Giant Nasal Rhinolith Hilton I. Price,1 Solomon BatnitzkY,1 Charles A. Karlin ,1 and Charley W. Norris 2 Nasopharyngeal rhinoliths are uncommon lesions that result from the complete or partial encrustation of an intra- nasal foreign body with mineral salts , mainly calcium and magnesium [1]. The first radiologic diagnosis of a rhinolith was made by Mac intyre (1900) [2] , only 4 years after Roe ntg en's discovery of x-rays . Rad iology is an invaluabl e inves t igat ion in the diagnosis of foreign bodies , and this is partic ularly true for rhinoliths. Foreign bodies of high rad io- density are easily identified and localized using conventional radiogr ap hy ; howeve r, tomography and especially com- puted tomography (CT), may be extremely helpful in local- izing foreign bodies of lower radiodensity . We present a patient with a giant nasal rhinolith, with a discussion of the c lini ca l and radiologic features. Case Report A 19-year-old man had pain in the ri ght maxilla and the palate, right nasal obstruction , and an odorous right nasal di scha rge . He had suff ered from numerous ep iso des of epist axis as a child. Thr ee years earlier, he underwent surge ry, at which time a mass inter- preted as an angi of ibr oma was exc ised from the medial wall of the ri ght max ill ary antrum . Just before th e prese nt admission , epistaxis recu rred and he was referred to our hospital with th e diagnosis of a r ecu rrent angiofibr oma. Physical exa mination revealed a healthy you ng man with no facial deformity . Exa mination of his nasal cavity showe d a normal left side. The nasal sep tum was deviated to the left sid e. The right nasal vault was occ upied by a pale, shining mass which was firm to palpation and nonfriable . In the nasopharyn x there was a pale, ye ll owis h-brown mass protruding through th e ri ght choa na with s urrounding puru lent material. The examinat ions of the mouth (es- pecia ll y the palate and teeth), larynx, eyes, and ears, were all norma l. Radiogr a phs of the paranasal sinu ses demonstrated a large, den sely ca lcified and well circumscribed mass occupying the right nasal cav ity and protruding into the nasop harynx (fig. 1 A). Tomog- ra phy co nfirmed th ese findings , as well as displacement of the nasal se ptum to the left, bowing of the medial wall of th e ri ght maxillary sinus laterall y, and opac ifi ca tion of th e ri ght maxillary sinus second- ary to obs tru ct ion of the ostium (fig. 1 B). CT of the paranasal sinu ses co nfirmed all these findings. In Received Oc tob er 2. 1980; accept ed a ft er revision November 14, 1980 . 37 1 ad dition , it add ed a further dimension with regard to the relation of th e mass to the surrounding paranasal st ruc tur es (fig . 1 C). The surrounding bo ny displacement rather than destruction confirmed its benign natur e. Th e density of the mass was 450 Hounsfi eld unit s. In view of th e previous diagnosis of an angiofibroma, bilateral selec tive exte rnal and int erna l carotid angiogr aphy was perfo rmed. This revealed anterior displacement of the branche s of th e ascend- ing pharyngeal and internal maxillary art eries in keeping with the size of the densely calc ified mass. However, there were no ab normal vessels nor any evid ence of a tumor stain. Bef ore s urg ery, the patient' s par ents were again qu estioned. Th ey recalled that when he was 4 years old a button had beco me emb edded in his nose, and an unsuccessful attempt was made to retrieve it. Surgical removal of the mass was initially attempt ed through th e vestibule. This proved to be im possib le; an incision and osteo tomy through the palate crea ted a porta l throug h which the rhinolith co uld be delivered . The nasal septum was redu ced to the midlin e. The pathologi c examination of th e mass co nfirmed it to be a rhinolith measuring 4.5 x 3. 5 x 3.5 cm in its greatest dimensions (fig. 1 D) . A nasal po lyp found during th e ope ration proved to be an angio fi- broma . Discussion Rhinoliths , or n asa l ca lculi, are ca l ca reous co ncretions that ari se secondary to the c omp lete or partial in crustat ion of intr anasal foreign bodies [1]. The for eign b ody incites a c hronic inflammatory r eac tion with deposition of mineral sa lts, mainly calc ium and magnesium [3]. The foreign body is usually exogenous in origin and may include bead s, buttons (as in our patient), fruit stones, pieces of pap er, and re tained nasal packing [1]. Less co mmonly , endogenous foreign material may form the nidus of the rhinolith. Th ese inclu de misp laced teeth, seq uestr a, and possibly blood clo ts, dried pus, and d esq uamated e pithelium [1]. The ro ut e of e ntry of the f ore ign body is u sua ll y a nteriorly , but some may enter through the choanae seco ndary to vomiting or co ughing [4]. Rhinoliths are rare , and for no appare nt re aso n have a hi gher incidence in females [5]. The foreign body most common ly is placed in the nasa l ca vity during childhood 'Department of Di agnost ic Radiol ogy , University of Kansa s Medical Center, Rainbow Blvd . at 39 th St., Kansas City, KS 66103. Address reprint requests 10 H. I. Pri ce . 2Department of Ear-Nose- Throat, Universit y of Kansas Medi cal Center, Kansas City, KS 66 103 . AJNR 2:371-373 , July / AU9uSt 1981 0195-6108 /81/ 0204- 37 1 $00 .00 © American Roentgen Ray Soci ety