- Email: [email protected]
Concholith: an unusual case
Concholith: An unusual case ENGIN DURSUN,
MD,
HAKAN KORKMAZ,
MD,
¨ NAL BAYIZ, U
MD,
F
oreign bodies of the nose and paranasal sinuses are not very uncommon, but true mineralized masses (MMs) are extremely rare in the nasal cavity.1,2 MMs can be exogenous or endogenous depending on the origin. Exogenous MMs are usually described as partially or completely encrusted foreign bodies, and endogenous ones arise around a normal structure such as misplaced teeth, blood clots, or dried nasal secretions.2,3 A foreign body starts an inflammatory reaction in the nasal cavity, which may end up in an accumulation of calcium carbonate and phosphate crystals. These are the main chemical constituents leading to the formation of MMs.3 Antrolith in the maxillary sinus and rhinolith in the nasal cavity are the names given according to the localization of MMs.1 MMs are most often found on the floor of the nose, about halfway between the anterior and posterior nares.1 They are usually asymptomatic but may also present with foul discharge, obstruction, epistaxis, halitosis, postnasal drip, slight to moderate swelling, headache, epiphora, and, rarely, nasal regurgitation.2,3 MMs may even erode into the maxillary sinus and may perforate the palate or nasal septum by pressure necrosis.2-4 The diagnosis of MM can be difficult even when the patient is symptomatic because of the limitations of conventional nasal examination, especially when located at the posterior aspect of the nasal cavity. MMs are usually grayish and have a hard gritty feel. They may be seen on plain radiographs, but a computed tomography (CT) scan is sometimes required to make the differential diagnosis.4 They may also present as incidental findings on radiographs, From the Department of Otorhinolaryngology–Head and Neck Surgery, Ministry of Health Ankara Training and Research Hospital. Reprint requests: Engin Dursun, MD, Ergin Sokak 43/5, Mebusevleri-Tandog˘an, Ankara 06580, Turkey; e-mail, [email protected]. Otolaryngol Head Neck Surg 2003;128:764-5. Copyright © 2003 by the American Academy of Otolaryngology–Head and Neck Surgery Foundation, Inc. 0194-5998/2003/$30.00 ⫹ 0 doi:10.1016/S1094-5998(02)23246-5 764
RAHMI KILIC ¸,
MD,
and ERDAL SAMI´M,
MD,
Ankara, Turkey
which are performed in dental and otorhinolaryngology clinics.1 Rigid nasal endoscopy is also useful in making the diagnosis.4 We present an unusual case of nasal MMs located within the middle concha bullosa. CASE REPORT A 45-year-old woman presented to our clinic with a 6- to 7-month history of headache, nasal congestion, postnasal drainage, and snoring. Anterior rhinoscopy and endoscopic examination revealed bilateral middle turbinate hypertrophy and purulent discharge. Acoustic rhinomanometric measurements were in accordance with the patient’s subjective symptoms and findings. CT scans demonstrated bilateral middle concha bullosa and a radiopaque mass within the left middle concha (Fig 1A). The patient underwent endoscopic sinus surgery. Bilaterally lateral wall resections were performed for concha bullosa, and a gray nasal mass (Fig 1B) was easily extirpated from the bullous cavity. The mass underwent chemical analysis via x-ray diffractometry. This analysis revealed calcium carbonate as the major constituent. In regular follow-up examination, the patient’s major symptoms improved and results of the endoscopic examination were normal in appearance. DISCUSSION Foreign bodies are sometimes lodged at the time of accidents, but most are self-inserted by children.2 The variety of the retrieved objects is amazingly wide, including beads, beans, seeds, sand, fruit stones, impression materials, tire valves, erasers, buttons, paper, cotton, wool, metals, oak tree twigs, button batteries, and wood screws.1-3 However, the formation of MMs very rarely occurs even with the presence of foreign bodies. In general, an object in the nasal cavity becomes calcified as it contacts with nasal secretions. This mass grows gradually through the precipitation of salts on the surface. Infections and air-drying may increase the mineralization process.1 Although there have been more than 600 rhinolith cases reported in the literature,1 we could
Otolaryngology– Head and Neck Surgery Volume 128 Number 5
Fig 1. (A) Coronal CT scan shows bilateral middle concha bullosa (extensive type) and a radiopaque mass localized within the left middle concha. (B) Extirpated mineralized mass (8 ⫻ 6 mm).
not found any report of MMs located within the middle concha bullosa. Because of the location of the MM in our case, we described this unique entity as a “concholith.” Although the etiology and pathogenesis of MM are not fully understood, it is thought that the predisposing factor is the entry of a foreign body. However, other very important factors are also
DURSUN et al 765
required for this transformation because only a tiny fraction of a foreign body becomes petrified. An inflammation followed by precipitation of salts results in obstruction and stagnation. In unilateral choanal atresia, subsequent infections, inflammations, and fibrosis may eventually produce an MM. Air flow currents, which probably help concentration and crystallization, are also needed. Time seems to be an important factor; it is not known how long it takes for a foreign material to become encrusted.2 The outer surface of an MM is mainly composed of calcium phosphate, organic material, and water. Calcium carbonate and magnesium phosphate are also found in varying amounts. Magnesium carbonate, iron, zinc, sodium, potassium, oxalate, and chloride have been found, usually in trace amounts.1 Analysis of the inorganic components of MMs has been carried out with different methods such as chemical analysis and the use of infrared spectroscopy, x-ray diffractometry, the electron microprobe, and neutron activation analysis.4 In our case, analysis was carried out with x-ray diffractometry and calcium carbonate was found. The absence of any evidence of a foreign material led us to the diagnosis of an endogenous MM. The differential diagnosis should include calcified nasal polyp, ossifying fibroma, odontoma, osteoma, osteosarcoma, chondroma, or chondrosarcoma, or calcified angiofibroma if the MMs are large and extensive.2 REFERENCES
1. Appleton SS, Kimbrough RE, Engstrom HIM. Rhinolithiasis: a review. Oral Surg 1988;65:693-8. 2. Ezsias A, Sugar AW. Rhinolith: An unusual case and update. Ann Otol Rhinol Laryngol 1997;106:135-8. 3. Wickham MH, Barton RPE. Nasal regurgitation as the presenting symptom of rhinolithiasis. J Laryngol Otol 1988;102:59-61. 4. Stoney P, Bingham B, Okuda I, et al. Diagnosis of rhinoliths with rigid endoscopy. J Otolaryngol 1991;20:408-11.
MD,
HAKAN KORKMAZ,
MD,
¨ NAL BAYIZ, U
MD,
F
oreign bodies of the nose and paranasal sinuses are not very uncommon, but true mineralized masses (MMs) are extremely rare in the nasal cavity.1,2 MMs can be exogenous or endogenous depending on the origin. Exogenous MMs are usually described as partially or completely encrusted foreign bodies, and endogenous ones arise around a normal structure such as misplaced teeth, blood clots, or dried nasal secretions.2,3 A foreign body starts an inflammatory reaction in the nasal cavity, which may end up in an accumulation of calcium carbonate and phosphate crystals. These are the main chemical constituents leading to the formation of MMs.3 Antrolith in the maxillary sinus and rhinolith in the nasal cavity are the names given according to the localization of MMs.1 MMs are most often found on the floor of the nose, about halfway between the anterior and posterior nares.1 They are usually asymptomatic but may also present with foul discharge, obstruction, epistaxis, halitosis, postnasal drip, slight to moderate swelling, headache, epiphora, and, rarely, nasal regurgitation.2,3 MMs may even erode into the maxillary sinus and may perforate the palate or nasal septum by pressure necrosis.2-4 The diagnosis of MM can be difficult even when the patient is symptomatic because of the limitations of conventional nasal examination, especially when located at the posterior aspect of the nasal cavity. MMs are usually grayish and have a hard gritty feel. They may be seen on plain radiographs, but a computed tomography (CT) scan is sometimes required to make the differential diagnosis.4 They may also present as incidental findings on radiographs, From the Department of Otorhinolaryngology–Head and Neck Surgery, Ministry of Health Ankara Training and Research Hospital. Reprint requests: Engin Dursun, MD, Ergin Sokak 43/5, Mebusevleri-Tandog˘an, Ankara 06580, Turkey; e-mail, [email protected]. Otolaryngol Head Neck Surg 2003;128:764-5. Copyright © 2003 by the American Academy of Otolaryngology–Head and Neck Surgery Foundation, Inc. 0194-5998/2003/$30.00 ⫹ 0 doi:10.1016/S1094-5998(02)23246-5 764
RAHMI KILIC ¸,
MD,
and ERDAL SAMI´M,
MD,
Ankara, Turkey
which are performed in dental and otorhinolaryngology clinics.1 Rigid nasal endoscopy is also useful in making the diagnosis.4 We present an unusual case of nasal MMs located within the middle concha bullosa. CASE REPORT A 45-year-old woman presented to our clinic with a 6- to 7-month history of headache, nasal congestion, postnasal drainage, and snoring. Anterior rhinoscopy and endoscopic examination revealed bilateral middle turbinate hypertrophy and purulent discharge. Acoustic rhinomanometric measurements were in accordance with the patient’s subjective symptoms and findings. CT scans demonstrated bilateral middle concha bullosa and a radiopaque mass within the left middle concha (Fig 1A). The patient underwent endoscopic sinus surgery. Bilaterally lateral wall resections were performed for concha bullosa, and a gray nasal mass (Fig 1B) was easily extirpated from the bullous cavity. The mass underwent chemical analysis via x-ray diffractometry. This analysis revealed calcium carbonate as the major constituent. In regular follow-up examination, the patient’s major symptoms improved and results of the endoscopic examination were normal in appearance. DISCUSSION Foreign bodies are sometimes lodged at the time of accidents, but most are self-inserted by children.2 The variety of the retrieved objects is amazingly wide, including beads, beans, seeds, sand, fruit stones, impression materials, tire valves, erasers, buttons, paper, cotton, wool, metals, oak tree twigs, button batteries, and wood screws.1-3 However, the formation of MMs very rarely occurs even with the presence of foreign bodies. In general, an object in the nasal cavity becomes calcified as it contacts with nasal secretions. This mass grows gradually through the precipitation of salts on the surface. Infections and air-drying may increase the mineralization process.1 Although there have been more than 600 rhinolith cases reported in the literature,1 we could
Otolaryngology– Head and Neck Surgery Volume 128 Number 5
Fig 1. (A) Coronal CT scan shows bilateral middle concha bullosa (extensive type) and a radiopaque mass localized within the left middle concha. (B) Extirpated mineralized mass (8 ⫻ 6 mm).
not found any report of MMs located within the middle concha bullosa. Because of the location of the MM in our case, we described this unique entity as a “concholith.” Although the etiology and pathogenesis of MM are not fully understood, it is thought that the predisposing factor is the entry of a foreign body. However, other very important factors are also
DURSUN et al 765
required for this transformation because only a tiny fraction of a foreign body becomes petrified. An inflammation followed by precipitation of salts results in obstruction and stagnation. In unilateral choanal atresia, subsequent infections, inflammations, and fibrosis may eventually produce an MM. Air flow currents, which probably help concentration and crystallization, are also needed. Time seems to be an important factor; it is not known how long it takes for a foreign material to become encrusted.2 The outer surface of an MM is mainly composed of calcium phosphate, organic material, and water. Calcium carbonate and magnesium phosphate are also found in varying amounts. Magnesium carbonate, iron, zinc, sodium, potassium, oxalate, and chloride have been found, usually in trace amounts.1 Analysis of the inorganic components of MMs has been carried out with different methods such as chemical analysis and the use of infrared spectroscopy, x-ray diffractometry, the electron microprobe, and neutron activation analysis.4 In our case, analysis was carried out with x-ray diffractometry and calcium carbonate was found. The absence of any evidence of a foreign material led us to the diagnosis of an endogenous MM. The differential diagnosis should include calcified nasal polyp, ossifying fibroma, odontoma, osteoma, osteosarcoma, chondroma, or chondrosarcoma, or calcified angiofibroma if the MMs are large and extensive.2 REFERENCES
1. Appleton SS, Kimbrough RE, Engstrom HIM. Rhinolithiasis: a review. Oral Surg 1988;65:693-8. 2. Ezsias A, Sugar AW. Rhinolith: An unusual case and update. Ann Otol Rhinol Laryngol 1997;106:135-8. 3. Wickham MH, Barton RPE. Nasal regurgitation as the presenting symptom of rhinolithiasis. J Laryngol Otol 1988;102:59-61. 4. Stoney P, Bingham B, Okuda I, et al. Diagnosis of rhinoliths with rigid endoscopy. J Otolaryngol 1991;20:408-11.