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Maxillary Antrolith: Report of a Case
Auris' Nasus' Larynx (Tokyo) 15, 185-189 (1988)
MAXILLARY ANTROLITH: REPORT OF A CASE Tetsuya
ISHIYAMA,
M. D.
Department of Otolaryngology, Shinshu University School of Medicine, Matsumoto, Japan
A case of maxillary antrolith in a 60-year-old male is presented. Complaints were mucous discharge and a small amount of periodic bleeding from the right nasal cavity, of two months' duration. CT scan revealed a small calcified mass in the right maxillary sinus. By Caldwell-Luc operation an antrolith was removed from the right maxillary sinus with chronic sinusitis. This was 0.6 x 0.4 x 0.3 cm in size and 0.03 g in weight. Histopathological studies showed calcium deposition around the necrotic mass. Chemical analysis of the specimen revealed calcium phosphate (65 %), calcium carbonate (8 %) and albuminous material (27%). Lithiasis is uncommon in nasal cavities and paranasal sinuses. Approximately 600 rhinoliths have been described, but the occurrence of maxillary stones has been less common than that of rhinoliths (DAVIS and WOLFF, 1985). The purpose of this report is to present a case of maxillary antrolith and to discuss the characteristics of the lesion with review of the literatures. CASE REPORT
A 60-year-old Japanese male was referred to the ENT department at Matsumoto National Hospital, Matsumoto, Japan on April 17, 1987, with complaints of mucous discharge and periodic bleeding from the right nasal cavity of two months' duration. The past history included pulmonary tuberculosis at age 30 and radiation therapy of the right parotid tumor at age 48. Examination revealed mucous secretion in the right middle meatus. There were no significant findings in physical examinations. A radiograph (occipitomental projection) showed a diffuse opacity in the right maxillary sinus (Fig. I). CT scan demonstrated a small calcified mass in the right maxillary sinus (Fig. 2). A chest radiograph, electrocardiogram, complete blood count, electrolytes, urinalysis and results of liver function test were all Received for publication July 6, 1988 185
186
T.ISHIYAMA
Fig. 1. Waters' view radiograph showing (arrowed) diffuse shadow in the right maxillary sinus.
Fig. 2.
CT scan showing (arrowed) a small calcified mass in the right maxillary sinus.
within normal limits. The patient was admitted to the hospital, and the right maxillary antrum was explored by the Caldwell-Luc operation under local anesthesia. Edematous antral lining and accumulated secretion were found, and a small antrolith was located on the medial wall of mucous membrane in the maxillary sinus. They were removed surgically. Antibiotic coverage was continued for the first postoperative week. The patient showed an uneventful course and discharged on the
MAXILLARY ANTROLITH
187
If' f f fl " f f J 11:1 1'·UI111fllllMfU Fig. 3.
A removed maxillary antrolith.
Fig. 4. Photomicrograph (H & E, x 20) showing calcified material (arrowed) around the necrotic mass. Table 1.
Chemical analysis of maxillary antroliths (%). ----------
Calcium phosphate Calcium carbonate Magnesium phosphate Magnesium carbonate Organic matter
----------
CUNNINGHAM
SHOJI
SHIMIZU
ISHIYAMA
75.8 8.4
50 19
32
65 8
68 5.3 6.6
31
27
eighth postoperative day. Pathology-Macroscopic (Fig. 3): An irregularly shaped uneven specimen measuring 0.6 X 0.4 X 0.3 cm, weighing 0.03 g, white-gray in color. On cross-section, the yellow-gray core was seen in the center. Microscopic (Fig. 4): The calcified material was deposited around the necrotic mass. Chemical analysis: Sixty-five percent of calcium phosphate, 8 % of calcium carbonate and 27 % of albuminous material.
188
T.ISHIYAMA DISCUSSION
Forty-three cases of maxillary antroliths have been reported in the literature (ICHIMURA, KIGAWADA, and IINUMA, 1975). Reported maxillary antroliths varied in size. A large stone was 3.9 x 3.5 cm in size and 25.5 g in weight (MUHLEN, 1908). Two stones were found in a maxillary sinus, they were 3.5 x 2.3 X 2.7 cm, 13.5 g and 3.2 x 2 x 1.8 cm, 8.3 g (SEIDEL, 1919). The antrolith of this report was small, and was revealed by CT scan. Maxillary antroliths and rhinoliths are formed by calcium deposition around the core. Stones are generally classified into two types according to the origin of the nucleus, one is endogenous (blood, mucus, WBCs, RBCs), and another is exogenous (beads, button, seeds, paper, tooth roots, and so forth) (KARGES, EVERSOLE, and POINDEXTER, 1971). Of the 13 instances of antroliths reviewed in the literature, 6 were definitely of the exogenous type (CRIST and JOHNSON, 1972). As exogenous origin, LORD (1944) reported a case of antrolith with a paper nucleus. WRIGHT (1927) described a tooth root nucleus that had been dislodged into the antrum years previously. The nucleus of this antrolith was a necrotic tissue which was endogenous origin. Variations in anatomy or other factors that increase stasis of nasal and lacrimal secretions are postulated to result in concentrations of inorganic salts that may in turn form calculi (KARGES et al., 1971). It seems that disturbed ciliary movement and edematous mucous membrane of sinus disturb the excretion of the calculus in the nasal discharge. Chemical analyses of maxillary antroliths have been reported such as shown on the Table I (CUNNINGHAM, LORD, MANLEY, and POLSON, 1945; SHOJI, FUKuo, SAKAKURA, and MIYOSHI, 1981; SHIMIZU, HIROTA, and IINUMA, 1987). OPPIKOFER (1907) described an antrolith which was composed of 40.72 %CaO, 40.52 % P 2 0 5 , 3.81 % MgO, 11.91 % organic substance and 1.66 % water. Symptoms of this lesion are usually nasal discharge and nasal obstruction, are sometimes headache, nasal bleeding, postnasal discharge and facial pain which are symptoms associated with sinusitis (KARGES et al., 1971; CRIST and JOHNSON, 1972). The symptoms of this case were unilateral nasal discharge and periodic nasal bleeding, so malignancy was suspected. The presence of calcified stones must be considered in any case of sinusitis or rhinitis that does not respond to conservative therapy (DAVIS and WOLFF, 1985). It would seem that the factors necessary for antrolith formation are long-standing chronic infection associated with poor drainage and the presence of a foreign body in the sinus, most commonly of dental tissue, for a number of years (BOWERMAN, 1969). CT scan examination is useful for the diagnosis of a small maxillary antrolith. I wish to thank Prof. Kiichiro Taguchi, Shinshu University School of Medicine, for permission to publish the report and for his helpful criticism.
MAXILLARY ANTROLITH
189
REFERENCES BOWERMAN, J. E.: The maxillary antrolith. J. Laryngol. Otol. 83: 873-882, 1969. CRIST, R. F., and JOHNSON, R. L.: Antrolith: Report of case. J. Oral Surg. 30: 694-695, 1972. CUNNINGHAM, A.T., LORD, O.c., MANLEY, C.H., and POLSON, C.l.: Rhinoliths: The report of antral and three nasal stones. J. Laryngol. Otol. 60: 253-256, 1945. DAVIS, 0., and WOLFF, A.: Rhinolithiasis and maxillary antrolithiasis. Ear, Nose Throat J. 64: 421-426, 1985. IcHIMURA, K., KIGAWADA, M., and hNUMA, T.: Antrolithiasis, report of two cases. Otolaryngology (Tokyo) 47: 121-127, 1975. KARGES, M. A., EVERSOLE, L. R., and POINDEXTER, B. J., Jr.: Antrolith: report of case and review of literature. J. Oral Surg. 29: 812-814, 1971. LORD, O. C.: Antral rhinolith. J. Laryngol. Otol. 59: 218-222, 1944. MUHLEN, A.: Ein Fall von Steinbildung in der Kiefer- und Keilbeinhohle. Arch. Laryngol. u. Rhinol. 21: 371-374, 1908. OPPIKOFER, E.: Ueber Steinbildung in der Kieferhohle. Arch. Laryngol. u. Rhinol. 20: 31-37, 1907. SEIDEL, 0.: Ober Steinbildung in der highmorshohle. Arch. Ohren-, Nasen- u. Kehlkopfheilkunde. 104: 106-119, 1919. SHIMIZU, Y., HIROTA, Y., and IINUMA, T.: Report of antral rhinolith. Otolaryngology (Tokyo) 59: 597-602, 1987. SHOJI, K., FUKuo, H., SAKAKURA, Y., and MIYOSHI, Y.: A case of a maxillary antrolith. Practica Otologica (Kyoto) 74: 1333-1337, 1981. WRIGHT, A. l.: A case of chronic frontal and antral sinusitis due to a rhinolith. J. Laryngol. Otol. 42: 192-193, 1927.
Request reprints to:
T. Ishiyama, M. D., Department of Otolaryngology, Shinshu University School of Medicine, 3-1-1 Asahi, Matsumoto 390, Japan
MAXILLARY ANTROLITH: REPORT OF A CASE Tetsuya
ISHIYAMA,
M. D.
Department of Otolaryngology, Shinshu University School of Medicine, Matsumoto, Japan
A case of maxillary antrolith in a 60-year-old male is presented. Complaints were mucous discharge and a small amount of periodic bleeding from the right nasal cavity, of two months' duration. CT scan revealed a small calcified mass in the right maxillary sinus. By Caldwell-Luc operation an antrolith was removed from the right maxillary sinus with chronic sinusitis. This was 0.6 x 0.4 x 0.3 cm in size and 0.03 g in weight. Histopathological studies showed calcium deposition around the necrotic mass. Chemical analysis of the specimen revealed calcium phosphate (65 %), calcium carbonate (8 %) and albuminous material (27%). Lithiasis is uncommon in nasal cavities and paranasal sinuses. Approximately 600 rhinoliths have been described, but the occurrence of maxillary stones has been less common than that of rhinoliths (DAVIS and WOLFF, 1985). The purpose of this report is to present a case of maxillary antrolith and to discuss the characteristics of the lesion with review of the literatures. CASE REPORT
A 60-year-old Japanese male was referred to the ENT department at Matsumoto National Hospital, Matsumoto, Japan on April 17, 1987, with complaints of mucous discharge and periodic bleeding from the right nasal cavity of two months' duration. The past history included pulmonary tuberculosis at age 30 and radiation therapy of the right parotid tumor at age 48. Examination revealed mucous secretion in the right middle meatus. There were no significant findings in physical examinations. A radiograph (occipitomental projection) showed a diffuse opacity in the right maxillary sinus (Fig. I). CT scan demonstrated a small calcified mass in the right maxillary sinus (Fig. 2). A chest radiograph, electrocardiogram, complete blood count, electrolytes, urinalysis and results of liver function test were all Received for publication July 6, 1988 185
186
T.ISHIYAMA
Fig. 1. Waters' view radiograph showing (arrowed) diffuse shadow in the right maxillary sinus.
Fig. 2.
CT scan showing (arrowed) a small calcified mass in the right maxillary sinus.
within normal limits. The patient was admitted to the hospital, and the right maxillary antrum was explored by the Caldwell-Luc operation under local anesthesia. Edematous antral lining and accumulated secretion were found, and a small antrolith was located on the medial wall of mucous membrane in the maxillary sinus. They were removed surgically. Antibiotic coverage was continued for the first postoperative week. The patient showed an uneventful course and discharged on the
MAXILLARY ANTROLITH
187
If' f f fl " f f J 11:1 1'·UI111fllllMfU Fig. 3.
A removed maxillary antrolith.
Fig. 4. Photomicrograph (H & E, x 20) showing calcified material (arrowed) around the necrotic mass. Table 1.
Chemical analysis of maxillary antroliths (%). ----------
Calcium phosphate Calcium carbonate Magnesium phosphate Magnesium carbonate Organic matter
----------
CUNNINGHAM
SHOJI
SHIMIZU
ISHIYAMA
75.8 8.4
50 19
32
65 8
68 5.3 6.6
31
27
eighth postoperative day. Pathology-Macroscopic (Fig. 3): An irregularly shaped uneven specimen measuring 0.6 X 0.4 X 0.3 cm, weighing 0.03 g, white-gray in color. On cross-section, the yellow-gray core was seen in the center. Microscopic (Fig. 4): The calcified material was deposited around the necrotic mass. Chemical analysis: Sixty-five percent of calcium phosphate, 8 % of calcium carbonate and 27 % of albuminous material.
188
T.ISHIYAMA DISCUSSION
Forty-three cases of maxillary antroliths have been reported in the literature (ICHIMURA, KIGAWADA, and IINUMA, 1975). Reported maxillary antroliths varied in size. A large stone was 3.9 x 3.5 cm in size and 25.5 g in weight (MUHLEN, 1908). Two stones were found in a maxillary sinus, they were 3.5 x 2.3 X 2.7 cm, 13.5 g and 3.2 x 2 x 1.8 cm, 8.3 g (SEIDEL, 1919). The antrolith of this report was small, and was revealed by CT scan. Maxillary antroliths and rhinoliths are formed by calcium deposition around the core. Stones are generally classified into two types according to the origin of the nucleus, one is endogenous (blood, mucus, WBCs, RBCs), and another is exogenous (beads, button, seeds, paper, tooth roots, and so forth) (KARGES, EVERSOLE, and POINDEXTER, 1971). Of the 13 instances of antroliths reviewed in the literature, 6 were definitely of the exogenous type (CRIST and JOHNSON, 1972). As exogenous origin, LORD (1944) reported a case of antrolith with a paper nucleus. WRIGHT (1927) described a tooth root nucleus that had been dislodged into the antrum years previously. The nucleus of this antrolith was a necrotic tissue which was endogenous origin. Variations in anatomy or other factors that increase stasis of nasal and lacrimal secretions are postulated to result in concentrations of inorganic salts that may in turn form calculi (KARGES et al., 1971). It seems that disturbed ciliary movement and edematous mucous membrane of sinus disturb the excretion of the calculus in the nasal discharge. Chemical analyses of maxillary antroliths have been reported such as shown on the Table I (CUNNINGHAM, LORD, MANLEY, and POLSON, 1945; SHOJI, FUKuo, SAKAKURA, and MIYOSHI, 1981; SHIMIZU, HIROTA, and IINUMA, 1987). OPPIKOFER (1907) described an antrolith which was composed of 40.72 %CaO, 40.52 % P 2 0 5 , 3.81 % MgO, 11.91 % organic substance and 1.66 % water. Symptoms of this lesion are usually nasal discharge and nasal obstruction, are sometimes headache, nasal bleeding, postnasal discharge and facial pain which are symptoms associated with sinusitis (KARGES et al., 1971; CRIST and JOHNSON, 1972). The symptoms of this case were unilateral nasal discharge and periodic nasal bleeding, so malignancy was suspected. The presence of calcified stones must be considered in any case of sinusitis or rhinitis that does not respond to conservative therapy (DAVIS and WOLFF, 1985). It would seem that the factors necessary for antrolith formation are long-standing chronic infection associated with poor drainage and the presence of a foreign body in the sinus, most commonly of dental tissue, for a number of years (BOWERMAN, 1969). CT scan examination is useful for the diagnosis of a small maxillary antrolith. I wish to thank Prof. Kiichiro Taguchi, Shinshu University School of Medicine, for permission to publish the report and for his helpful criticism.
MAXILLARY ANTROLITH
189
REFERENCES BOWERMAN, J. E.: The maxillary antrolith. J. Laryngol. Otol. 83: 873-882, 1969. CRIST, R. F., and JOHNSON, R. L.: Antrolith: Report of case. J. Oral Surg. 30: 694-695, 1972. CUNNINGHAM, A.T., LORD, O.c., MANLEY, C.H., and POLSON, C.l.: Rhinoliths: The report of antral and three nasal stones. J. Laryngol. Otol. 60: 253-256, 1945. DAVIS, 0., and WOLFF, A.: Rhinolithiasis and maxillary antrolithiasis. Ear, Nose Throat J. 64: 421-426, 1985. IcHIMURA, K., KIGAWADA, M., and hNUMA, T.: Antrolithiasis, report of two cases. Otolaryngology (Tokyo) 47: 121-127, 1975. KARGES, M. A., EVERSOLE, L. R., and POINDEXTER, B. J., Jr.: Antrolith: report of case and review of literature. J. Oral Surg. 29: 812-814, 1971. LORD, O. C.: Antral rhinolith. J. Laryngol. Otol. 59: 218-222, 1944. MUHLEN, A.: Ein Fall von Steinbildung in der Kiefer- und Keilbeinhohle. Arch. Laryngol. u. Rhinol. 21: 371-374, 1908. OPPIKOFER, E.: Ueber Steinbildung in der Kieferhohle. Arch. Laryngol. u. Rhinol. 20: 31-37, 1907. SEIDEL, 0.: Ober Steinbildung in der highmorshohle. Arch. Ohren-, Nasen- u. Kehlkopfheilkunde. 104: 106-119, 1919. SHIMIZU, Y., HIROTA, Y., and IINUMA, T.: Report of antral rhinolith. Otolaryngology (Tokyo) 59: 597-602, 1987. SHOJI, K., FUKuo, H., SAKAKURA, Y., and MIYOSHI, Y.: A case of a maxillary antrolith. Practica Otologica (Kyoto) 74: 1333-1337, 1981. WRIGHT, A. l.: A case of chronic frontal and antral sinusitis due to a rhinolith. J. Laryngol. Otol. 42: 192-193, 1927.
Request reprints to:
T. Ishiyama, M. D., Department of Otolaryngology, Shinshu University School of Medicine, 3-1-1 Asahi, Matsumoto 390, Japan