often larger than the soft tissue defect. Two layer closure is therefore desirable in order to reduce wound contracture and the likelihood of wound breakdown due to infection with recurrence of the fistula (Quayle, 1981).
Case report
A 24-year-old lady presented to the Oral Surgery clinic complaining of a ‘hole in her palate’ which had been present for 7 months. This had been associated with an unpleasant discharge from her nose into her mouth and occasionally small pieces of ‘gravel’ also had extruded from the hole. On further questioning she admitted that she had suffered from recurrent headaches and had had a persistent nasal discharge over the previous 2 years but no epistaxis nor pain from the area. Intra-oral examination revealed an inflammed oronasal fistual posteriorly in the midline of the hard palate (Fig. 1) and no other abnormality. Mirror examination of the post nasal space disclosed a mass obstructing the right posterior choanae. Radiographs (Fig. 2) showed the presence of a large calcified mass which appeared to occupy the posterior part of the right nasal cavity and extended into the maxillary antrum on the right. A CT scan showed an irregular mass 3x2 cm in dimension, composed mainly of calcified tissue confined to the posterior choanae (Received
8 July
1987; accepted 6 December
486
1987)
487
RHINOLITH
but distorting the lateral wall of the nasal cavity and the inferior turbinate bone (Fig. 3). A differential diagnosis of infected rhinolith or osteochondroma was considered. As the patient was concerned by the unpleasant discharge from the oro-nasal fistual it was decided to repair the fistula as part of the surgical procedure to remove the mass.
Fig. 1
Fig. 2 Figure l-Photograph
Fig. 3 showing the palatal perforation
preoperatively.
Figure 2-The lateral radiograph of the facial bones showing the extent of the mass and its irregular opacification. A differential diagnosis of rhinolith or osteochondroma was considered.
Figure 3-A CT scan showing clearly that the mass occupies the nasal cavity and does not invade the maxillary antrum. The gross distortion of the right lateral nasal wall is clearly shown.
488
BRITISH
JOURNAL
OF ORAL
& MAXILLOFACIAL
SURGERY
Surgical technique Under general anaesthesia the mass was approached via a Le Fort I maxillary osteotomy. Prior to making the osteotomy cuts the osteotomy site was marked out and Champy bone plates were positioned across the proposed osteotomy site and the screw holes drilled. The plates were then removed and the osteotomy cuts were completed in the usual manner followed by the maxilla being fractured downwards, so as to provide good access for removal of the mass lying within the nasal cavity which was ulcerating through the nasal mucosa. This approach also gave excellent access for primary closure of the nasal mucosa. The palatal mucosa was repaired by suturing from the oral aspect. The maxilla was then replaced and fixed using the Champy plates in their pre-determined positions. No intermaxillary fixation was necessary and the patient made an uneventful postoperative recovery. Discussion
Rhinoliths are irregular hard calcareous bodies, grey or brown in colour, found in the nasal passages and are relatively uncommon (Polson, 1943). These stones usually occur unilaterally in the lower half of the nasal cavity (Marfatia, 1968) and are thought to be formed by the gradual accretion of calcium and mineral salts around a nidus within the nasal lumen which may be either endogenous or exogenous in origin. Exogenous calculi appear to be more common (Davis & Wolff, 1985) and these are usually foreign bodies, often introduced many years previously during childhood, which have become chronically infected (Chaker et al., 1978) and subsequently encrusted with calcified tissue. Occasionally rhinoliths may develop in association with occupational factors such as sawdust (Hunt et al., 1966), coal dust and cement dust (Polson, 1943). Rhinoliths developing from endogenous nuclei, such as misplaced teeth or sequestrae, are more rare and sometimes rhinoliths form without any identifiable nucleus. Although the mechanism by which mineralisation of calculi is initiated is not yet fully understood, organic components are believed to play a part (Osuoji & Rowles, 1974) and it has been postulated that blood clot, epithelial debris and inspissated pus may form the initial endogenous nidus in these cases (McNab-Jones, 1971). This is further supported by reports of endogenous rhinoliths occurring in cases of choanal atresia (Ali, 1967; Worgan, 1966) where stasis of nasal and lacrymal secretions promote infection and stone formation. Rhinoliths tend to increase in size over a number of years and usually first present in early adult life with symptoms of chronic nasal discharge or obstruction (Hunt et al., 1966). Occasionally patients may complain of symptoms associated with local tissue destruction such as facial pain, swelling or epistaxis, giving rise to the suspicion of a malignant growth (Abu-Jaudeh, 1951; Price et al., 1981). However the true diagnosis may be suspected if there is a past history of a foreign body having been introduced into the nose. Radiographic findings are usually the most helpful, A densely calcified mass is suggestive of a rhinolith which may have an annular appearance, the centre of which may have a greater or lesser density depending on the nature of the nidus. Occasionally it is possible to identify the nature of the foreign body which forms the nidus from its radiographic appearance. The differential diagnosis should include calcified polyps, odontomes, granulomas, granulomatous diseases, sequestration following local osteomyelitis, osteomas, calcified odontogenic cysts, chondrosarcoma and osteosarcoma. Tomography and CT, scanning demonstrate the full extent of distortion and destruction of the
RHINOLITH
489
surrounding structures (Price et al., 1981) and are helpful when deciding on the most appropriate surgical approach. Small, soft calculi can often be crushed and removed in a piecemeal fashion through an anterior transnasal approach (Hunt et al., 1966) or, if bulky, displaced posteriorally into the nasopharynx (Marano et al., 1970) taking care to avoid aspiration. In some cases a formal submucous resection may be required to provide sufficient space for transnasal removal (Ishrat-Husain, 1967). Larger calculi may be impacted and difficult to remove especially if the lateral nasal wall has been eroded or displaced and in these cases a Caudwell-Luc approach has been advocated (McNab-Jones, 1952 & 1971) although troublesome haemorrhage may be a problem in these cases (Dutta, 1973). Extremely large rhinoliths however may require an external exposure through a lateral rhinotomy incision (Abu-Jaudeh, 1951; Perrone, 1968) and Price et al. (1981) have reported a case where a rhinolith was removed through a palatal osteotomy although the operative details of this case are not described. There have only been a few reports of large rhinoliths causing oro-nasal fistulae (Allen, 1966; Conrad, 1968; Bicknell, 1970; Gill & Lal, 1977; O’Dowling, 1984). These were not repaired except in the case reported by Gill & La1 (1977) in which bilateral Veau flaps were used in conjunction with nasal flaps to provide a two layer. closure of a mid-line palatal perforation. In the case reported the patient presented with a troublesome oro-nasal fistula. It was therefore decided that the fistula should be repaired as part of the initial surgical procedure. This was easily achieved through the Le Fort I maxillary osteotomy which allowed the nasal mucosa to be repaired directly and palatal fistula repaired from within the mouth. The defect was not bone grafted as this was considered to be unnecessary. Had the defect been larger, however, then this could have easily been achieved through the access provided by this downfracture technique. Acknowledgements I would like to thank Mr D. Russell for his kind permission to report his case and the Departments Medical Illustration at the Glasgow Dental Hospital and the Western Infirmary, Glasgow preparation of the illustrations.
of for
References Abu-Jaudeh, C. N. (1951). A giant rhinolith. Laryngoscope 61, 271. Ali, D. S. (1967). Congenital unilateral choanal atresia associated with a rhinolith. Jourruzl of Laryngology and Otology, 81, 359. Allen, S. G. (1966). A rhinolith presenting in the palate. British Journal of Oral Surgery, 4, 240. Bicknell, P G. (1970). Rhinolith perforating the hard palate. Journal of Laryngology and Otology, 84, 1161. Carder, H. M. & Hill, J. J. (1966). Asymptomatic rhinolith. Laryngoscope, 76, 524. Chaker. A. C.. Schwarz. G. S. & Kole. G. L. (1978). Ear, Nose and Throat \ , Bilateral rhinolithiasis. Jo&zal, S?, 50. Conrad, G. J. (1968). Rhinolith perforating the hard palate. Journal of Laryngology and Otology, 82, 1155. Davis, 0. & Wolff, A. (1985). Rhinolithiasis and maxillarv antrolithiasis. Ear, Nose and Throat Journal, i 64, 421. Deyasi, S. (1968). Rhinolith. Journal of Laryngology and Otology, 82, 481 Dutta, A. (1973). Rhinolith. Journal of Oral Surnerv, 31, 876. Eliachar, I.‘ & Schalit, M. (1970). Rhinolithiasis. Akhive~ of Otolaryngology, 91, 88. Gill, R. S. & Lal, M. (1977). Perforation of the hard palate by a rhinolith and its repair. Journal of Laryngology and Otology, 91, 85. Hunt, M. J., Cotton, B. P. & Joseph, D. J. (1966). Rhinoliths. Archives of Otolaryngology, 83, 256. I
BRITISH
490 Ishrat-Husain, Journal,
JOURNAL
OF ORAL
S. (1967). Rhinolith:
& MAXILLOFACIAL
SURGERY
a rare cause of chronic cough. Canadian Medical Association
91, 540.
Jain, R. K. & Frommer, H. H. (1982). Incidental finding of rhinoliths in panoramic radiography. New York State Dental Journal, 48, 530. Marano, P. D., Smart, E. A. & Kolodny, S. C. (1970). Rhinolith simulating osseous lesion: report of a case. Journal of Oral Surgery, 28, 615. Marfatia, P. T. (1968). Rhinolith: a brief review of the literature and a case report. Postgraduate Medical Journal,
44, 478.
R. F. (1952). Rhinoliths. Journal of Laryngology and Otology, 66, 462. R. F. (1971). Affections of the external nose and nasal cavities. In: Scott-Brown’s Diseases of the Ear, Nose and Throat. 3rd Ed. Volume 3, pp. 39-42. London: Butterworth and Co. O’Dowling, I. B. (1984). A rhinolith perforating the hard palate. Journal of the Irish DentalAssociation, McNab-Jones, McNab-Jones, 30, 2.
Osuoji, C. I. & Rowles, S. L. (1974). Studies on the organic composition of dental calculus and related calculi. Calcified Tissue Reserve, 16, 193. Perrone, J. A. (1968). An unusual rhinolith. Laryngoscope, 78, 279. Polson, C. J. (1943). On rhinoliths. Journal of Laryngology and Otology, 58, 79. Price, H. I., Batnitzky, S., Karlin, C. A. & Norris, C. W. (1981). Giant nasal rhinolith. American Journal
of Neuroradiology,
2, 371.
Quayle, A. A. (1981). A double flap technique for the closure of oro-nasal and oro-antral fistulae. British Journal
of Oral Surgery,
19, 132.
Sharma, B. G. & Sahni, R. C. (1981). Unilateral rhinolithiasis. Australasian Radiology, 25, 132. Teachey, W. S. & Smith, R. 0. (1973). Rhinolith: an unusual cause of septal perforation. Journal of the Florida Medical Association,
60, 24.
Varley, E. W. B. (1964). Rhinolith: an incidental finding. British Journal of Oral Surgery, 2, 40. Worgan, D. (1966). Unilateral choanal atresia associated with a rhinolith. Journal of Laryngology and Otology, 80, 418.