Palatal and Nasal Necrosis from Cocaine Use (PDF)

IN BRIEF PRACTICE  Nasal inhalation of cocaine (‘snorting’) can have severe destructive effects on the nasal and palatal tissues.  The commonest causes of naso-palatal fi...

IN BRIEF PRACTICE  Nasal inhalation of cocaine (‘snorting’) can have severe destructive effects on the nasal and palatal tissues.  The commonest causes of naso-palatal fistula are trauma, tumour, Wegener’s granulomatosis and syphilitic gumma.  Palatal defects can be repaired using a variety of techniques. Palatal and nasal necrosis resulting from cocaine misuse N. M. Goodger,1 J. Wang2 and M. A. Pogrel3 The potential social and economic harm caused by cocaine addiction is well known. The wider health risks and potential nasal complications of septal perforation and nasal collapse are also recognised. We report a case of oro-nasal fistula secondary to cocaine misuse and discuss the aetiology, management and potential methods of repair. INTRODUCTION CASE REPORT wore a removable obturator. Microbiolo- Cocaine is an alkaloid, which was original- A 43-year-old Caucasian female presented gy, histopathology and serological exami- ly used by South American Indians as a with a 3 cm by 1.5 cm oro-nasal commu- nation showed only necrotic bone and stimulant. It was introduced to medicine nication coupled with destruction of the soft tissue with no other pathology. The by Köller in the 1880s as a local anaesthet- nasal septum and lateral walls of the nose patient was advised of the diagnosis and ic. More recently, its stimulant effects have (Fig 1). She gave a five year history of informed that further cocaine use would led to its use as a recreational drug result- nasal cocaine usage, initially at a frequen- result in progression of the defect and pre- ing in social, economic and physical harm. cy of two to three times a month but devel- vent successful closure of the fistula. In Oral intake of cocaine may result in anaes- oping into a daily habit 18 months prior to order to monitor the compliance with this thesia of the tongue or gingiva. Inhalation presentation. The patient reported that advice, the patient was followed up for six of cocaine (snorting) has been associated she had always snorted through the left months after the initial debridement. At with epistaxis, chronic rhinitis, nasal sep- nostril. the end of this period the defect was tal perforation and destruction of the lat- Her initial symptoms were some thick- observed to be static in size with healthy eral nasal walls which may lead to the sad- ening of the left nasal sill, and this was fol- soft tissue margins and no evidence of dle nose deformity.1 Reduction in the sense lowed by a nasal septal perforation. The necrosis or bony sequestrum. Definitive of smell, nasopharyngeal ulceration and oro-nasal fistula developed as a small hole reconstruction was therefore undertaken dysphonia have also been described. How- approximately three years prior to presen- using an anteriorly based lateral tongue ever, the appearance of a large oro-nasal tation and had gradually increased in size. flap to repair the defect after freshening of perforation in addition to destruction of She had chronic drainage from the com- the wound edges. The patient was placed the septum and lateral walls of the nose munication and had been intermittently in intermaxillary fixation at the end of the has only rarely been reported. prescribed penicillin and clindamycin over procedure to safeguard the repair. The the preceding six months. She denied pedicle was divided under general anaes- cocaine use in the six months prior to thetic three weeks later once the flap was referral but she still presented with multi- vascularised from the periphery (Fig 2). 1*Consultant Oral and Maxillofacial Surgeon, Kent and ple small bony sequestrae and areas of soft The patient made a good post operative Canterbury Hospital, Ethelbert Road, Canterbury, Kent, tissue necrosis. There was no history of recovery but shortly thereafter was lost to CT1 3NG; 2Former resident, Department of Oral and Maxillofacial Surgery, University of California, San trauma. follow up. Francisco; 3Professor and Chairman, Department of Oral Under general anesthesia, the area was and Maxillofacial Surgery, University of California, San thoroughly debrided to include both hard DISCUSSION Francisco. *Correspondence to: Dr Nicholas Goodger and soft tissues, prior to planned second- In addition to cocaine misuse, possible Email: [email protected] ary definitive reconstruction. Multiple causes of midline palatal necrosis include specimens were sent for microbiology and the gumma of tertiary syphilis, tumour, Refereed Paper histopathological examination. She healed trauma, chronic infection (often fungal), Received 21.04.04; Accepted 15.07.04 doi: 10.1038/sj.bdj.4812171 well following this procedure, with no Wegener’s granulomatosis, and midline © British Dental Journal 2005; 198: 333–334 further areas of necrosis, and initially granuloma, which is normally caused by BRITISH DENTAL JOURNAL VOLUME 198 NO. 6 MARCH 26 2005 333 PRACTICE higher incidence of connective tissue dis- orders in women. The most important tenet of treatment is cessation of the cocaine habit and the exclusion of another underlying disease process by biopsy and serology. Patients need to be counselled on the risks of con- tinued cocaine misuse and the likely poor outcome from surgery if the misuse is con- tinued. However, it can be difficult to Fig. 1 Necrotic nasal tissue visible through check patient compliance. It is well recog- Fig. 2 Postoperative photograph showing palatal midline palatal fistula nised that those with a drug habit may be repair with tongue flap following division of the less than truthful about drug use and urine pedicle. and blood tests will usually only detect angiocentric T-cell lymphoma. The histo- metabolites from cocaine use 48–72 hours ry, serology, microbiology and histopathol- prior to the test. Thus, lack of deterioration situation is that if the patient were to use ogy ruled these out as possible causes of the palatal defect with no evidence of cocaine in the postoperative period the leaving only the cocaine misuse. The soft tissue necrosis or bone and cartilage resultant vasoconstriction could result in mechanism is thought to be the intense sequestration may be a good indicator of a flap failure. vasoconstriction caused by the cocaine, halt in cocaine use. The loss of patients to follow up has been which causes necrosis of the affected tis- Treatment options include accepting reported by others.3 This may be consistent sues associated with chondritis and the defect with or without permanent with the patients’ re-involvement with osteomyelitis of the exposed cartilage and obturation3 or surgical repair once a peri- drugs. Patients are motivated to attend and bone. The thickening of the nasal sill prior od of observation and non-progression of receive treatment for the defect because of to septal perforation in the current case the defect has elapsed. Definitive surgical the nasal escape distorting speech and diffi- was probably a manifestation of underly- reconstruction could be by means of a cleft culty in eating, but once the treatment is ing chondritis. palate type procedure, a local pedicle flap complete that motivation may be lost. Thirteen previous cases of palatal such as the tongue flap used in this and necrosis secondary to cocaine misuse are other cases,3,4 temporalis flap or buccal fat 1. Messinger E. Narcotic septal perforations due to drug addiction. J Am Med Assoc 1962; 179: 964. recorded in the literature.2–3 In only one of pad graft. The pedicled tongue flap is a 2. Sittel C, Eckel H E. Nasal cocaine abuse presenting as these cases — a 53-year-old man — was the straightforward and reliable technique and a central facial destructive granuloma. Eur Arch destruction caused by granulomatous vas- provides good tissue bulk. Where exten- Otorhinolaryngol 1998; 255: 446. culitis confirmed by positive antineu- sive palatal destruction has occurred, a 3. Mari A, Arranz C, Gimeno X et al. Nasal cocaine abuse and centrofacial destructive process: report trophil cytoplasmic antibody (ANCA) more versatile approach could be achieved of three cases including treatment. Oral Surg Oral serology. It is of particular note that as in using a microvascular free flap with or Med Oral Pathol Oral Radiol Endod 2002; 93: our case, 10 previous cases were in women without simultaneous bone transfer.5,6 435–439. with a mean age of 33.6 years. The rela- Suitable donor sites with bone would 4. Posnick J C, Getz S B. Surgical closure of end-stage palatal fistulas using anteriorly-based dorsal tively young age group may reflect the include the radial forearm, iliac crest, tongue flaps. J Oral Maxillofac Surg 1987; 45: population to which cocaine is available scapula and split metatarsal flap. Soft tis- 907. rather than the disease process itself, since sue reconstruction alone could be affected 5. Turk A E, Chang J, Soroudi A E et al. Free flap closure the remaining two male cases were 36 and by the use of a radial forearm, dorsalis in complex congenital and acquired defects of the palate. Ann Plast Surg 2000; 45: 274. 37 years old, but it has been suggested that pedis or other musculocutaneous microvas- 6. Futran N D, Haller J R. Considerations for free-flap females may be more susceptible to gross cular flap. The potential drawback to the reconstruction of the hard palate. Arch Otolaryngol palatal necrosis in a similar way to the use of microvascular reconstruction in this Head Neck Surg 1999; 125: 665. 334 BRITISH DENTAL JOURNAL VOLUME 198 NO. 6 MARCH 26 2005