Abstract
A young adult female originally presented with necrosis of the nasal cavity mucosa and septum after sniffing crushed acetaminophen. She underwent endoscopic sinus surgery and debridement but continued to use acetaminophen intranasally. Four months later, the destruction had extended to include the posterior pharyngeal wall and subglottis. The diagnosis was confirmed by polarizable talc found on biopsy of the subglottis. While nasal insufflation of cocaine and hydrocodone-acetaminophen has been well-documented, intranasal abuse of exclusively acetaminophen is not well understood. This case demonstrates the destructive potential of intranasal acetaminophen use and may help physicians recognize unusual signs and symptoms of intranasal drug abuse.
Highlights
Nasal insufflation has long been associated with abuse of cocaine and more recently, prescription narcotics
When these medications are abused via nasal insufflation, there is a well-documented history of necrosis of the nasal septum, soft palate, and hard palate
In addition to being a rare documented case of acetaminophen abuse, this case report is unique in the extent of damage, with necrosis and talc expanding into the subglottic region
Summary
Nasal insufflation has long been associated with abuse of cocaine and more recently, prescription narcotics. A young adult female with a history of chronic pain, multi-substance abuse, and obsessivecompulsive disorder originally presented with a history of necrosis of her nasal septum with chronic crusting for greater than six months She reported symptoms consistent with Eustachian tube dysfunction, but no hearing loss. Diffuse erosive damage was observed along the nasal mucosa with crusted pill debris and blood occluding the choanae and middle meatus At this time, the patient was taken to the operating room for endoscopic sinus surgery including bilateral maxillary antrostomy, total ethmoidectomies, and sphenoidotomies. A) 100x magnification of hematoxylin and eosin stained slide showing ulcerated mucosa (white line) and refractile pill material (red arrowhead); B) 100x magnification slide with polarized light highlighting talc fragments from pill remnants She presented to the office four months later with continued postnasal drip, nasal crusting, and eustachian tube dysfunction with a normal audiogram. The patient restarted intranasal acetaminophen use and requires regular in-office nasal debridement, and continues to have some pharyngeal discomfort as well as vocal strain
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