MedPix Medical Image Database COW - Case of the Week Case Contributor: Dr. Balasubramanian Thiagarajan Affiliation: Unlisted Institution

MedPix No: History Pt Demographics: Age = 30 y.o. Gender = woman 30 years old female patient reported to the outpatient department with complaints of:1. Blocking sensation left nasal cavity - 6 years2. Foul smelling blood stained discharge left nasal cavity - 6 years3. Head ache confined to the left side of the head on and off - 3 years Downloaded by (-1)

MedPix No: EXAM & LABS On examination:Left nasal cavity on examination showed spherical reddish mulberry like mass. Felt stony and brittle to touch. Postnasal space showed sero sanguineous discharge.

* Xray paranasal sinuses Water*s view showing Rhinolith* * 1. Radio opaque spherical mass seen occupying the inferior meatus in the left nasal cavity* Downloaded by (-1)

* CT scan para nasal sinuses plain axial cut * *1. CT scan paranasal sinuses plain axial cut showes radio opaque spherical mass occupying the inferior meatus of the left nasal cavity. It extends posteriorly up to the level of choana * Downloaded by (-1)

FINDINGS 1. Xray paranasal sinuses water*s view showed radio opaque spherical mass occupying the left nasal cavity.2. Axial CT cuts of para nasal sinus showed radio opaque spherical mass extending from the anterior nasal cavity on the left side to the posterior portion of the left nasal cavity.

DIFFERENTIAL DIAGNOSIS What is your Differential Diagnosis? Foreign body nasal cavity

Diagnosis: Rhinolith Dx Confirmed by: Histopathology

DISCUSSION Rhinoliths are of two types: - - Exogenous type:If concretions occur around a foreign body then the rhinoloith is known to be exogenous in nature. - Endogenous type: If it forms around a blood clot or inspissated mucous plug then it is known to be endogenous in nature. Gauze swabs inadvertantly left in the nose can also act as a nidus for the formation of rhinolith. - - This disorder is more common in females - - Clinical features: These patients have unilateral nasal discharge, which may be serosanguinous in nature. As the rhinolith increases in size, the symptoms of nasal obstruction become more pronounced and the patient may manifest with unilateral purulent nasal discharge. Swelling of the nose, face epiphora could be some of the symptoms. - - On probing the presence of a stony hard structure could be identified. It is common in the inferior meatus. - - Management: Complete removal of the offending mass is the dictum. If the rhinolith is reasonably small it can be remove per via naturalis without incision. If it is large attempt must be made to break it to manageble pieces to facilitate per via naturalis removal. If attempts to break the mass fail then lateral rhinotomy should be resorted to for complete removal of the mass.