COCAINE-INDUCED MIDLINE DESTRUCTIVE LESIONS: TWO CASE REPORTS

Abstract

BACKGROUNDChronic cocaine insufflation contributes to progressive damage of the sino-nasal mucosa. This is primarily attributed to the potent vasoconstrictive properties of cocaine, producing ischemic necrosis. In a small percentage of cocaine abusers, these damages culminate in the destruction of osteocartilagenous structures of the nasal cavity. The most common manifestations are nasal septal perforation, palatal perforation, and lateral nasal wall destruction involving the nasal turbinates. When at least 2 of these manifestations are detected, the diagnosis of a cocaine-induced midline destructive lesion (CIMDL) should be considered in the potential etiology.CASE REPORTMost CIMDL lesions are asymptomatic, limited in extent, and incidentally detected. We present 2 cases of asymptomatic CIMDLs first recognized as incidental findings on cone beam computed tomography (CBCT) scans. Both cases presented with nasal septal perforation and varying degrees of lateral wall erosion of the nasal turbinates. The medical histories did not include prior surgeries or pathologic conditions that could account for these midline lesions. On further inquiry, the patients admitted to chronic recreational use of cocaine.DISCUSSION/CONCLUSIONSThe radiologic appearance of CIMDL mimics granulomatosis with polyangiitis. In granulomatosis with polyangiitis, sino-nasal symptoms are present in almost all affected individuals and are often the first manifestations of the disease. Moreover, soft tissue nodules often accompany any osseocartilaginous destruction. Other inflammatory diseases, infectious diseases, and neoplasms may also have similar manifestations. Therefore, attributing midline destructive lesions to cocaine use is challenging yet paramount given the variety of possible etiologies and the potential implications for patient care. However, patients are often reluctant to disclose a history of recreational drug use. The disclosure of cocaine use is essential to establish the correct diagnosis and to avoid unnecessary or inappropriate diagnostic testing. Nevertheless, in the absence of cocaine use, a thorough medical examination and appropriate laboratory tests will be necessary to rule out other etiologies. Chronic cocaine insufflation contributes to progressive damage of the sino-nasal mucosa. This is primarily attributed to the potent vasoconstrictive properties of cocaine, producing ischemic necrosis. In a small percentage of cocaine abusers, these damages culminate in the destruction of osteocartilagenous structures of the nasal cavity. The most common manifestations are nasal septal perforation, palatal perforation, and lateral nasal wall destruction involving the nasal turbinates. When at least 2 of these manifestations are detected, the diagnosis of a cocaine-induced midline destructive lesion (CIMDL) should be considered in the potential etiology. Most CIMDL lesions are asymptomatic, limited in extent, and incidentally detected. We present 2 cases of asymptomatic CIMDLs first recognized as incidental findings on cone beam computed tomography (CBCT) scans. Both cases presented with nasal septal perforation and varying degrees of lateral wall erosion of the nasal turbinates. The medical histories did not include prior surgeries or pathologic conditions that could account for these midline lesions. On further inquiry, the patients admitted to chronic recreational use of cocaine. The radiologic appearance of CIMDL mimics granulomatosis with polyangiitis. In granulomatosis with polyangiitis, sino-nasal symptoms are present in almost all affected individuals and are often the first manifestations of the disease. Moreover, soft tissue nodules often accompany any osseocartilaginous destruction. Other inflammatory diseases, infectious diseases, and neoplasms may also have similar manifestations. Therefore, attributing midline destructive lesions to cocaine use is challenging yet paramount given the variety of possible etiologies and the potential implications for patient care. However, patients are often reluctant to disclose a history of recreational drug use. The disclosure of cocaine use is essential to establish the correct diagnosis and to avoid unnecessary or inappropriate diagnostic testing. Nevertheless, in the absence of cocaine use, a thorough medical examination and appropriate laboratory tests will be necessary to rule out other etiologies.