Endoscopic Removal of Intranasal Supernumerary Tooth Presenting as NasalObstruction and EpistaxisPham TT1,2, Chau SM3, Ifegwu IO4, Wang BY4* and Wong BJF2,3,5

1School of Medicine, University of California, Irvine, Orange, CA 92868, USA2Beckman Laser Institute, University of California, Irvine, CA 92617, USA3Department of Otolaryngology-Head and Neck Surgery, University of California, Irvine, Orange, CA 92868, USA4Department of Pathology and Laboratory Medicine, University of California, Irvine, Orange, CA 92868, USA5Department of Biomedical Engineering, University of California, Irvine, CA 92617, USA*Corresponding author: Wang BY, Department of Pathology and Laboratory Medicine, University of California, Irvine, Orange, CA 92868, USA,Tel: (714)456-6141; E-mail: bevwang@uci.edu

Received date: 10 August 2018; Accepted date: 29 August 2018; Published date: 31 August 2018

Citation: Pham TT, Chau SM, Ifegwu IO, Wang BY, Wong BJF (2018) Endoscopic Removal of Intranasal Supernumerary Tooth Presenting as NasalObstruction and Epistaxis. J Clin Radiol Case Rep. Vol.2 No.1:04.

Copyright: © 2018 Pham TT, et al. This is an open-access article distributed under the terms of the Creative Commons Attribution License,which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.

Abstract

Objective: Supernumerary teeth, presenting in excess ofnormal teeth, are commonly found in the upper incisorarea. However, supernumerary teeth appearing in thenasal cavity is rare and has primarily been documentedthrough case reports. Here we present a case report of anadult patient with nasal obstruction, decreased sense ofsmell, and intermittent epistaxis, who was found to havean intranasal supernumerary tooth by computedtomography imaging and pathological confirmation.

Methods: Case Report.

Results: Computed tomography imaging and endoscopicevaluation revealed a hyperdense mass in the nasal cavity.Pathology confirmed the presence of a calcified massconsistent with a supernumerary tooth in his nasal cavity.Following endoscopic extraction, the patient’s symptomsresolved.

Conclusion: Supernumerary teeth should be consideredon the differential diagnosis for nasal obstruction and beevaluated with radiology, endoscopy, and pathology toexclude serious or malignant conditions such aschondrosarcomas and osteosarcomas. Endoscopicremoval of supernumerary teeth is safe and effective.

Keywords: Supernumerary teeth; Intranasal; Nasal cavity;Tooth; Nasal floor; Nasal obstruction; Surgical; Ectopic;Calcified mass

IntroductionEctopic eruption of teeth has been described to occur in

various locations including the maxillary sinus, orbit, andpalate [1]. Teeth causing nasal obstruction and drainage are arare clinical entity and most cases have been reported in theform of case reports [2]. This paper aims to contributeinformation regarding the presentation and treatment of teethin the nasal cavity. Little is known about the origin of theseteeth since there are few reports but, in most cases, surgicalextraction has been an effective treatment.

Case ReportA 46-year-old male was referred by his primary care

provider to otolaryngology specialists for complaints of nasalobstruction and difficulty in breathing through his nasal cavity.He also had associated right nasal and mouth discomfort, andintermittent epistaxis. For his symptoms, he was previouslyplaced on ciprofloxacin and amoxicillin, as well as a nasalsteroid spray.

His past medical history was unremarkable, and he deniedasthma, diabetes, coronary artery disease, or renal disease. Hedenies sustaining any nasal or facial trauma or foreign bodyplacement. His only surgery was an open reduction andinternal fixation for a broken left arm. His social history wasunremarkable.

On examination, he had a firm, fibrous mass along his nasalfloor. Computed tomography (CT) imaging revealed thepresence of an irregular calcification of the right nasal airwayat the level of the anterior aspect of the inferior turbinate thatmeasured about 1 cm in size with a very complex shape(Figure 1). The differential diagnosis initially includedsupernumerary tooth, odontoma, inverting papilloma,

Case Report

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rhinolith, osteoma, polyp, malignant mass, infection, foreignbody, or a traumatic pyogenic granuloma.

Figure 1 Maxillofacial computed tomography scans of (A)Coronal, (B) Sagittal, and (C) Axial planes. The irregularcalcification is indicated by the red arrow.

He underwent bilateral nasal endoscopy with excision of theright nasal mass and right partial inferior turbinate resection.In the right nasal vault, there was friable granulation tissueover a calcified mass medial to the right inferior turbinate,lateral to the maxillary crest. This mass was firmly adherent tothe inferior turbinate. After excision, it was clear that the masscontained a small dense cylindrical central region withsurrounding polypoid mucosa or granulation tissue. Pathologyreports revealed a polypoidal structure with enamel anddentin tubules, consistent with a supernumerary tooth (Figure2). Fragments of sinonasal mucosa and polypoid granulationtissue with extensive chronic inflammation were also noted. AKotler airway was placed to facilitate nasal airflow duringhealing.

He healed well and on postoperative day five, when hisright-sided Kotler nasal airway was removed, he endorsedimproved nasal breathing. On follow-up one month aftersurgery, his nasal obstruction had resolved with nocomplications.

Figure 2 Pathological images of the extractedsupernumerary tooth showing (A) Polypoid structure, (B)Dentin tubules, and (C) Surrounding granulation tissue withextensive chronic inflammation.

DiscussionThe differential diagnosis for nasal obstruction is wide and

includes common diagnoses like foreign body impaction, nasalpolyp, infection and tumors. Benign tumors includehemangiomas, osteomas, dermoids, and odontomas, andexamples of malignant tumors include squamous cellcarcinoma, adenocarcinoma, adenoid cystic carcinoma,melanoma, olfactory neuroblastoma, and may others. It isimportant to use diagnostic tools such as radiographic imaging,endoscopy, and pathology to help guide diagnosis andtreatment, as well as rule out concerning malignancies. Incases where an intranasal radiopaque mass is found, thedifferential may narrow to focus on diagnoses such as foreignbody; rhinolith; bony mass; calcified tumor such as chondroidtumor, fibro-osseous tumor, olfactory neuroblastoma, invertedpapilloma, and odontoma; calcified neoplasm such aschondrosarcoma and osteosarcoma; or in this case report,supernumerary tooth. In contrast to odontomas, which aremixed benign odontogenic tumors divided into the compoundtype (formed by many small tooth like structures often heldtogether by a capsule) and the complex type (a singleamorphous mass of mature odontogenic tissue withoutstructural organization), supernumerary teeth are teeth ofnormal composition presented in addition to the tooth set,both in the primary and permanent dentitions [3].

In a few cases, teeth have been found outside the oral cavitywith the incidence of supernumerary teeth in the generalpopulation being 0.1-1% [4-6]. Supernumerary teeth are morecommonly present in the palate, maxilla, or orbit. However,the occurrence of intranasal teeth is rare, and literature ismostly limited to case reports and case series. Intranasal teethhave been diagnosed in all ages, ranging from young childrento the elderly [7]. Patients with intranasal teeth often presentwith unilateral obstruction and discomfort with some havingserous or purulent rhinorrhea [2,8-10]. External deviation ofthe nose has also been observed as well as epistaxis, nasalseptal abscess, paranasal sinusitis, and oronasal fistulas

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[11,12]. A few cases have been asymptomatic and found onlythrough imaging [13,14]. On examination, an intranasal toothmay be seen as a white bony mass in the nasal cavitysurrounded by granulation tissue and debris [6]. Imagingmodalities such as radiographs and CT scans may be used tofurther visualize the tooth. CT scans, especially may be helpfulin evaluating the depth of the implantation site to furtherinform surgical planning.

The etiology of nasal cavity eruption of teeth is not well-understood. Supernumerary teeth are more commonly relatedto the upper jaw, and these teeth develop either from a thirdtooth bud that arises from the dental lamina or possibly fromsplitting of the bud itself [4,15]. Some have proposed otherpathologies including tooth displacement secondary tomaxillofacial trauma, developmental abnormalities such ascleft lip or palate, or infection [2,11,15-17]. The developmentof an intranasal tooth after maxillofacial trauma has also beendescribed [18,19]. Other proposed theories touch on crowdeddentition, dense bone, or a genetic predisposition.

Once identified, treatment of supernumerary teeth focuseson extraction of the tooth to avoid further complications. Inchildren, it is suggested that the most appropriate time forextraction is after the roots of permanent teeth havecompletely formed to minimize the risk of negatively affectingtooth development [7,15,17]. In addition to removal, surgicalmethods should also evaluate the involvement of adjacentstructures [11,14]. Common surgical techniques taketransnasal and transpalatal approaches [20]. Past cases,including this one, have utilized endoscopic extraction of nasalteeth which has been successful in children and adults[11,13,17]. Endoscopic extraction affords many advantagessuch as optimal visualization, good illumination, more precisedissection, and improved postoperative course [7,11,13,14]. Inthis case, as with other cases, patients have experienced fullrecovery with relief of their nasal obstruction[1,2,5,7,9,11-14,18]. Reoccurrence of aberrant teeth growth isuncommon [17].

Although ectopic teeth in the nasal cavity are rareoccurrences with few reports in the literature, they must beconsidered as a possible cause of nasal obstruction. Imagingand direct observation of the nasal mucosa are importantmodalities for diagnosis. Ectopic teeth may causecomplications like infection, but most patients respond well toextraction and heal without reoccurrence of pathology.

AcknowledgementsNo funding sources were utilized for this research.

Conflict of InterestThe authors have no conflicts of interest to disclose.

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