Snorting the clivus away: an extreme case of cocaine-induced midline destructive lesion

Abstract

Cocaine is a drug with relevant socioeconomic and clinical implications, which is usually recreationally used for its stimulant effects. It is widely known that the habit of snorting cocaine is associated with a peculiar type of drug-induced chronic rhinitis, which leads to inflammation of the sinonasal mucosa, slowly progressing to a destruction of nasal, palatal and pharyngeal tissues. These characteristic lesions due to cocaine abuse are commonly called cocaine-induced midline destructive lesions (CIMDL). Diagnosis is not always straightforward, since various conditions, mainly vasculitis, might mimic this acquired condition. The extent of pharyngeal involvement varies, although often a prolonged abuse can trigger a progressive destruction of oral and nasal tissues, with development of infections and recurrent inflammation. Our article focuses on cocaine as a world health problem with important ear, nose and throat implications and discusses the difficulties in diagnosing and treating CIMDL, through a case report.

Figure 1

Endoscopic image showing the patient's extensive cocaine-induced midline destructive lesion, with ubiquitous crusting and mucous secretions. Hard and soft palate are lacking, as well as nasal septum and inferior nasal conchae. Clivus exposition, with signs of necrosis and inflammation at its margins, can be seen posteriorly.

Figure 2

Sagittal image from a CT scan showing lack of bony nasal septum and palate (hard and soft parts). The rhinopharyngeal mucosa is eroded by prolonged cocaine abuse, with occipital bone clivus exposition.

Figure 3

Endoscopical view of the patient after treatment and extensive douches and toilettes: rhinopharyngeal anatomy remains subverted, but acute inflammation signs decreased along with an improvement in patient's general health condition.