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Preoperative lateral view of the same patient. The tip is cranially and dorsally retracted as a result of the collapsed nasal pyramid. Colletti et al. Comprehensive Surgical Management of CIMDL. J Oral Maxillofac Surg 2014.
Source publication
Purpose
This article presents a review of the literature and proposes a protocol for managing acute and chronic midfacial cocaine-induced injuries.
Materials and Methods
This report describes a series of 4 patients affected by cocaine-induced midline destructive lesions. Three patients came to the authors' attention after 18 months of drug withdra...
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Reconstruction of defects of the head and neck remains a challenge to the reconstructive surgeon. This is due to the complex anatomy of the region as well as the age and comorbidities of the patients, which prevent the use of free tissue transfer as the primary tool of reconstruction. The supraclavicular artery (SCA) island flap is a well vasculari...
Citations
... Te treatment is complex and must include both medical-surgical and psychological management, since before carrying out any action, it is essential to abandon the consumption of this substance [26]. ...
... Debridement of necrotic tissue, local dressings, and saline washing may prove useful, along with the use of antibiotics in patients with infectious processes such as sinusitis or rhinitis [26][27][28]. ...
Background. Cocaine is the second most consumed drug worldwide, more than 0.4% of the global population, and has become a real public health problem in recent years. Its inhalation causes significant centrofacial lesions, grouped under the name cocaine-induced midline destructive lesion (CIMDL). These destructions are due to the conjunction of the vasoconstrictor, local prothrombogenic effects, and cytotoxic effects of cocaine. The ischemia produced by this substance is due to vasoconstriction that leads to nasal tissue necrosis and perforation of the nasal septum secondary to chondral necrosis. Case Presentation. A 36-year-old man, previously grappling with cocaine addiction, was hospitalized to undergo comprehensive clinical, microbiological, and radiological examinations because he was suffering from the emergence of crusts and ulceration in the nasal mucosa, accompanied by a palate perforation, a 39°C fever, and chills. Standard bacteriological culture was positive for coagulase-negative staphylococci and Escherichia coli, while mycological culture was positive for Candida tropicalis. The CT scan images of the sinuses confirmed the presence of palatal perforation and total destruction of the nasal septum, cartilaginous portion, maxillary sinus medial wall, lower and middle turbinates, and middle meatus. Nasal endoscopy revealed an exposition of the bony wall and displayed the exposition of the occipital bone’s clivus. A diagnosis of CIMDL was confirmed. Antibiotic therapy was decided based on antibiogram results by the consulting microbiologist. Debridement of necrotic tissue was done by nasal endoscopy with local cleaning and was repetitive during the first week to maintain the best cleanliness possible. The patient was discharged with oro-nasal hygiene instructions and referred for prosthetic rehabilation. As for the cocaine addiction, the patient was in follow-up with a psychologist in a specialized centre. Conclusion. The care is multidisciplinary. Psychological help and assistance are essential to guide patients to become cocaine free and to avoid a relapse. Weaning is a prerequisite for surgery. Rehabilitation of speech and swallowing is necessary. Many local flaps or micro-anastomoses are possible.
... Recurrent infections with nasal microbes such as Staphylococcus aureus may occur and confirmation with culture and eradication with antibiotics may be needed because the sinonasal deformities predispose to recurrent sinusitis [58,80]. Reconstructive sinonasal surgery can be pursued in patients once abstinence is confirmed and sinonasal mucosa has healed [81]. Assistance with mental health or substance abuse programs should be pursued to help reduce recidivism and optimize outcomes [80]. ...
Introduction:
Vasculitis conditions are often serious and sometimes fatal diseases, therefore it is paramount to diagnose correctly and treat appropriately. Mimics of primary vasculitis can include either non-inflammatory syndromes or secondary vasculitis where the underlying etiology of the vasculitis is being driven by infection, malignancy, drug-effect or other.
Areas covered:
This review comprises six individual cases of vasculitis mimics. Each case is presented and the clinical, radiographic, and histological features that distinguish the case from primary vasculitis are highlighted. Key mimics in large, medium and small vessel vasculitis are outlined.
Expert opinion:
The diagnosis of vasculitis requires a comprehensive assessment of clinical, radiographic, and histologic features. Clinicians should be familiar with mimics of primary vasculitis conditions. In the case of non-inflammatory mimics, it is important to differentiate from primary vasculitides in order to avoid unnecessary and potentially harmful immunosuppression. For cases of secondary vasculitis, identification of the correct etiologic cause is critical because treatment of the underlying stimulus is necessary for successful management and outcomes.
... Cocaine hydrochloride salt is administered either via the intravenous route or by sniffing. The latter is known for causing various dire local side effects such as nasal congestion, rhinitis, epistaxis, erosion, nasal septal perforation, and oronasal communication, which is also known as cocaine fistula or cocaine-induced midline destructive lesions 2) . Many techniques and procedures have been described in literature for closing these defects such as turned over palatal flap, tongue flap, temporalis muscle flap, and radial forearm free flap with many disadvantages and a success rate that is quite unknown due to the scarcity of data, systematic reviews, and meta-analysis. ...
... Many techniques and procedures have been described in literature for closing these defects such as turned over palatal flap, tongue flap, temporalis muscle flap, and radial forearm free flap with many disadvantages and a success rate that is quite unknown due to the scarcity of data, systematic reviews, and meta-analysis. However, it has been established in literature that the closure of these defects is very frustrating and prone to high failure rates owing to the diminished blood supply of the surrounding local tissues 2) . This study aims to provide a new surgical protocol for management of cocaine fistula that is reliable and easy to perform and causes minimal donor site morbidity. ...
... In this case frequent relining will be required as the size of the defect grows. Obturators have been successful in improving speech and preventing food and liquid regurgitation into the nose 1,2,9,10) . On the other hand, the surgical reconstructive approach provides a definitive solution that can be performed with local, regional, or distant flaps. ...
Objectives: To present a new protocol for closure of cocaine fistulae using a combination of palatal flap delay and facial artery musculomucosal flap demonstrating its reliability for closing these challenging defects and its advantages compared to the other used techniques such as turned over palatal, tongue, temporalis muscle, and radial forearm free flaps.
Methods: Eight patients presenting with oronasal communication who admitted sniffing cocaine were treated using palatal flap delay in combination with facial artery musculomucosal flap after quitting cocaine abuse. All cases were followed up for a period of 12-18 months where healing pattern, signs and symptoms of breakdown, recurrence, or residual fistulae in addition to patient satisfaction using a visual analog scale were evaluated.
Results: All eight patients showed a very good healing pattern without any signs and symptoms of breakdown, recurrence, or residual fistulae. VAS assessment for patient satisfaction where 10 being the most satisfied showed that four patients reported score 10, three reported score 9, and one reported score 8.
Conclusions: The combination of palatal flap delay and FAMM flap is very reliable for cocaine fistulae closure.
... Cocaine, an alkaloid extracted from Erythroxylum coca plant leaves through a desiccation and maceration process [1], has been widely employed for decades for different purposes, ranging from local anesthesia to recreational use [2][3][4]. While it was first introduced in modern medicine by Koller in 1884 for its anesthetic and vasoconstrictive actions [5], its recreational use stems from its stimulating effect on the central nervous system [1]. ...
... This kind of self-administration, often coupled with chronic and compulsive use, results in repeated vasoconstrictions which may induce ischemia and subsequent necrosis of the mucosal lining of the nose. After repeated exposures, mucosal damage might be followed by nasal cartilaginous structures damage (e.g., the cartilaginous portion of the nasal septum, which is the most common localization of cocaine-induced lesion [4]) and bony structures damage (e.g., hard palate, maxillary bone, anterior skull base [4,7]). Furthermore, such chronic damage and facial midline structural support loss lead to external nose and facial middle third deformities and/or life-threatening infections [4,8,9]. ...
... This kind of self-administration, often coupled with chronic and compulsive use, results in repeated vasoconstrictions which may induce ischemia and subsequent necrosis of the mucosal lining of the nose. After repeated exposures, mucosal damage might be followed by nasal cartilaginous structures damage (e.g., the cartilaginous portion of the nasal septum, which is the most common localization of cocaine-induced lesion [4]) and bony structures damage (e.g., hard palate, maxillary bone, anterior skull base [4,7]). Furthermore, such chronic damage and facial midline structural support loss lead to external nose and facial middle third deformities and/or life-threatening infections [4,8,9]. ...
Purpose
Intranasal cocaine is known to potentially lead to midline destructive lesions. The present systematic review was undertaken to systematically define the localization of cocaine-induced midline destructive lesions and their prevalence and to propose a practical classification of these lesions.
Methods
A PRISMA-compliant systematic review was performed in multiple databases with criteria designed to include all studies published until March 2021 providing a precise definition of cocaine-induced midline lesions in humans. We selected all original studies except case reports. After duplicate removal, abstract and full-text selection, and quality assessment, we reviewed eligible articles for lesion localization, patients’ demographics, exposure to cocaine, and relationship with external nose destruction.
Results
Among 2593 unique citations, 17 studies were deemed eligible (127 patients). All studies were retrospective case series. The destructive process determined a septal perforation in 99.2% of patients. The distribution prevalence decreased from the inferior third of the sinonasal complex (nasal floor and inferolateral nasal wall, respectively, 59% and 29.9% of patients) to the middle third (middle turbinate and ethmoid, 22.8% of patients), and ultimately to neurocranial structures (7.9% of patients). Nasal deformities were inconsistently reported across reviewed studies. Cocaine use duration, frequency, and status were reported only occasionally.
Conclusion
Based on the distribution prevalence observed, we propose a four-grade destruction location-based classification. Future prospective studies following the evolution of cocaine-induced lesions are needed to validate our classification, its relationship with lesion evolution, and whether it represents a reliable tool for homogeneous research results reporting.
... Se realizó una selección de los artículos publicados entre enero de 1999 y diciembre de 2019 en las bases de datos PubMed, Cochrane y Google Schoolar. La búsqueda fue realizada en diciembre de 2019 utilizando el término cocaine junto con alguno de los términos: head and neck, neck, otorhinolaryngology, nasal, nasal cavity, paranasal, sinus, sinusitis, cartilage, nose, snorting, intranasal, palate, oral cavity, midline, midfacial, pharynx, [ 58 ] Rev. ORL, 2022, 13, 1, 55-70 nasopharynx, oropharynx, hypopharynx, larynx, glottis, throat, hearing loss, ear, otitis, vertigo, tongue, mediastinum, orbit o ulcer. ...
... El diagnóstico diferencial de la CIMDL es amplio y se debe hacer principalmente con lo que anteriormente se conocía como granuloma maligno de la línea media, e incluía la granulomatosis con poliangeitis y el linfoma de células NK/T, la sarcoidosis, infecciones (sífilis terciaria, tuberculosis, lepra, leishmaniasis o por hongos como es el caso de la actinomicosis o mucormicosis), policondritris recurrente, rinoscleroma, enfermedad relacionada con IgG4, esclerosis inflamatoria [ 60 ] Rev. ORL, 2022, 13, 1, 55-70 orbitaria idiopática o pseudotumor esclerosante orbitario [52][53][54][55][56][57][58][59][60]. ...
... Una revisión más amplia de Poon et al reveló una frecuencia similar de trombosis microvascular en casos de sospecha de levamisol tóxico: las biopsias mostraron únicamente patología trombótica en 14 de 22 casos (64%), características trombológicas y vasculíticas en 7 de 22 casos (32%), y únicamente vasculitis en solo 1 caso (4%) [62]. [ 61 ] Rev. ORL, 2022, 13, 1, [55][56][57][58][59][60][61][62][63][64][65][66][67][68][69][70] El tratamiento de las lesiones cutáneas inducidas por el consumo de cocaína adulterada con levamisol va a depender de la gravedad del cuadro. El cese del consumo de cocaína es fundamental para la resolución de las lesiones; ya que en muchas ocasiones el cuadro cede únicamente con estas medidas [36][37][38]93] y reaparece o se exacerba tras un nuevo consumo [62]. ...
Introducción y objetivo: El consumo de cocaína se ha asociado a patología a múltiples niveles, pero ésta es especialmente relevante a nivel de cabeza y cuello, por ser la vía intranasal una de sus más frecuentes vías de consumo. Este trabajo describe las principales manifestaciones clínicas del consumo de cocaína en el área otorrinolaringológica, y se analizan algunos de los diagnósticos diferenciales que se han de descartar. Método: Se realizó una revisión bibliográfica vía, PubMed, Cochrane y Google Schoolar con artículos publicados entre 1999 y 2019 con la palabra cocaine junto con diferentes términos de búsqueda, siguiendo los criterios PRISMA para la selección de artículos. Resultados: La búsqueda inicial redujo los artículos a 641, finalizando la selección en 63 artículos, a los cuales se añadieron otros 66 desde otras fuentes. Finalmente, 129 artículos fueron incluidos en la presente revisión sistemática. Conclusiones: La necrosis de la línea media y la perforación septal son las manifestaciones más frecuentemente descritas asociadas al abuso de cocaína. Sin embargo, esta sustancia puede originar otras muchas lesiones en cabeza y cuello, generalmente de difícil diagnóstico, sobre todo cuando el paciente niega el abuso de sustancias.
... CIMDL are often overlooked in clinical practise, particularly if a history of cocaine inhalation is not sought or volunteered. Although several reconstructive procedures or maxillary obturator prosthesis have been proposed to repair palatal defects, the best therapeutic choice is still a matter of discussion [10,[14][15][16][17][18][19][20]. ...
The prolonged use of intranasal cocaine can destroy the nasal architecture with the erosion of the palate, turbinates, and ethmoid sinuses causing cocaine-induced midline lesions (CIMDL). The CIMDL display a clinical pattern mimicking variable diseases. The aim of this study was to highlight the difficulties in reaching a correct diagnosis through the evaluation of eight new cases. The diagnostic procedures followed in these patients included: detailed medical history, clinical and histological examination, computed tomography and magnetic resonance imaging, laboratory findings (complete blood count, sedimentation rate, antinuclear antibody test, rheumatoid factor, venereal disease research laboratory test, leishmaniasis and fungal serology, antineutrophil cytoplasmic antibodies ANCA test), and chest X-ray. All patients complained of epistaxis, halitosis, nasal scabs and obstruction, decreased sense of smell and/or taste, oro-nasal regurgitation of solids and liquids with recurrent sinus infections, and chronic facial pain. On clinical examination, all patients showed palate perforation with variable nasal structure involvement and presented a strong positivity for ANCA tests with a p-ANCA pattern. The followed protocol for the CIMDL diagnosis allowed for a relatively quick and conclusive diagnosis in all patients. A multidisciplinary approach is mandatory in the management of CIMDL, involving dental professionals, maxillofacial surgeons, and psychologists.
... Cocaine is known to cause necrosis of the soft tissues secondary to its vasoconstrictive effects, which has negative functional and cosmetic outcomes of the midface and adjacent structures. 1 This necrosis can lead to nasal collapse and central midface destruction, commonly involving the nasal septum, lateral nasal wall, and/or hard palate. [2][3][4][5] To our knowledge, there are no reports of acquired cleft lip from cocaine abuse. We report a case of intranasal cocaine use causing a cleft lip deformity, and successful reconstruction with a modified Millard technique. ...
... Nasal collapse, septal perforation, and palatal erosion have been well documented in the literature. [1][2][3][4][5][6][7] In this case, cocaine use led not only to a palate fistula but also to a cleft lip deformity over time. To our knowledge, there are no reports of acquired cleft lip from cocaine abuse. ...
... Some groups advocate a strict period of drug abstinence of at least 18 months prior to pursuing surgery. 4 This patient developed a chronic nasolabial fistula postoperatively, which was not repaired because of its asymptomatic nature. However, given the robust and stable state of this patient's surgical site, safe repair is thought to be feasible in the future, although care must be taken not to devascularize the tissue. ...
Introduction:
Cocaine is known to cause necrosis of the soft tissues secondary to its vasoconstrictive effects, which has negative functional and cosmetic outcomes of the midface and adjacent structures. To our knowledge, cleft lip caused by cocaine use has not been described in the literature.
Case presentation:
A 52-year-old man presented with a deformity of the lip and nasal sill, septal perforation, and hard palate fistula secondary to long-term cocaine use. The patient underwent lip reconstruction using a modified Millard technique and had a lasting favorable cosmetic outcome more than 5 years after surgery.
Discussion:
We report a case of cocaine abuse causing cleft lip, and successful reconstruction with a modified Millard technique.
... Of the total sample, 61.16% (n = 74) reported use of cocaine, while 55.37% (n = 67) used crack and 28.18% (n = 31) reported the use of both substances ( Table 2). The median total abstinence time, without the use of any substance, was 9 days (IQ [5][6][7][8][9][10][11][12][13][14][15][16][17][18][19][20][21][22]. Regarding the use of other drugs, cocaine users reported only the use of alcohol more often than crack users, followed by the use of alcohol and tobacco. ...
... This study [16] did not present data on the duration of use of the substances in relation to the presence of dysphagia. However, other studies [18,19], carried out in Italy and Spain, report users with symptoms of dysphagia who used cocaine and/ or crack for more than 5 years, as observed in the data of the present study. Thus, it is possible to infer that the chance of presenting symptoms of dysphagia is greater in chronic use of cocaine and crack than in acute use. ...
The original version of this article unfortunately contained a mistake. The spelling of the Sheila Taminini de Almeida name was incorrect.
... Of the total sample, 61.16% (n = 74) reported use of cocaine, while 55.37% (n = 67) used crack and 28.18% (n = 31) reported the use of both substances ( Table 2). The median total abstinence time, without the use of any substance, was 9 days (IQ [5][6][7][8][9][10][11][12][13][14][15][16][17][18][19][20][21][22]. Regarding the use of other drugs, cocaine users reported only the use of alcohol more often than crack users, followed by the use of alcohol and tobacco. ...
... This study [16] did not present data on the duration of use of the substances in relation to the presence of dysphagia. However, other studies [18,19], carried out in Italy and Spain, report users with symptoms of dysphagia who used cocaine and/ or crack for more than 5 years, as observed in the data of the present study. Thus, it is possible to infer that the chance of presenting symptoms of dysphagia is greater in chronic use of cocaine and crack than in acute use. ...
Users of cocaine and/or crack may present symptoms of dysphagia due to changes in anatomical structures caused by the use of these substances. The objective of this study was to investigate the presence of symptoms suggestive of dysphagia in users of cocaine and/or crack seeking treatment, as well as to investigate the quality of life of these individuals related to their swallowing condition. A cross-sectional study from September 2015 to December 2016, with 121 users of cocaine and/or crack, was conducted. 59 of them called a telemarketing service and 61 sought treatment at the Centro de Atenção Psicossocial Álcool e Drogas in Porto Alegre (Psychosocial Alcohol and Drug Center). Users were screened and asked to fill the Eating Assessment Tool questionnaire. Users who presented themselves at the center were submitted to the Tool Volume-Viscosity Swallow Test. Users with symptoms of dysphagia responded to the Quality of Life in Swallowing questionnaire. Of all the interviewees, 22.3% (n = 27) reported symptoms suggestive of dysphagia and 2% of the individuals, submitted to swallowing test, presented cough in the liquid consistency. The scores showed a negative impact on quality of life, mainly related to fatigue, sleep, feeding duration, and fear of eating. Significant numbers of users of cocaine and/or crack referred to symptoms suggestive of dysphagia and significant impairments in quality of life, which require specific care in feeding this population in order to assist in their rehabilitation.
... The mechanism may be related to chronic inflammatory process and immunosuppression. 4,9,11 Given the prevalence of narcotics or cocaine abuse, it is likely VPD from intranasal substance abuse is underreported. The social and communication consequence of VPD can be significant. ...
Objective
Intranasal substance abuse with cocaine or opioids can result in complications involving the midline nasal and oral structures. When the defect involves the velopharyngeal musculature, this leads to velopharyngeal dysfunction (VPD). This article aims to illustrate this clinical entity through a series of four patients and a review of the literature.
Methods
A series of four cases of VPD due to intranasal narcotic use and their management are discussed. A comprehensive search in PubMed was conducted for cases of VPD associated with intranasal drug use in the English‐language literature.
Results
Four female patients presented with symptoms of VPD, including worsening nasal regurgitation, poor speech intelligibility, and hypernasal speech. One patient presented with nasopharyngeal stenosis. All patients admitted to intranasal cocaine, methamphetamine, and/or prescription narcotics use prior to the onset of symptoms. The diagnosis was confirmed with abnormal velopharyngeal musculature seen on nasopharyngoscopy. Both conservative and surgical treatment options were proposed. A literature review identified nine cases of VPD. Erosion of the velum was seen in all cases. Reported treatments included obturator prosthetic, local flap, and free flap. Ancillary investigations were not consistently pursued to rule out other etiologies to VPD.
Conclusion
Intranasal illicit drug use can result in destructive changes leading to VPD. This is the largest case series to date of this difficult clinical problem. Management principles including options for conservative and surgical interventions are summarized.
Level of Evidence
4. Laryngoscope, 2018
