Rhinolithiasis is an uncommon and frequently overlooked cause of unilateral nasal symptoms, often mimicking chronic rhinosinusitis (CRS) and leading to delayed diagnosis. We present a case of a female factory worker with a 2-year history of persistent unilateral rhinorrhea, nasal obstruction, and progressive sinonasal symptoms, resulting in significant impairment in quality of life. She initially presented with a foul-smelling, blood-tinged nasal discharge that was refractory to multiple courses of medical therapy, including intranasal corticosteroids, saline irrigation, and antibiotics. Nasal endoscopy eventually revealed a hard, yellowish intranasal mass occupying the left nasal cavity. Computed tomography demonstrated a densely calcified lesion within the left nasal cavity consistent with a rhinolith, with associated mucosal disease in adjacent sinuses. Despite continue medical management, symptom burden remained high, with only minimal improvement of Sinonasal Outcome Test (SNOT-22) scores (94 to 75), underscoring the limitations of medical therapy in such cases. The patient was subsequently planned for definitive surgical management via endoscopic excision of the rhinolith. This case underscores the importance of maintaining a high index of suspicion for rhinolithiasis in patients presenting with unilateral, foul-smelling nasal discharge unresponsive to standard CRS treatment. Early endoscopic evaluation and imaging are critical to prevent prolonged morbidity, avoid unnecessary medical therapy, and facilitate timely, definitive intervention.

Dr Nelson Lacsamana Jr. is a third-year resident in Otorhinolaryngology-Head and Neck Surgery at the University of the Philippines-Philippine General Hospital. His clinical interests include head and neck oncology and rhinology, with research focused on thyroid and sinonasal diseases.