Rhinoliths form through the gradual deposition of mineral concretions within the nasal cavity. These concretions are generally classified as either exogenous or endogenous, depending on the origin of the foreign material that serves as the nidus for mineral deposition [1]. An exogenous rhinolith develops when the nidus originates from an external source introduced into the nasal cavity, such as beads, seeds, stones, cotton, ointment residues, or nasal tampons [1,2]. Conversely, an endogenous rhinolith arises from the deposition of the patient’s own tissues or biological materials, such as bone fragments, blood clots, ectopic teeth, mucus plugs, or desquamated epithelium, which act as a nidus for calcification [2,3].

Although the earliest documented case of rhinolithiasis dates back to the 17th century, diagnostic challenges persist due to the condition’s rarity, slow progression, insidious onset, and nonspecific clinical presentation [4]. Rhinolithiasis typically manifests as unilateral nasal obstruction, persistent purulent or foul-smelling nasal discharge, halitosis, occasional epistaxis, and facial pain [5]. These symptoms often overlap with more common nasal conditions, such as nasal polyps or chronic rhinosinusitis, frequently leading to misdiagnosis and delayed management [6]. The prevalence of rhinolithiasis remains low, and the condition is often detected incidentally during radiologic evaluation or medical examinations for unrelated concerns [7]. Rhinoliths can occur at any age but are most frequently identified in young adults, particularly during the third decade of life [8]. This report describes an uncommon case of bilateral rhinoliths extending into the nasopharynx and emphasizes the importance of considering rhinolithiasis in the differential diagnosis and clinical evaluation of patients with chronic unilateral or atypical nasal symptoms.

A 45-year-old woman presented to the ENT outpatient department with a 5-year history of persistent left-sided nasal obstruction and foul-smelling nasal discharge. She also reported intermittent sneezing, dull frontal headaches, and a sensation of heaviness over the forehead. The patient had received multiple courses of antibiotics and nasal decongestants for presumed chronic rhinosinusitis, with only transient symptomatic relief. There was no history of nasal trauma, previous nasal surgery, or known foreign body insertion during childhood or adulthood. She denied facial pain, anosmia, fever, or other systemic symptoms.

Anterior rhinoscopy revealed a grayish, hard mass deep within the left nasal cavity, partially obscured by mucopurulent discharge (Fig. 1). The nasal septum was midline, and mild mucosal edema was observed. Diagnostic nasal endoscopy identified multiple firm, irregular masses along the nasal floor bilaterally, with greater involvement on the left side and posterior extension into the choana and nasopharynx. The right nasal cavity was partially occupied, and there was no evidence of ulceration, bleeding, or granulation tissue.

Non-contrast computed tomography (CT) of the paranasal sinuses confirmed multiple well-defined hyperdense masses within the posterior nasal cavities bilaterally, extending into the nasopharynx and oropharynx, more prominently on the left side (Fig. 2). No evidence of bony erosion or involvement of adjacent sinuses or orbital structures was observed, effectively excluding other differential diagnoses such as calcified polyps, osteomas, or fungal concretions.

A diagnosis of bilateral rhinolithiasis was established. Endoscopic surgical removal was performed under general anesthesia. The rhinoliths were brittle, stony hard, and measured approximately 1×0.5 cm each, with an average weight of about 1 g per stone. Multiple fragments were carefully extracted using a 0° rigid endoscope, Blakesley forceps, and suction. The underlying mucosa appeared inflamed but intact, without necrosis or granulation tissue. Histopathological examination confirmed laminated mineralized structures with pigmented cores, consistent with rhinoliths. Chemical analysis revealed the composition to be predominantly calcium oxalate.

Postoperatively, the patient experienced immediate relief from nasal obstruction and malodor. She was discharged the following day with instructions for nasal irrigation, antibiotics, and analgesics. At the 3-month follow-up, nasal endoscopy showed healthy mucosa with no evidence of recurrence, and the patient remained asymptomatic.

Rhinolithiasis was first described by Bartholin in 1654 as a stony-hard foreign body that had developed around a cherry stone [9]. Since that initial report, only about 800 cases of rhinolithiasis have been documented worldwide [10]. This condition is extremely rare, with an estimated incidence of 1 in 10,000 ENT outpatient cases [11]. Globally, approximately 3 cases per 100,000 patients presenting with nasal complaints are reported annually [12]. The exact pathogenesis of rhinolith formation remains incompletely understood. Current evidence suggests that chronic inflammation, localized infection, altered pH, and mechanical factors—such as repeated sneezing, nose-blowing, or minor mucosal trauma—facilitate the gradual deposition of calcium, magnesium, and phosphate salts around a nidus over time [13]. Exogenous rhinoliths are more commonly reported, with successful removal of foreign materials documented in 15%–37% of cases [14,15].

Rhinolithiasis is more prevalent in developing countries, where nasal foreign bodies or childhood trauma may go unnoticed and untreated [16,17]. Several reports indicate a higher prevalence among females and in rural populations, suggesting these as potential risk factors. Kharoubi [14], for example, reported 20 patients over 17 years, of whom 55% were female, while Benhoummad et al. [15] documented 16 cases with 68% female patients. Bilateral rhinolithiasis is exceptionally rare (Table 1). In both the studies by Kharoubi [14] and Benhoummad et al. [15], only a single bilateral case was identified, and isolated reports by Yaşar and Öner [18], Sadri [19], and Zafar et al. [20] further confirm its rarity.

Clinically, rhinolithiasis presents with nonspecific symptoms such as nasal obstruction, fetid rhinorrhea, epistaxis, crusting, and occasional facial discomfort [21]. In adults, diagnosis is frequently delayed or incidental, as seen in our patient, who underwent long-term treatment for presumed sinusitis before the bilateral rhinoliths were identified. Radiologic and endoscopic evaluations are complementary diagnostic tools. Nasal endoscopy provides direct visualization, whereas CT imaging offers precise assessment of the lesion’s size, density, extent, and relationship to surrounding structures [22]. In posterior or bilateral cases, CT plays a crucial role in confirming the diagnosis, determining the exact size and location of the rhinoliths, and identifying non-aggressive calcified intrasinus masses without bone destruction. It also aids in detecting concurrent sinusitis or other nasal complications [23]. Moreover, CT demonstrates greater sensitivity and specificity than magnetic resonance imaging or standard radiography for detecting calcifications and differentiating rhinoliths from partially calcified neoplasms, such as osteosarcoma or chondrosarcoma, and benign lesions such as osteomas [23,24]. CT is thus essential for distinguishing rhinoliths from calcified polyps, fungal concretions, or neoplasms [25]. In the present case, CT confirmed bilateral intranasal calcifications extending into the nasopharynx, which guided surgical planning.

Histopathologic analysis, though not always required, helps confirm the diagnosis of calcified lesions. Rhinoliths typically contain laminated calcium phosphate, oxalate, and carbonate, with occasional magnesium salts and organic cores [26]. In our case, pathology revealed laminated calcified concretions with pigmented cores, consistent with previous reports, and excluded other calcified sinonasal entities. Surgical removal remains the definitive treatment. Endoscopic extraction is preferred due to its minimally invasive nature, enhanced visualization, and preservation of mucosal integrity. Techniques include piecemeal removal using Blakesley forceps, suction, or curettes, and en bloc extraction when possible. Large or posterior rhinoliths may require fragmentation, angled endoscopes, or adjunctive transoral assistance [27]. In our case, bilateral rhinoliths were successfully extracted using a 0° rigid endoscope with Blakesley forceps and suction, without complications such as epistaxis, septal perforation, or mucosal trauma.

Untreated rhinolithiasis can result in septal perforation, turbinate atrophy, chronic sinusitis, and, in rare cases, oroantral or nasolacrimal fistula formation [28]. Surgical outcomes are generally excellent, with low recurrence and rapid symptom resolution, consistent with existing literature [19,20]. Our patient achieved complete relief from nasal obstruction and discharge. Comparison with previously reported bilateral cases (Table 1) reveals several important clinical insights: 1) bilateral rhinolithiasis with posterior nasopharyngeal extension is exceedingly rare; 2) nonspecific symptoms often lead to prolonged misdiagnosis; and 3) early recognition through CT and endoscopic evaluation ensures effective management and prevents long-term complications.

In conclusion, bilateral rhinolithiasis with posterior extension presents a significant diagnostic challenge because of its slow progression, rarity, and nonspecific manifestations. Clinicians should maintain a high index of suspicion in patients with persistent unilateral or atypical nasal symptoms. Nasal endoscopy combined with CT imaging is crucial for accurate localization, differential diagnosis, and surgical planning. Prompt endoscopic removal remains the treatment of choice, providing complete symptom resolution and preventing potential long-term complications.