Clinical History
Chronic cocaine snorting abuse with perforation of the nasal septum and ischemic necrosis of the turbinates.
Imaging Findings
He was referred by a general practitioner to the department of radiology because of recurrent headaches, rhinorrhea, decreased olfactory sense and recurrent episodes of nose bleeding.
Noncontrast coronal CT scan of the paranasal sinuses shows on (coronal section of through the central part of the nasal cavity) an edematous swelling of the mucous membranes within the left nasal cavity and bilateral mucosal thickening on the floor of the maxillary sinuses.
Coronal section 12 mm more anteriorly demonstrates perforation of the bony nasal septum, which results in a free communication between the left and right nasal cavity. The middle turbinates are missing.
On coronal s ection even more anteriorly, the anterior portion of the inferior turbinates is also missing, and the cartilaginous part of the nasal septum has completely disappeared.
The CT findings, combined with anamnestic data obtained form the patient's mother, establish the diagnosis of chronic cocaine snorting abuse with perforation of the nasal septum and ischemic necrosis of the turbinates.
Discussion
Cocaine is an alkaloid derived from the coca leaf, which in the late 1800's was introduced into medical practice as a potent vasoconstrictive drug.
Chronic intranasal cocaine abuse is known to cause nasal symptoms, as well as structural damage to the nasal septum. Nasal symptoms frequently mimic allergic vasomotoric rhinitis and include rhinorrhea and sniffing, nasal crusting and post-nasal drip.
The desintegration of the bony and the cartilaginous nasal septum is caused by vasoconstriction of the capillary arteries in the mucosa. This leads to ulcerations and the subsequent cell death. The cocaine user often is not aware that this is happening because of the numbing effect of the drug. Chronic cocaine use can devastate the internal support structures of the nose which may ultimately result in collapse of the nasal bridge with saddle deformity.
Perforation of the nasal septum is not only caused by the vasoconstrictive effects of the drug, but is also believed to be related to the presence of contaminants and local factors.
In the differential diagnosis, other causes of nasal septal perforation (e.g. syphilis) should be considered. In most instances, the definitive diagnosis should be obtained by combining the CT-findings, as described, with a thorough, anamnesis of the patient or family.
Differential Diagnosis List
Chronic cocaine snorting abuse
Final Diagnosis
Chronic cocaine snorting abuse
