Palate perforation differentiates cocaine-induced midline destructive lesions from granulomatosis with polyangiitis

Pearls & Oy-sters: Frontal Lobe Syndrome Secondary to Cocaine-Induced Midline Destructive Lesions

Cocaine-induced midline destructive lesions (CIMDL) are a rare complication of chronic intranasal cocaine use involving the centrofacial mucosal structures, often with nasal septum perforation and, in severe cases, involvement of neurocranial structures. Patients present with nasal obstruction, epistaxis, facial pain, nasal ulcerative lesions with crusting, and septal and palate perforation causing dysphagia and nasal reflux. CNS involvement is uncommon.We report a 47-year-old man with a history of nasal cocaine use who developed a subacute frontal syndrome secondary to cribriform plate destruction complicated by bilateral frontal lobe empyema and abscesses and extensive white matter involvement. The frequent presence of serum antineutrophil cytoplasmic antibodies (ANCA) in CIMDL makes this uncommon presentation challenging to differentiate from localized granulomatosis with polyangiitis. While ANCA antibodies may play a role in CIMDL, immunosuppression is not indicated and may lead to iatrogenesis.CIMDL should be considered in patients with isolated frontal lobe syndrome. Eliciting a history of cocaine use and obtaining toxicologic studies are essential in the diagnosis of CIMDL.

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

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.

Cocaine-associated Eustachian tube stenosis causing chronic 'glue ear': a rare cocaine-induced destructive lesion

BACKGROUND

Cocaine is one of the most used recreational drugs. Whilst medical uses exist, chronic recreational nasal use of cocaine is associated with progressive destruction of the osseocartilaginous structures of the nose, sinuses and palate - termed cocaine-induced midline destructive lesions.

CASE REPORT

A 43-year-old male with a history of chronic cocaine use, presented with conductive hearing loss and unilateral middle-ear effusion. Examination under anaesthesia revealed a completely stenosed left Eustachian tube orifice with intra-nasal adhesions. The adhesions were divided and the hearing loss was treated conservatively with hearing aids. Whilst intra-nasal cocaine-induced midline destructive lesions are a well-described condition, this is the first known report of Eustachian tube stenosis associated with cocaine use.

CONCLUSION

This unique report highlights the importance of thorough history-taking, rhinological and otological examination, and audiometric testing when assessing patients with a history of chronic cocaine use. This paper demonstrates the complexity of managing hearing loss in such cases, with multiple conservative and surgical options available.

The role of ANCA in the management of cocaine-induced midline destructive lesions or ENT pseudo-granulomatosis with polyangiitis: a London multicentre case series

OBJECTIVE

In this multicentric study involving three London hospitals, we compared ANCA-positive and ANCA-negative cocaine-induced midline destructive lesions (CIMDL) patients to assess how presence of antineutrophil cytoplasmic antibodies (ANCA) may correlate with disease severity. Our secondary aims are to better classify etiology centered around ANCA positivity and, consequently, better disease management.

METHODS

A retrospective review was performed to identify patients with CIMDL seen between January 2019 and December 2022. Population data including age, sex, presentation, endoscopic findings, duration of cocaine use and active use of cocaine, type of treatment, laboratory (including ANCA serology), radiological, and histological findings were collected.

RESULTS

Forty CIMDL patients (25 male, median age of 42 years) were identified. The majority of them (72.5%) presented with either a septal perforation, a saddle nose deformity (22.5%), and/or a palatal fistula (20.0%). ANCA was positive in 71.1% of cases (66.7% p-ANCA). No statistically significant differences in the general characteristics, type of treatment, laboratory results, radiological or histological findings were observed when comparing ANCA-positive and ANCA-negative CIMDL patients or when comparing p-ANCA and c-ANCA patients. Similarly, no statistically significant difference was obtained when comparing the pattern of distribution of lesions between the two groups.

CONCLUSIONS

A large percentage of CIMDL patients showed positive ANCA test (71.1%) and in the majority of the cases a p-ANCA pattern specifically targeting PR3 (p-ANCA, PR3 + MPO-). However, ANCA positivity or presence of a specific ANCA pattern was not associated with more severe presentation or more aggressive disease. Given its similarities to granulomatosis with polyangiitis (GPA), we recommend the use of the term "cocaine-induced ENT pseudo-GPA" instead of CIMDL.

LEVEL OF EVIDENCE

IV Laryngoscope, 134:2609-2616, 2024.

When inflammation is not just inflammation-A review of systemic diseases of the nose and sinuses part 2: Granulomatosis with polyangiitis and eosinophilic granulomatosis with polyangiitis

BACKGROUND

Chronic rhinosinusitis is a very common condition. Granulomatosis with polyangiitis (GPA) and eosinophilic granulomatosis with polyangiitis (eGPA) are systemic diseases which can contribute to the development of chronic rhinosinusitis in select patients.

OBJECTIVE

Characterize the presenting features, diagnostic criteria, workup, and management of granulomatosis with polyangiitis and eosinophilic granulomatosis with polyangiitis as they are encountered in otolaryngology clinics.

METHODS

Full length manuscripts published 2000 or later were reviewed. A separate search was conducted for each disease. Pertinent clinical features related to sinonasal manifestations of GPA and eGPA were collected and reported in this review.

RESULTS

467 references were discovered during literature review process. In total, 42 references for GPA and 35 references for eGPA were included in this review.

CONCLUSION

GPA and eGPA are vasculitis syndromes which commonly present in the context of multisystem disease. For GPA, pulmonary and renal disease are common; for eGPA a history of asthma is nearly ubiquitous. Sinonasal disease is a very common feature for both disease processes and may precede the development of systemic symptoms in many patients. Clinical work up and diagnosis is complex and generally requires multidisciplinary care. Treatment primarily consists of immunosuppressive agents, and a number of steroids, steroid sparing agents, and biologics have been shown to be effective. The role of sinus surgery includes tissue biopsy for diagnosis, functional surgery for symptom management in select cases, and reconstruction of cosmetic and functional defects.

Granulomatosis with polyangiitis or its mimic? A case report

Differentiation between granulomatosis with polyangiitis (GPA) limited to the upper airways and cocaine-induced midline destructive lesion (CIMDL) may be particularly difficult because of their common histopathologic features and antineutrophil cytoplasmic antibody (ANCA) profiles. We herein present a case involving a young woman with an initial diagnosis of GPA based on upper and lower airway manifestations and constitutional symptoms, histopathologic evidence of granulomas, a positive cytoplasmic ANCA indirect immunofluorescent test result, and proteinase 3 positivity by enzyme-linked immunosorbent assay (ELISA). CIMDL was confirmed based on the appearance of a hard palate perforation, positivity for methylecgonine on urine toxicology, a positive perinuclear ANCA indirect immunofluorescent test result, and subsequent human neutrophil elastase (HNE) ANCA positivity by ELISA. Finally, based on the coexistence of CIMDL, constitutional symptoms, and lower airway manifestations, the diagnosis was modified to cocaine-induced GPA mimic. Urine toxicology for cocaine and HNE ELISA are indicated in young patients with GPA who develop limited airway disease to check for the presence of CIMDL and cocaine-/levamisole-induced ANCA-associated vasculitis. Continued abstinence from cocaine is the first-choice therapy for both CIMDL and cocaine-induced GPA mimic.

Periorbital Emphysema Due to Traumatic Pneumothorax

Periorbital emphysema is rare and associated with facial trauma. Its main distinguishing feature is crepitation on palpation of the edema. It resolves spontaneously in a few days, but there are cases of orbital compartment syndrome that can lead to loss of vision. Here we present the case of a 55-year-old male who came to the emergency department for bilateral periorbital edema associated with non-steroidal anti-inflammatory drug (NSAID) usage, for pain following a fall from a ladder. He was treated with antihistamines and corticosteroids, for presumed allergic reaction, but without response, and subsequently developed acute onset dyspnea. Chest x-ray revealed a left pneumothorax in the context of chest trauma. Chest CT scan after drain placement shows extensive subcutaneous emphysema. In the differential diagnosis of periorbital edema, in addition to allergic, inflammatory, and systemic causes, the traumatic ones should not be excluded.

[Cocaine-induced vasculitis and mimics of vasculitis]

Cocaine is a psychotropic tropane alkaloid and stimulant drug. Nasal insufflation of cocaine powder is a common route of administration. In Germany, cocaine is frequently adulterated with levamisole, an anthelminthic drug with immunomodulatory effects. Both substances are linked to various autoimmune conditions. Cocaine-induced midline destructive lesions cause a progressive destruction of osteocartilaginous structures within the upper respiratory tract and can mimic localized granulomatosis with polyangiitis. In addition, systemic vasculitis due to cocaine and levamisole has been reported. Differentiation of these conditions from primary vasculitis can be challenging because antineutrophil cytoplasmic antibodies (ANCA) are commonly detected. Early diagnosis of these conditions is crucial as clinical improvement is closely related to drug cessation.

Nanoplatforms: The future of oral cancer treatment

Background and Aims

Cytotoxicity is a key disadvantage of using chemotherapeutic drugs to treat cancer. This can be overcome by encapsulating chemotherapeutic drugs in suitable carriers for targeted delivery, allowing them to be released only at the cancerous sites. Herein, we aim to review the recent scientific developments in the utilization of nanotechnology-based drug delivery systems for treating oral malignancies that can lead to further improvements in clinical practice.

Methods

A comprehensive literature search was conducted on PubMed, Google Scholar, ScienceDirect, and other notable databases to identify recent peer-reviewed clinical trials, reviews, and research articles related to nanoplatforms and their applications in oral cancer treatment.

Results

Nanoplatforms offer a revolutionary strategy to overcome the challenges associated with conventional oral cancer treatments, such as poor drug solubility, non-specific targeting, and systemic toxicity. These nanoscale drug delivery systems encompass various formulations, including liposomes, polymeric nanoparticles, dendrimers, and hydrogels, which facilitate controlled release and targeted delivery of therapeutic agents to oral cancer sites. By exploiting the enhanced permeability and retention effect, Nanoplatforms accumulate preferentially in the tumor microenvironment, increasing drug concentration and minimizing damage to healthy tissues. Additionally, nanoplatforms can be engineered to carry multiple drugs or a combination of drugs and diagnostic agents, enabling personalized and precise treatment approaches.

Conclusion

The utilization of nanoplatforms in oral cancer treatment holds significant promise in revolutionizing therapeutic strategies. Despite the promising results in preclinical studies, further research is required to evaluate the safety, efficacy, and long-term effects of nanoformulations in clinical settings. If successfully translated into clinical practice, nanoplatform-based therapies have the potential to improve patient outcomes, reduce side effects, and pave the way for more personalized and effective oral cancer treatments.

Use of a Fiberoptic-Laser Approach During Endoscopic Sinus Surgery: A Cadaver Feasibility Study

Aims

The aim of the present study is to evaluate the clinical applicability of laser energy during an oro-nasal endoscopic approach (ONEA) in the management of the anterior maxillary sinus wall.

Methods

An experiment on three adult human cadavers was performed to study the nasal cavities with angled rigid scopes and using the ONEA technique. In order to evaluate the effectiveness of laser energy on the bone, the drilling effect was compared to laser energy (1470 nm diode laser, continuous wave, power 8, 9 and 10 W).

Results

Compared to a rigid angled scope, the ONEA technique allowed complete visualization of the anterior wall of the maxillary sinus. Microscopic analysis of frontal bone revealed similar bone Exeresis with high-speed drilling (270.28 μm) and laser approaches (285.73-456.6 μm).

Conclusions

The laser ONEA technique is an innovative, mini-invasive, and safe approach to the anterior wall of the maxillary sinus. Additional study is warranted to further develop this technique.

Distribution of cocaine-induced midline destructive lesions: systematic review and classification

Purpose

Intranasal cocaine is known to potentially lead to midline destructive lesions. The present systematic review was undertaken to systematically define the localization of cocaine-induced midline destructive lesions and their prevalence and to propose a practical classification of these lesions.

Methods

A PRISMA-compliant systematic review was performed in multiple databases with criteria designed to include all studies published until March 2021 providing a precise definition of cocaine-induced midline lesions in humans. We selected all original studies except case reports. After duplicate removal, abstract and full-text selection, and quality assessment, we reviewed eligible articles for lesion localization, patients’ demographics, exposure to cocaine, and relationship with external nose destruction.

Results

Among 2593 unique citations, 17 studies were deemed eligible (127 patients). All studies were retrospective case series. The destructive process determined a septal perforation in 99.2% of patients. The distribution prevalence decreased from the inferior third of the sinonasal complex (nasal floor and inferolateral nasal wall, respectively, 59% and 29.9% of patients) to the middle third (middle turbinate and ethmoid, 22.8% of patients), and ultimately to neurocranial structures (7.9% of patients). Nasal deformities were inconsistently reported across reviewed studies. Cocaine use duration, frequency, and status were reported only occasionally.

Conclusion

Based on the distribution prevalence observed, we propose a four-grade destruction location-based classification. Future prospective studies following the evolution of cocaine-induced lesions are needed to validate our classification, its relationship with lesion evolution, and whether it represents a reliable tool for homogeneous research results reporting.

The importance of clinical presentation on long-term outcomes of external dacryocystorhinostomies: Our experience on 245 cases

PURPOSE

External dacryocystorhinostomy (EXT-DCR) is a surgical approach commonly used to treat post-canalicular acquired lacrimal obstruction whose success rate has been described, equally with endoscopic DCR, to be superior to other available treatments.

METHODS

At San Raffaele Hospital, Milan (Italy), from January 2008 to December 2020, 245 EXT-DCRs were performed. All patients underwent routine pre-operative work-up including Jones tests and probing and irrigation of the lacrimal pathway; when necessary, a multidisciplinary approach with nasal endoscopy was performed. The surgical approach was followed by positioning of a bicanalicular stent which was left in place for 6 months. Success was defined as resolution of clinical signs/symptoms and free lacrimal flow on functional test.

RESULTS

Of the cases enrolled, 26.9% were treated for recurrent epiphora (group 1), and 73.1% for epiphora associated with chronic dacryocystitis (group 2). After a median follow-up of 71 months, group 1 had success at T0 (1 month) and T1 (long-term) of 81.8% and 60.6%, respectively, compared to 93.8% and 77.7% in group 2. Statistical analysis showed a significant association with surgery both at T0 (p = 0.018) and T1 (p = 0.012) with group 2 showing better outcomes. Additionally, the cosmetic outcome of the external scar was defined as invisible in 91.8% of cases and slightly visible in 8.2%.

CONCLUSIONS

External dacryocystorhinostomy provides long-term reliable results particularly in case of chronic dacryocystitis. Moreover, the optimal esthetic outcome of the external scar should be no longer considered the only guiding principle of treatment modality, particularly in the elderly.

Early diagnosis of oral squamous cell carcinoma may ensure better prognosis: A case series

Oral squamous cell carcinoma is an extremely malignant tumour: in order to reduce mortality and morbidity, early diagnosis and treatment is the clinician's best weapon.

Gene Expression Analysis in Patients with Cocaine-Induced Midline Destructive Lesions

BACKGROUND AND OBJECTIVES

Cocaine users may present with positive antineutrophil cytoplasmic antibodies (ANCA) and severe midline destructive lesions (CIMDL) which are histologically characterized by massive apoptosis. However, histopathological and laboratory studies suggest that autoimmunity may not be the main pathogenic driver. We analyzed gene expression both in cell lines of nasal mucosa exposed to cocaine and in CIMDL patients to determine whether genetic predisposition might cause such lesions, which are observed in a minority of cocaine abusers.

MATERIALS AND METHODS

The genetic expression profile of nasal mucosa exposed to cocaine was analyzed. Rare variants of expressed genes were searched in patients with CIMDL using exome sequencing and bio-informatics.

RESULTS

We identified 462 genes that were induced by cocaine, mainly related to apoptosis and autophagy in response to oxidative stress. Under the hypothesis that genes linked to the phenotype are also induced by cocaine itself, a rare variants burden test was performed to select genes that were significantly enriched in rare mutations. Next, 11 cocaine abusers with CIMDL and no other relevant medical comorbidities underwent exome sequencing, and 12 genes that were significantly enriched in the burden test and present in at least 10 patients were identified. An in-depth analysis of these genes revealed their involvement in apoptosis, tissue homeostasis, autophagy, and response to oxidative stress.

CONCLUSIONS

Oxidative stress and rare genetic alterations in the response to reactive oxygen species, apoptosis, autophagy, and tissue regeneration are plausible drivers of damage affecting nasal mucosa exposed to cocaine crystals and, consequently, the pathogenic mechanism behind CIMDL.

Long-term results of a balloon-assisted endoscopic approach in failed dacryocystorhinostomies

Purpose

Endoscopic endonasal balloon-assisted dacryoplasty is a minimally invasive surgical approach that can be applied after failure of dacryocystorhinostomy with recurrence of distal acquired lacrimal obstruction.

Methods

At the Department of Otolaryngology, San Raffaele Hospital, Milan (Italy), from December 2016 to October 2020, 14 patients underwent trans-nasal balloon-assisted dacryoplasty after a failed dacryocystorhinostomy (both external and endoscopic endonasal). The routinary pre-operative work-up included multidisciplinary study of the lacrimal disease, which consisted in primary ophthalmological and otorhinolaryngological visits associated with nasal endoscopy, in which a radiological exam was added if needed. The surgical approach includes pneumatic enlargement of the stenotic rhinostomy, created during the primary dacryocystorhinostomy, using a high-pressure trans-nasal balloon catheter. Anatomical success was considered when the ostium was patent upon irrigation, while functional success was considered as resolution of epiphora or free lacrimal flow on functional test.

Results

Among 14 patients included and after a mean follow-up of 19.5 months (range 13–51 months), anatomic success was achieved in 100% of patients and functional success was achieved in the 85.7% (12/14). Operative time ranged from 9 to 28 min (mean 18 min) and no complications were reported.

Conclusion

Trans-nasal balloon-assisted dacryoplasty is a mini-invasive surgical approach to treat failed dacryocystorhinostomies with reliable and stable outcomes in the long term. The absence of post-surgical complications, high success rate and short operative time are the main features of this innovative procedure.

Rhinitis Phenotypes

Rhinitis is an umbrella term of a group of upper airway diseases with nasal symptoms and signs with different etiologies and various clinical features or traits. It can be classified into different "phenotypes," based on these observable traits. A proper differential diagnosis is necessary to adequately manage the disease. The objective of this review is to clarify the concept of rhinitis phenotypes while analyzing the clinical features and/or traits of each in order to determine a proper differential diagnosis and appropriate treatment.

Solitary Extramedullary Plasmacytoma Presenting as Asymptomatic Palatal Erythroplakia: Report of a Case

Solitary plasmacytoma (SP) is a rare malignant tumor of plasma cells with no systemic spread; however, when it disseminates and affects multiple skeletal sites, it is called multiple myeloma (MM). The etiology of solitary plasmacytoma is unknown, with two possible subtypes: solitary extramedullary plasmacytoma (EMP) and solitary bone plasmacytoma (SBP). We present a case of EMP arising as asymptomatic erythroplakia of the palate, which is rarely described in the literature. The definitive diagnosis was obtained with immunohistochemical studies, after which the lesion was subjected to excisional biopsy. At present, after two years of close follow-up, the patient has shown no signs of relapse or conversion to MM. The uniqueness of the case highlights the possibility of an atypical EMP lesion in the head and neck, thus posing a diagnostic and therapeutic challenge for physicians.

Mucosal Melanoma of the Hard Palate: Surgical Treatment and Reconstruction

Mucosal melanomas of the head and neck region are uncommon pathologies that can affect the oral cavity, and are characterized by a high rate of mortality. Considering the lack of knowledge regarding risk and prognostic factors, current best clinical practice is represented by a large surgical excision with disease-free margins, eventually associated with a reconstructive flap. Indeed, given the frequent necessity of postoperative radiotherapy and fast healing process, a reconstruction of the surgical gap is advisable. Even if several flaps have been most commonly used, the submental island flap represents a valid alternative thanks to local advantages and similar oncologic outcomes compared to free flaps.

Cocaine-Induced Midline Destructive Lesions: A Real Challenge in Oral Rehabilitation

Cocaine abuse is associated with severe local effects on mucosal and osteocartilaginous structures, with a centrifugal spreading pattern from the nose, a condition known as cocaine-induced midline destructive lesions (CIMDL). When the soft or hard palate is affected, a perforation may occur, with subsequent oro-nasal reflux and hypernasal speech. Both diagnosis and therapy (surgical or prosthetic) constitute a serious challenge for the physician. The cases of three patients affected by cocaine-induced palatal perforation and treated with a palatal obturator at San Raffaele Dentistry department between 2016 and 2019 are presented. In addition, the literature was reviewed in search of papers reporting the therapeutic management in patients affected by cocaine-induced palatal perforation. All the patients in our sample suffered from oro-nasal reflux and hypernasal speech, and reported a significant impact on interpersonal relationships. The results at the delivery of the obturator were satisfactory, but the duration of such results was limited in two cases, as the progression of the disease necessitated continuous modifications of the product, with a consequent increase in costs and a reduction in patient satisfaction. In conclusion, the therapy for palatal defects in CIMDL includes both reconstructive surgery and prosthetic obturators, the latter being the only possibility in the event of active disease. It successfully relieves symptoms, but the long-term efficacy is strongly related to the level of disease activity.

Clinical efficacy of dupilumab in the treatment of severe chronic rhinosinusitis: The first case outside of a clinical trial

Treatment options for severe CRSwNP are limited. Dupilumab is a safe, well-tolerated, and effective alternative in patients with poor control of symptoms, corticosteroid-dependent disease, and high rates of recurrence of nasal polyps after surgery.

Surgical treatment of cocaine-induced palatal perforations: Report of three cases and literature review

Destruction of the osteocartilaginous framework of the nose and sinuses is a well-known side effect of inhaled cocaine. Palate involvement is, however, a very uncommon event that may lead to oronasal communication with the subsequent food and liquids reflux and nasal speech. Given the addictive character of this etiologic agent, the management of cocaine-induced palatal perforations tends to be conservative by means of a prosthetic obturator. In this paper three cases with surgically treated cocaine-induced palatal perforations are reported and a review of the literature is made focusing on the management of this process. Despite the usual reluctancy, surgical palatal reconstruction should be considered in selected committed patients as a definitive solution for the annoying rhinolalia and solid-liquid reflux to the nose, thus improving their quality of life and social relationships.

Key words:Cocaine, oral fistula, palate, palatal perforation, oronasal communication.

Oral Cancer and Precancer: A Narrative Review on the Relevance of Early Diagnosis

Oral cancer (OC) is an uncommon malignancy in Western countries, being one of the most common cancers in some high-risk areas of the world. It is a largely preventable cancer, since most of the different risk factors identified, such as tobacco use, alcohol consumption, and betel nut chewing, are behaviors that increase the likelihood of the disease. Given its high mortality, early diagnosis is of utmost importance. Prevention and the anticipation of diagnosis begin with identification of potentially malignant lesions of the oral mucosa and with local conditions promoting chronic inflammation. Therefore, every lesion must be recognized promptly and treated adequately. The clinical recognition and evaluation of oral mucosal lesions can detect up to 99% of oral cancers/premalignancies. As stated by the World Health Organization, any suspicious lesion that does not subside within two weeks from detection and removal of local causes of irritation must be biopsied. Surgical biopsy remains the gold standard for diagnosis of oral cancer. Adjunctive tools have been developed and studied to help clinicians in the diagnostic pathway, such as toluidine blue vital staining and autofluorescence imaging. In the near future other methods, i.e., identification of salivary markers of progression may help in reducing mortality due to oral cancer.

Cocaïne et lésions destructrices centro-faciales : à propos d'un cas

INTRODUCTION

Cocaine use is associated with multiple complications, some of which can mimic systemic diseases, especially Antineutrophil Cytoplasmic Antibody (ANCA) associated vasculitis. We report a case of Cocaine Induced Midline Destructive Lesions (CIMDL) for which a diagnosis of granulomatosis with polyangiitis (GPA) was discussed.

CASE REPORT

A 42-year-old male, cocaine consumer, was admitted in our department for a centrofacial destructive process. He had no extra ear, nose and throat (ENT) involvement. ANCA were positive with a perinuclear fluorescence pattern and an anti-Proteinase 3 specificity. Regarding this unusual immunologic pattern and in the absence of histological argument for a GPA, a diagnosis of CIMDL was made.

CONCLUSION

CIMDL is a centrofacial destructive process due to intranasal cocaine use. It is frequently associated with the presence of p-ANCA with both anti-HNE and anti-PR3 specificity.

The role of surgery in antineutrophil cytoplasmic antibody-associated vasculitides affecting the nose and sinuses: A systematic review

Background:

The ear, nose and throat region has been reported to be one of the commonest sites involved in antineutrophil cytoplasmic antibody (ANCA)–associated vasculitis diseases and often precedes the diagnosis of ANCA–associated vasculitis by many months. Although treatment for ANCA–associated vasculitis primarily requires systemic immunosuppressive therapy, there are specific indications for sinonasal surgery during the course of the disease process. The three major roles for surgery in sinonasal vasculitis are to aid diagnosis through biopsy, enable symptom relief and nasal reconstructive surgery consideration when in remission.

Purpose:

The aim of this systematic review is to provide an overview of the surgical procedures which can be performed in patients with ANCA–associated vasculitis presenting with sinonasal involvement.

Materials and methods:

A systematic literature search was performed for scientific articles on MEDLINE (PubMed Advanced MEDLINE Search) and EMBASE. The search included all articles up to April 2020.

Conclusion:

Surgical intervention during the active phase of ANCA–associated vasculitis disease can improve the patient’s symptoms and enable histological diagnosis. The surgical decision to manage the nose requires a multidisciplinary approach involving the vasculitis specialist and the ear, nose and throat surgeon. Nasal reconstruction can be performed to restore form and function but only when the disease is in remission so as to maximise success and minimise complications.

Clinical characteristics of patients with granulomatosis with polyangiitis and microscopic polyangiitis in ENT practice: a comparative analysis

ENT manifestations are commonly observed in patients with small vessel vasculitis (SVV). The main aim of this study was to analyse and present the clinicopathological characteristics of individuals with SVV emphasising otorhinolaryngological symptoms. This study evaluated 64 patients, 41 with granulomatosis with polyangiitis (GPA) and 23 with microscopic polyangiitis (MPA). Herein, we compare the clinicopathologic features of GPA and MPA. The average age at diagnosis was 50.2 and 56.2 years, for GPA and MPA, respectively. 57 patients (89%) were antineutrophil cytoplasmic antibody (ANCA) positive, 34 (59.6%) for anti-proteinase 3 (PR3)-ANCA and 21 (36.8%) for myeloperoxidase (MPO)-ANCA. 7 patients (10.9%) were ANCA negative. The most commonly affected organs were lungs (76.56%), ear, nose, throat (ENT) (75%) and kidneys (73.44%). ENT disorders mainly appeared as chronic rhinosinusitis and epistaxis and preceded SVV diagnosis by an average 14.4 months. In the majority of patients, ENT disorders were the first symptoms of SVV and preceded its systemic transformation. Pulmonary, ENT and nervous manifestations were more common in GPA, whereas the prevalence of renal, gastrointestinal, cutaneous, cardiovascular and ocular disorders was higher in MPA. The results of our study emphasise the high prevalence of ENT symptoms in patients with SVV, especially in those with GPA. We highlight the significant role of the otorhinolaryngologist in early SVV diagnosis and management. Any patient with persistent ENT symptoms or ENT dysfunctions not responding to standard otorhinolaryngological treatment should be precisely and rapidly evaluated for the presence of systemic dysfunctions (especially renal and pulmonary). Realising the differences and similarities between GPA and MPA is crucial in undelayed SVV diagnosis and proper treatment.