- 68 -
J Rhinol 18(1), 2011 www.ksrhino.or.kr
INTRODUCTION
Aberrant teeth can occur in sites outside of the oral cav- ity, and can be supernumerary, deciduous, or permanent.
The ectopic eruption of a tooth into the nasal cavity is quite rare.1) 2) Although not difficult to diagnose, an ectopic tooth in the nasal cavity is easily missed due to the lack of symptoms and the variable clinical presentation. Indeed, the diagnosis of an ectopic tooth in the nasal cavity is of- ten made incidentally during routine clinical or radiologic examinations.3) We report a unique case of intranasal ec- topic tooth eruption into the nasal cavity, which caused significant nasal symptoms in an otherwise healthy patient and was removed endoscopically.
CASE REPORT
A 36-year-old female was referred to the Otorhinolar- yngology Clinic with a long-standing history of right na- sal obstruction, excessive nasal mucoid discharge, and an
intranasal mass. There was no history of facial trauma or surgery. No cleft palate or congenital abnormalities were noted, and the patient was otherwise healthy. The patient was initially examined in an outpatient clinic where a mass lesion in the right nasal cavity was identified. Spe- cifically, a yellowish-white mass surrounded by grayish granulation tissue was seen in the nasal cavity. The mass apparently erupted from the floor of the right nasal cavity, below the inferior turbinate. On palpation with a suction tip, the mass was firm and fixed on the floor of the nasal cavity (Fig. 1). On intraoral dental examination, the right upper premolar was absent from its normal position. The patient had a prosthesis of the 1st molar of the right max- illa. No embrasure between the premolar and the 1st mo- lar was noted.
Panoramic radiography was obtained after the dental consultation, which showed a radiopaque lesion on the floor of the right nasal cavity below the inferior turbinate, and one ipsilateral upper premolar was missing from the oral cavity (Fig. 2). Coronal computed tomography showed a tooth-shaped mass on the floor of the right nasal cavity ; the attenuation of the mass was the same as that of the oral teeth. Bilateral ethmoidal and right maxillary sinus- itis was also noted (Fig. 3).
The ectopic tooth was extracted under local anesthesia.
Using a 0° telescope and various nasal forceps, the tooth was removed through the anterior naris. Post-operative
Ectopic Eruption of a Tooth into the Nasal Cavity with Sinusitis ： A Case Report
Jang Won Choi, MD, Hong Seok Park, MD, Beom Seok Park, MD and Soo Kweon Koo, MD, PhD
Department of Otorhinolaryngology-Head and Neck Surgery, Busan St. Mary’s Medical Center, Busan, Korea ABSTRACT
The ectopic eruption of teeth into the nasal cavity is a rare phenomenon. Ectopic tooth eruptions commonly occur in the palate and maxillary sinus, but have also been reported in the mandibular condyle, coronoid process, orbit, and nasal cavities.
The clinical manifestations of intranasal teeth are quite variable; however, intranasal teeth can be an incidental finding during routine examination in patients without nasal discomfort. Herein we report a unique case of an intranasal ectopic tooth that erupted into the nasal cavity and caused significant nasal symptoms in an otherwise healthy patient. The intranasal tooth was removed endoscopically.
KEY WORDS：Ectopic ToothㆍNasal ObstructionㆍSinusitis.
Address correspondences and reprint requests to Soo Kweon Koo, MD, PhD, Department of Otorhinolaryngology-Head and Neck Surgery, Busan St. Mary’s Medical Center, 538-41 Yongho- dong, Nam-gu, Busan 608-838, Korea
Tel：+82-51-933-7220, Fax：+82-51-956-1956 E-mail：[email protected]
Received for publication on December 1, 2010 Accepted for publication on January 4, 2011 online©MLComm
Choi et al：A Case of Ectopic Tooth Eruption into the Nasal Cavity / 69
DISCUSSION
Ectopic eruption refers to teeth that have erupted in an abnormal location. Ectopic teeth are commonly seen in the palate and maxillary sinus, but have also been report- ed in the mandibular condyle, coronoid process, orbit, and nasal cavities.1)4)5) Intranasal teeth are particularly rare, and can be supernumerary, deciduous, or permanent. Ec- topically erupted deciduous or permanent teeth have nor- mal-shaped dental elements, but supernumerary teeth are deformed in appearance, with cone-, peg-, or triangular- shaped crowns.6) Supernumerary teeth occur more com- monly intranasally than deciduous or permanent teeth.4) Our case was an ectopic permanent premolar.
Based on other case reports, most intranasal teeth ap- pear as a unilateral single tooth in the nasal cavity rather than multiple teeth in the nose or teeth in both nasal cavi- ties.3) There are slightly more cases of intranasal teeth in male subjects (60%) than in females (40%), but there is no predilection for the right or left side.7)
The etiology of ectopic nasal teeth remains obscure, al- though many different explanations exist, including de- velopmental disturbances, such as cleft palate; teeth dis- placed by trauma or cysts; displacement of a developing tooth secondary to a maxillary infection, either odonto- genic or rhinogenic; hereditary factors, including Gard- ner’s syndrome and cleidocranial dysostosis; obstruction of downward eruption secondary to crowding of denti- tion, persistent deciduous teeth, or exceptionally dense bone; and the root of an unusually long tooth projecting into the nose.1)4)8)
If symptomatic, the clinical manifestations of ectopic teeth in the nasal cavity are varied and can include unilat- eral nasal obstruction, epistaxis, chronic nasal discharge, nasal bleeding was controlled with Merocel packing. Af-
ter removal of the surrounding debris and granulation tis- sue, the size and shape of the extracted tooth was exam- ined (Fig. 4).
The patient had an uneventful recovery and the present- ing symptoms were completely relieved after surgery.
Fig. 1. Pre-operative endoscopic findings show a protruding yel- low-white mass (black arrow) with surrounding gray granulation tissue on the floor of the right nasal cavity below the inferior turbi- nate. S : nasal septum, T : inferior turbinate.
Fig. 3. Pre-operative axial (A) and coronal (B) ostiomeatal unit computed tomogra- phy scans. A tooth-shaped mass is evi- dent on the floor of the right nasal cavity.
A coronal scan reveals that the attenua- tion of the mass is the same as that of the oral teeth. Bilateral ethmoidal and right
maxillary sinusitis is also noted. A B
Fig. 2. The panoramic dental radiograph shows a radiopaque le- sion (white arrow) on the floor of the right nasal cavity below the inferior turbinate.
70 / J Rhinol 18(1), 2011
nasal or facial pain and headache, chronic localized ulcer- ation, deviation of the nasal septum, necrotic or granula- tion tissue in the nasal cavity, a rhinolith, signs of parana- sal sinusitis, and chronic intraoral fistulas.2)4) Ectopic nasal teeth may also be asymptomatic and only incidentally rec- ognized during routine clinical or radiologic examinations.
The diagnosis of ectopic nasal teeth is based mainly on clinical and radiologic findings. Clinically, through an an- terior rhinoscope or endoscope, intranasal teeth are most often detected on the floor of the nasal cavity, and are of- ten an ivory white mass without any covering, or a tumor- like lesion surrounded by granulation and necrotic debris;
however, the tooth may be completely or incompletely embedded in the nasal mucosa and thus may be over- looked.9) Careful inspection of dentition and consultation from a dentist is necessary in the differential diagnosis of supernumerary, deciduous, or permanent teeth. The differ- ential diagnosis should include a foreign body, rhinolith, inflammatory lesion due to syphilis, tuberculosis, or fungal infection with calcification, benign or malignant tumors, ex- ostosis, odontomas, osteomas, or cystic lesions.6)8) Radio- logic examination may be helpful in the pre-operative pa- tient assessment, assisting in the differential diagnosis and evaluation of the exact depth of the eruption site.8)10) Caldwell’s, Water’s, and lateral views of the skull, pan- oramic radiography, and computed tomography may guide diagnosis and management. Panoramic radiogra- phy has the added advantage of giving a detailed view of the normal dentition and computed tomography can be useful in evaluating the depth of the eruption site.
Removal of intranasal teeth is generally advocated to alleviate the symptoms and prevent complications. How- ever, an asymptomatic patient can be observed with close radiographic follow-up.4) To avoid injury during develop- ment, the best time to remove the tooth is after the roots of the permanent tooth have completely formed.11) The surgical approach can be either transnasal or transpalatal.
Operative methods depend on the involvement of struc- tures adjacent to the tooth and potential complications arising from extraction of the tooth.2)12) The transnasal en- doscopic approach is recommended because of good illu- mination, clear visualization, avoidance of injury to the surrounding mucosa, and precise dissection.6)12) In our case, extraction of the intranasal tooth was uneventful un- der a rigid endoscope and the result was satisfactory.
저자역할(Author Contributions)
최장원, 박홍석, 박범석, 구수권은 본 연구에서 모든 자료에 접근할 수 있으며 자료의 완전성과 자료 분석의 정확성에 책임을 지고 있 습니다. 연구 기획：구수권. 자료 해석 및 분석：최장원, 박홍 석, 박범석. 논문초안：최장권. 논문수정：구수권. 연구 총괄：
구수권.
REFERENCES
1) Thawley SE, LaFerriere KA. Supernumerary nasal tooth. Laryn- goscope 1977;87(10):1770-3.
2) Murty PS, Hazarika P, Hebbar GK. Supernumerary nasal teeth.
Ear Nose Throat J 1988;67(2):128-9.
3) Lin IH, Hwang CF, Su CY, Kao YF, Peng JP. Intranasal Tooth:
Report of Three Cases. Chang Gung Med J 2004;27(5):385-9.
4) Smith RA, Gordon NC, De Luchi SF. Intranasal Teeth. Report of two cases and review of the literature. Oral Surg Oral Med Oral Pathol 1979;47(2):120-2.
5) Sood VP, Kakar PK. Intra-nasal tooth. Eye Ear Nose Throat Mon 1975;54(9):343-5.
6) Spencer MG, Couldery AD. Nasal tooth. J Laryngol Otol 1985;99 (11) :1147-50.
7) Yeung KH, Lee KH. Intranasal tooth in a patient with a cleft lip and alveolus. Cleft Palate Craniofac J 1996;33(2):157-9.
8) Chen A, Huang JK, Cheng SJ, Sheu CY. Nasal teeth: report of three cases. AJNR Am J Neuroradiol 2002;23(4):671-3.
9) Hitschler WJ. Nasal teeth: report of a case Arch Otolaryngol 1938;
28:911-5.
10) Pracy JP, Williams HO, Montgomery PQ. Nasal teeth. J Laryngol Otol 1992;106(4):366-7.
11) Martinson FD, Cockshott WP. Ectopic nasal dentition. Clin Radiol 1972;23(4):451-4.
12) Lee FP. Endoscopic extraction of an intranasal tooth: a review of 13 Cases. Laryngoscope 2001;111(6):1027-31.
Fig. 4. After removal of the surrounding purulent debris the ecto- pic permanent premolar was found to measure 1.8×0.9×0.6 cm3.
