Twenty-nine years of silence: a rare case report of long-term retained nasal coin presenting as rhinolithiasis in adulthood

Introduction

Foreign bodies (FBs) lodged in the nasal cavity commonly appear in pediatric practice, yet cases persisting into adulthood remain rare (1,2). Nasal FBs retained over extended periods often provoke chronic inflammatory reactions, tissue necrosis, and granulation tissue formation, which subsequently lead to rhinolith formation, particularly when involving metallic objects (3). A rhinolith arises from gradual deposition of mineral salts as mineral salts-like calcium carbonate and phosphate-slowly coat the retained item or surrounding mucus, yielding symptoms that range from airway blockage and discharge to nosebleeds and an unpleasant smell (4). Meanwhile, metallic fragments pose additional complications through corrosion and oxidative degradation, that further irritate the mucosa and heighten swelling, pain, and purulent discharge (5,6).

Delayed diagnosis usually stems from vague symptoms, embarrassment, or a provider’s oversight, making management significantly harder because granulomatous changes and lithiasis may advance unnoticed (7). Clinicians face added difficulty when patients defer care, imaging studies are scarce, or findings are wrongly attributed to chronic rhinosinusitis or allergic rhinitis (8).

Although computed tomography (CT) scans yield an exhaustive view of nasal and paranasal structures, plain X-ray remains pragmatic in situations where patients decline further radiation exposure (8). Definitive treatment for deeply lodged or corrosion-causing nasal FBs generally involves endoscopic surgery performed under general anesthesia, a strategy that effectively resolves the symptoms and prevents further complications such as septal perforation and chronic sinusitis (9).

This case report documents an exceptionally rare case of a metallic FB retained in the nasal cavity for almost three decades, drawing attention to its peculiar diagnostic, therapeutic, and psychological facets. This account underscores the critical importance of maintaining clinical vigilance for prolonged nasal FB retention in adults presenting with chronic unilateral nasal symptoms, emphasizing timely diagnosis, appropriate psychological counseling, and definitive surgical management. We present this case in accordance with the CARE reporting checklist (available at https://acr.amegroups.com/article/view/10.21037/acr-2025-180/rc).

Case presentation

A 35-year-old male presented to outpatient clinic with complaints of ongoing drainage from his left nostril that had steadily increased over the past year. He described the fluid as initially dark yellow and metallic in smell, but it later became dark brown and flowed so freely that he often had to pack his nostrils with tissue or gauze. The day before his visit, he noted a rose-colored streak in the discharge, and that change finally drove him to seek medical attention. When he was six years old, the patient reported that he pushed a penny (1 cent coin) into his left nostril. He does not recall his immediate reaction, but it is certain he did not inform his parents. The coin went unnoticed and caused no symptoms for several years, and eventually he completely forgot the incident. There was no notable family medical history, and he reported no history of nasal trauma, nasal surgery, or identified allergies. Socially, he is independent, with no smoking, alcohol, or drug use. Regarding psychosocial background, he tends to rely on avoidance-oriented coping, especially when confronted with medical issues.

Clinical findings

When presented to the clinic visit, an anterior rhinoscopic examination was performed and revealed limited visualization, as the suspected object appeared lodged far back behind the inferior turbinate on the left nasal cavity. Because of the restricted view, anterior and lateral head X-rays were ordered. X-ray showed the lodged coin, and the patient was urgently referred to the ear, nose and throat (ENT) clinic as a suspected case of rhinolith.

Timeline of symptoms

The progression of symptoms is illustrated in Figure 1 and Table 1 shows detailed description of complaints and actions.

Figure 1 Showing timeline of previous complaints and actions taken by the patient. OTC, over-the-counter.

Diagnostic assessment

Anterior and lateral head X-ray was ordered. In current practice, non-contrast CT is preferred for persistent unilateral sinonasal symptoms; radiographs were used here as an immediately available adjunct for a suspected radiopaque coin. Skull X-rays revealed a sharply defined, 17-mm radio-opaque object lodged in the left posterior nasal cavity. Adjacent bones remained intact, paranasal sinuses looked clear except for minimal mucosal thickening in the left maxillary sinus, and no additional FBs or fractures were seen. Figure 2 illustrates frontal and lateral skull X-rays.

Figure 2 Frontal and lateral skull X-rays. (A) Occipitomental (Waters) view. (B) Left lateral view. (C) Right lateral view.

Therapeutic intervention

The first attempt to extract the FB in the clinic failed because the object was fragile and broke apart; it was later identified as a corroded coin. Because the coin had been lodged for so long and was so brittle, the team decided to remove it surgically under general anesthesia. The patient voiced considerable anxiety about the procedure, admitting that his long-standing fear of surgery had delayed his visit for treatment. After a detailed discussion of the possible risks and benefits, he gave informed consent. The operation was booked for the next day. In the operative room, nasal endoscopy showed a large, calcified, round metallic FB impacted posterior to the inferior turbinate in the left nasal cavity as shown in Figure 3A. The object appeared blackened and corroded, partially covered in thick granulation tissue, and surrounded by purulent debris. The granulation tissue was dissected, and the coin was freed. On manipulation and dissection, the coin was fragile and fragmented easily into small pieces; with tiny pieces suctioned and the FB was salvaged in six pieces. After complete removal, endoscopic inspection showed edematous mucosa with raw areas at the impaction site as shown in Figure 3B; oozing was controlled with suction cautery, and a hemostatic matrix (Surgiflo) was applied to cover the injured surface. Figure 4 shows the six salvaged fragments.

Figure 3 Intraoperative endoscopic view. (A) The impacted coin lodged within the nasal cavity. (B) After foreign body removal and ablation, before applying Surgiflo hemostatic matrix.

Figure 4 Retrieved fragments of the degraded coin following surgical removal from the left nasal cavity. A total of six pieces were salvaged.

Follow-up and outcomes

The patient was followed postoperatively at 1, 4, 8, and 16 weeks. The recovery course was uneventful, with complete resolution of presenting symptoms. Nasoendoscopic evaluations were performed at each follow-up visit, consistently demonstrating healthy-appearing nasal mucosa without evidence of recurrence or complications.

All procedures performed in this study were in accordance with the ethical standards of the institutional and/or national research committee(s) and with the Declaration of Helsinki and its subsequent amendments. Written informed consent was obtained from the patient for publication of this case report and accompanying images. A copy of the written consent is available for review by the editorial office of this journal.

Discussion

The literature demonstrates considerable variation in retention duration, ranging from 5 (10) to 50 years (11), with metallic objects showing particular propensity for prolonged retention without significant symptoms. Bahranifad et al. (12) reported a 22-year-old female with an 18-year retention of calcified cotton vegetation, while the Turkish case series documented a 63-year-old male with a bullet retained for over 50 years (11). A pediatric case report from Tanzania described an 11-year retention period in a 12-year-old patient (13), highlighting that prolonged retention can occur across all age groups. Collectively, published cases indicate that FBs can remain asymptomatic for decades, with symptoms often manifesting only when complications develop or the object begins to deteriorate.

Long-term nasal FB retention involves complex inflammatory processes leading to rhinolith formation through mineral salt deposition. Research indicates that calcium carbonate, magnesium phosphate, and other mineral salts gradually coat retained objects, with the composition varying based on individual nasal secretion chemistry (14). Previous research analyzing rhinolith composition revealed calcium carbonate and magnesium phosphate in six patients, magnesium carbonate and magnesium phosphate in three patients, and various combinations of calcium and magnesium compounds in others (14). The formation is accelerated by factors including concomitant sinusitis, allergic rhinitis, and individual variations in secretion mineral content (15).

Metallic FBs present unique challenges due to corrosion processes that create additional inflammatory responses. Button battery cases demonstrate the most severe tissue damage through electrochemical processes, generating corrosive hydroxides and causing thermal burns, while inert metallic objects like coins typically cause mechanical irritation and serve as nuclei for mineral deposition (16,17).

The clinical presentation of long-term nasal FBs follows predictable patterns, with unilateral purulent discharge being the most common symptom across all reported cases (11,12,18). The progression typically involves initial asymptomatic periods lasting years to decades, followed by gradual onset of symptoms including metallic odor, color changes in discharge, and eventual bloody discharge (19,20). The presented case’s timeline mirrors this pattern, with 29 years of asymptomatic retention followed by progressive symptom development over one year.

Hulse et al. (10) described a 15-year-old patient with 5-year symptom duration, presenting with left-sided nasal obstruction and foul-smelling discharge, while a 63-year-old man with a retained bullet for over 50 years was reported to be asymptomatic until late presentation (11). The pediatric rhinolith case from Tanzania presented with the pathognomonic sign of house flies following the patient due to foul-smelling discharge, emphasizing the characteristic odor associated with these conditions (13).

Diagnostic challenges and imaging characteristics

Diagnostic challenges are consistent across literature, with misdiagnosis being a recurring theme in long-term retention cases (12,20,21). Multiple studies report patients being treated for chronic rhinosinusitis, allergic rhinitis, or recurrent viral infections for years before accurate diagnosis. The 25-year surgical blade retention case was discovered only when the object pierced through the skin, highlighting how these FBs can remain completely hidden from routine examination (22).

Surgical management and outcomes

Endoscopic removal under general anesthesia represents the gold standard for long-term retained FBs, with success rates approaching 100% when appropriate surgical planning is employed (11,12,23). The surgical approach varies based on object location, size, type and degree of granulation tissue formation. Cases involving extensive granulation tissue or object fragmentation, as seen in the presented case and the corroded coin examples, require meticulous dissection and complete fragment removal to prevent recurrence (20).

A case involving a glass fragment retained for approximately 30 years required comprehensive surgical intervention including polypectomy, fungal removal, and turbinate conchoplasty due to extensive secondary complications (24). In contrast, several reports were amenable to direct endoscopic extraction, emphasizing the importance of individualized surgical planning based on complications and object characteristics.

Reported short-term postoperative outcomes are generally favorable when complete removal is achieved, with immediate symptom resolution and no reported recurrences in the literature (11,12,20). The Turkish bullet case reported complete symptom resolution with no complications at follow-up, while the cotton vegetation case showed complete healing within one month (11,12).

Complications

Long-term complications vary significantly based on FB type, location, and individual host factors. The literature documents complications ranging from simple mucosal irritation to severe complications including septal perforation, chronic sinusitis, fungal infections, and anatomical deformities (11,25). The 30-year glass fragment case developed multiple complications including chronic sinusitis, nasal polyps, and fungal infection, requiring comprehensive surgical management beyond simple FB removal (20).

Button battery cases represent the most severe complication spectrum, with reported cases of septal perforation, nasal adhesions, and saddle nose deformity occurring within months of retention. These cases contrast sharply with inert metallic objects that can remain relatively benign for decades before causing significant complications as seen in the current case (26).

Clinical implications

The comparative analysis of long-term nasal FB patients provides essential insights for therapeutic management that transcend individual case presentations. The occurrence of extended asymptomatic intervals succeeded by abrupt symptom emergence constitutes a significant therapeutic concern. Healthcare practitioners must acknowledge that the absence of symptoms does not preclude the existence of retained FBs, and that the emergence of symptoms frequently correlates with the degradation of the item or the onset of secondary problems, rather than the initial retention incident. This comprehension should guide clinical decision-making in the assessment of patients with chronic rhinosinusitis unresponsive to standard treatment modalities.

These criteria indicate that effective management necessitates not just surgical proficiency but also psychological evaluation and counseling to mitigate fundamental obstacles to healthcare access. This research indicates that healthcare systems ought to formulate specialized strategies for managing patients exhibiting protracted concealing behaviors, including psychological support services and adapted communication techniques that mitigate stigma and promote earlier engagement.

The diagnostic issues regularly documented in the literature indicate that existing diagnostic techniques may be insufficient for detecting long-term persistent FBs. The common misdiagnosis of chronic rhinosinusitis or allergic rhinitis shows that we need to be more systematic when figuring out what is wrong with those who have chronic one-sided nasal symptoms.

The surgical outcomes across the reviewed cases demonstrate the importance of careful preoperative planning and technique selection based on FB characteristics and complications. Cases involving corroded or fragmented objects require specialized approaches that anticipate object fragility and plan for complete fragment retrieval. The successful outcomes reported across all cases suggest that endoscopic techniques under general anesthesia provide optimal visualization and control for these complex procedures. This approach requires multidisciplinary expertise and careful patient counseling regarding potential complications and outcomes.

Recommendations

Long-term functional and quality-of-life outcomes are insufficiently studied; therefore, conclusions about durability should be cautious until longitudinal data are available. Research into optimal surgical techniques for heavily corroded or fragmented FBs could improve outcomes and reduce complications. The development of clinical prediction tools to identify patients at risk for prolonged retention could facilitate earlier intervention and prevent complications.

Patient perspective

Initially, I felt hesitant and anxious about my condition. I delayed seeking treatment for so long that I nearly forgot about the foreign body in my nose. Once I finally decided to seek help, I was relieved to have clear communication with my healthcare team. The preoperative counseling I received helped ease my fears and gave me the confidence to move forward with the surgery.

Conclusions

This case highlights the essential necessity of sustaining a heightened index of suspicion for long-retained nasal FBs, even in adult patients with ambiguous or persistent unilateral nasal symptoms. When they do, they can cause serious problems like foul discharge, granulation tissue formation, and rhinolithiasis. Early imaging, particularly plain X-rays, can provide significant diagnostic insights, especially when endoscopic viewing is restricted. The best way to deal with deeply embedded or rusted objects is to surgically remove them while the person is under general anesthesia. Timely detection and care not only avert additional consequences such as chronic sinusitis and mucosal damage but also offer psychological alleviation for the sufferer.

Acknowledgments

We would like to express our sincere gratitude to Dr. Abdullah Alsalamah, who provided valuable care during the patient’s last follow-up. Special thanks also go to Mr. Ahmed Alenazi, the operating room coordinator, for consistently reviewing preoperative instructions with the patient and ensuring proper preparation for the surgical procedure. We also acknowledge Ms. Budoor Almuqaybl from the nursing staff clinic for her dedicated support throughout the patient’s care. Their collective efforts and commitment were integral to the successful management of this case.

Footnote

Reporting Checklist: The authors have completed the CARE reporting checklist. Available at https://acr.amegroups.com/article/view/10.21037/acr-2025-180/rc

Peer Review File: Available at https://acr.amegroups.com/article/view/10.21037/acr-2025-180/prf

Funding: None.

Conflicts of Interest: All authors have completed the ICMJE uniform disclosure form (available at https://acr.amegroups.com/article/view/10.21037/acr-2025-180/coif). The authors have no conflicts of interest to declare.

Ethical Statement: The authors are accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved. All procedures performed in this study were in accordance with the ethical standards of the institutional and/or national research committee(s) and with the Declaration of Helsinki and its subsequent amendments. Written informed consent was obtained from the patient for the publication of this case report and accompanying images. A copy of the written consent is available for review by the editorial office of this journal.

Open Access Statement: This is an Open Access article distributed in accordance with the Creative Commons Attribution-NonCommercial-NoDerivs 4.0 International License (CC BY-NC-ND 4.0), which permits the non-commercial replication and distribution of the article with the strict proviso that no changes or edits are made and the original work is properly cited (including links to both the formal publication through the relevant DOI and the license). See: https://creativecommons.org/licenses/by-nc-nd/4.0/.

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