Oral Rehabilitation for a Patient with Cocaine-Induced Midline Destructive Lesions

Abstract

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.

Figure 1

Typical saddle-nose deformities with columellar retraction and nasal collapse.

Figure 2

Complete edentulous maxilla with an oro-nasal-antral communication.

Figure 3

The panoramic X-ray reveals a complete edentulous maxilla with a radiolucent image of the nasal cavity and maxillary sinuses showing nasal destruction with sinus communication.

Figure 4

Axial CT scan image showing the necrosis of the osseo-cartilagineous of the nasal septum and turbinate, and the destruction of the nasal wall of the left maxillary sinus and the sinus membrane of the right maxillary membrane is very thick and hypertrophied.

Figure 5

Coronal section of the CT scan revealed a wide erosion of midline structures, the absence of the nasal septum, and partial disappearance of the turbinates. Note the palatal perforation that establishes an oronasal communication.

Figure 6

The sagittal images of the CT scan revealed bony and cartilaginous destruction of the nasal septum and the palate. The rhinopharyngeal mucosa is eroded with occipital bone clivus exposition.

Figure 7

(a) Lateral views of the finished and polished prosthesis obturator. (b) Prosthesis obturator inserted intraorally.