A large oronasal defect

A man in his late 50s with a history of regular cocaine use reported dysphagia, weight loss, and sticking chewing gum to his hard palate to stop food entering his nose (fig 1). On examination he had a nasal voice and a large oronasal defect. Computed tomography showed extensive destruction of the nasal septum and the left sided paranasal sinuses. An endoscopy was performed for visualisation and biopsy. Laboratory findings showed an atypical pattern of positive serum antineutrophil cytoplasmic antibodies (ANCA), perinuclear antineutrophilic cytoplasmic antibody (p-ANCA), and antihuman elastase antibodies suggestive of a vasculitis. A biopsy of the nasal cavity showed no evidence of malignancy or granulomas.bmj;385/apr18_6/e079667/F1F1f1Fig 1The cocaine induced destruction of this patient’s nasal architecture is termed a cocaine induced midline destructive lesion. This condition can be precipitated by vasculitis caused by the common use of the antihelminth drug levamisole as an adulterant in cocaine. Levamisole is an immunomodulatory…



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