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Rhinology/Allergy

(095) Cocaine-Induced Midline Destructive Lesion Presenting with Medial Rectus Necrosis

Monday, October 2, 2023
2:45 PM – 3:45 PM East Coast USA Time
Has Audio

    Presenting Author(s)

  • Nicholas A. Rossi, MD

    Resident Physician
    University of Texas Medical Branch Hospitals
    Galveston, Texas, United States

    • Co-Author(s)

  • NM

    Nishat A. Momin, MD

    Resident Physician
    The University of Texas Medical Branch at Galveston
    Sugar Land, TX, USA

  • Natalie Chamness, BBA

    MD candidate 2024
    University of Texas Medical Branch
    Waco, Texas, United States

  • HP

    Harold S. Pine, MD

    Professor
    University of Texas Medical Branch
    Galveston, Texas, United States

    • Senior Author(s)

  • SS

    Sepehr Shabani, MD

    Assistant Professor
    UTMB Department of Otolaryngology
    Galveston, Texas, United States

Disclosure(s):
Nicholas A. Rossi, MD: No relevant relationships to disclose.
Natalie Chamness, BBA: No relevant relationships to disclose.
Harold S. Pine, MD: No relevant relationships to disclose.
Sepehr Shabani, MD: No relevant relationships to disclose.


Introduction: Cocaine-induced midline destructive lesions (CIMDL) are increasingly recognized sequalae of intranasal cocaine abuse, yet diagnosis remains complicated, and reconstructive options are limited. In this study, we describe an unusual case of CIMDL that presented with medial rectus palsy and palatal fistula mimicking invasive fungal sinusitis, and we review the literature surrounding this rare entity.

Methods: The patient is a 34-year-old male with a 16-year history of daily cocaine abuse who presented for evaluation of two weeks of diplopia and palatal fistula in the setting of chronic facial pain. Physical examination revealed right medial rectus palsy and a subcentimeter palatal fistula. MRI Brain illustrated a 24 x 18 x 15 mm heterogeneously enhancing mass of the right superior nasal cavity with associated destruction of the lamina papyracea and medial rectus. Nasal endoscopy showed global black crusting of nasal mucosa as well as destruction of almost all native nasal architecture. The right middle turbinate appeared necrotic and black in color. A bedside biopsy was taken of the palatal fistula and right middle turbinate remnant.

Results: Frozen section pathologic analysis of the right middle turbinate remnant showed inflammatory debris without angioinvasion or fungal elements. Given the acuity of his ophthalmoplegia in the face of new palatal fistula and necrotic appearing nasal mucosa, he was taken to the OR urgently for nasal cavity debridement and biopsy. Intraoperatively, dense scarring was seen in the right periorbita coinciding with possible mass seen on MRI. Conservative biopsy was taken of this tissue and was negative for fungal elements or angioinvasion. ANCA screen was negative. Final diagnosis was CIMDL, and he was discharged uneventfully on postoperative day one.

Conclusions: Prompt recognition and adequate understanding of CIMDL is crucial for Otolaryngologists, especially in the setting of suspicion for possible invasive fungal sinusitis or vasculitis. The authors emphasize early surgical intervention to rule out invasive process as well as immediate cessation of the offending substance.