Endoscopic removal of an intranasal ectopic tooth

1. Introduction 

Eruption of a tooth into the nasal cavity is a rare clinical entity. However, the identification of such teeth can be important since they have the potential to cause considerable morbidity. Ectopic and supernumerary teeth may be present in many regions of the maxillofacial skeleton. Reported sites include the palate, maxillary sinus, mandibular condyle, coronoid process, orbit, nasal cavity, or through the skin [1], [2]. Ectopic teeth may be supernumerary, deciduous, or permanent teeth. Although the cause of intranasal eruption of teeth is unclear, trauma, infection, and abnormal development probably play a significant role.

With the recent advancement of endoscopy, several surgical techniques under endoscope have been developed. With the rise of cosmetic problems on external approaches, a nasal endoscopic technique has become necessary. We report a successful case of endoscopic extraction of an ectopic tooth located in the floor of the nasal cavity.

2. Case report 

A 12-year-old boy was referred to the Department of Otolaryngology-Head and Neck Surgery of Korea University College of Medicine for diagnosis and treatment of a radiopaque lesion in the right nasal cavity during a routine dental radiographic examination. The patient was asymptomatic and denied any pain, swelling, epistaxis, or nasal obstruction. Intraoral examination revealed impacted third molar teeth, with the remaining dentition and mucosa exhibiting no abnormalities. No previous history of maxillofacial trauma or surgery was elicited and the patient's general medical history was unremarkable. Nasal endoscopy revealed a 10 mm diameter mass lesion in the floor of the right nasal cavity (Fig. 1). Computed tomography of paranasal sinuses showed a radiopaque mass resembling a tooth on the floor of the nose, approximately halfway between the anterior and posterior portion of the naris (Fig. 2). No cystic or inflammatory changes were noted.

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Fig. 1. Preoperative endoscopic photography showing a whitish intranasal tooth covered with a mucous membrane in the floor of the right nasal cavity.

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Fig. 2. Coronal computed tomography of the paranasal sinuses showing a tooth in the floor of the right nose.

We performed the extraction of the ectopic tooth under general anesthesia using the 4 mm, 0 degree telescope with cold light halogen (Karl Storz, Tuttlingen, Germany). The supernumerary tooth on the right nasal floor was dislocated from its site of impaction and removed with Blakesley nasal forceps (Karl Storz, Tuttlingen, Germany) through nasal endoscopy. The mucous membrane covering the tooth, granulation tissue, and debris surrounding the tooth were also removed. Postoperative nasal bleeding was controlled with Merocel (Medtronic Xomed, Jacksonville, FL), which was removed 2 days postoperatively. The patient did well postoperatively and healed uneventfully. Over a 2-year period of postoperative observation, the patient remained in good health and did not report any symptomatology associated with teeth.

3. Discussion 

Intranasal ectopic teeth are rare. Yeung and Lee reviewed the literature and found a total of 41 well-documented cases [1]. The age at discovery of the intranasal teeth ranged from 3 to 62 years. There are slightly more cases of intranasal teeth found in male subjects than females. In regard to location, there was no side predilection in the literature [1], [2]. The teeth in question were said to have arisen mostly from the permanent dentition or to have been supernumerary [3], [4], [5].

The etiology of intranasal teeth is controversial. Many theories have been proposed, including developmental disturbances, such as cleft palate, teeth displaced by trauma, cysts, infection, obstruction to eruption secondary to crowding of dentition, persistent deciduous teeth, or dense bone [4], [5], [6], [7], [8], [9].

Intranasal teeth presented a variety of symptoms and signs, including nasal pain, nasal obstruction, epistaxis, headache, nasal discharge, mild fever, crusting of the nasal mucosa, localized ulceration, external deviation of the nose, nasal septal abscess, and nasal-oral fistula. Intranasal teeth may also be asymptomatic and may be only incidentally recognized during routine clinical or radiographic examination.

The diagnosis of an intranasal tooth can be made from ether clinical examination or radiographic examination. Clinically an intranasal tooth presents as a white mass without covering of nasal mucosa or as a protruding reddish mass, which is completely or incompletely embedded in the nasal mucosa. Intranasal tooth located in the floor or lateral wall of the nasal cavity can be surrounded by debris and granulation tissue. When intranasal masses are identified clinically, the differential diagnosis should include nasal foreign bodies, rhinoliths, bony sequestra, neoplasm, and exostoses [2], [4]. Radiographic examination may or may not be helpful in confirming the diagnosis of intranasal teeth because an intranasal tooth may appear only as a nonspecific radiopacity or a well-differentiated tooth in the affected nasal cavity.

The treatment of the intranasal tooth is early extraction when diagnosed because of the potential morbidity. In our experience, the result of the extraction of the nasal tooth under endoscopy guidance is satisfactory. Extraction of the intranasal tooth under endoscopic guidance has the advantages of good illumination, clear visualization, and precise dissection. As a more convenient, effective and safer method than the conventional open method, we think that the method of using a nasal endoscope can reduce morbidity and hospitalization period. This method can also obtain cosmetically satisfactory results. Asymptomatic teeth should also be removed. If the tooth is not removed, close radiographic follow-up is recommended.

In summary, an intranasal ectopic tooth is an uncommon arising in the nasal cavity. It may be confused with other nasal cavity mass. Rhinologists should be aware of this disease entity when encountering patients presenting with a nasal obstruction and nasal mass.