Comprehensive Management of Cocaine-Induced Midline Destructive Lesions: A Young-IfOS Consensus
Abstract
:1. Introduction
2. Materials and Methods
2.1. Panelists and Scope of Consensus Statement
2.2. Systematic Literature Review
2.3. Clinical Statement Development and Modified Delphi Survey
3. Results
4. Discussion
4.1. Disease Definition
4.2. Clinical Evaluation and Diagnosis
4.3. First-Line Management of CIMDL Patients
4.4. Surgical Management of Complications and Reconstructions
4.5. Limitations of the CCS
5. Conclusions
Author Contributions
Funding
Institutional Review Board Statement
Informed Consent Statement
Data Availability Statement
Acknowledgments
Conflicts of Interest
Abbreviations
RCNU | Recreational Cocaine Nasal Use |
CIMDL | Cocaine-Induced Midline Destructive Lesions |
Appendix A
References
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Item No. | Statement | Mean | Median | Min | Max | Outliers | Result | Delphi Round |
---|---|---|---|---|---|---|---|---|
1.1 | CIMDLs are defined as any structural lesion of the sinonasal complex ascertained in the context of a toxicological screening- or patient history-confirmed cocaine-snorting habit | 7.44 | 7.5 | 1 | 9 | 1 | consensus | 1 |
1.2 | CIMDLs can refer both to sinonasal and palatal lesions due to cocaine snorting | 8.83 | 9 | 8 | 9 | 0 | strong consensus | 1 |
1.3 | CIMDL diagnosis should not rely on auto-antibody testing, which might result positive or negative results in CIMDL patients | 8.50 | 9 | 7 | 9 | 0 | strong consensus | 3 |
Item No. | Statement | Mean | Median | Min | Max | Outliers | Result | Delphi Round |
---|---|---|---|---|---|---|---|---|
2.1 | Clinical assessment of potential CIMDLs should include face examination, anterior rhinoscopy, oral examination, and nasal endoscopy | 8.61 | 9 | 7 | 9 | 0 | strong consensus | 1 |
2.2 | The degree of nasal structures involvement can be assessed via the Nitro et al. classification of CIMDLs | 8.44 | 9 | 5 | 9 | 0 | consensus | 1 |
2.3 | Differential diagnoses for CIMDLs include vasculitis (including but not limited to granulomatosis with polyangiitis), T-cell or NK/T lymphoma, infectious disease (including, but not limited to, syphilis, leishmaniasis, yaws, leprosy, tuberculosis, and actinomycosis), chronic intestinal bowel disease (e.g., Crohn’s disease), chronic use of vasoconstrictor drugs, rhinotillexomania, trauma, other recreational intranasal drug use (amphetamine, acetaminophen–oxycodone), IgG4-related disease, relapsing polychondritis, rhinoscleroma, sclerosing orbital pseudotumor, and iatrogeny | 8.50 | 9 | 6 | 9 | 1 | consensus | 2 |
2.4 | In the case of isolated septal perforations, cocaine-snorting habits should be investigated in the patient history as well as traumas, prior nasal or nose-involving procedures (including radiotherapy and intranasal oxygen therapy), prolonged intranasal vasoconstrictor use, picking habits or history of foreign bodies, known infectious diseases, and known autoimmune disease or vasculitis | 8.67 | 9 | 7 | 9 | 0 | strong consensus | 2 |
2.5 | If an isolated septal perforation is not identified as a CIMDL, but no other causative factor can be identified, a biopsy should be considered with the patient, and—if ruled out—a personalized follow-up should be planned to check for lesion evolution, possibly with measurement and clinical image documentation | 8.33 | 9 | 7 | 9 | 0 | strong consensus | 2 |
2.6 | Patients presenting with a potential CIMDL grade II or higher, without a history of cocaine-snorting, should undergo a complete workup including serology (ESR, ANA, C-ANCA—with immunofluorescence for NPO and PR3 if positive—IgG4, and rheumatoid factor), rheumatology/internal medicine and infectious disease consultation, and nasal biopsy | 7.78 | 9 | 3 | 9 | 1 | consensus | 1 |
2.9 | In patients presenting with a potential CIMDL without a history of cocaine snorting and with negative workup and cocaine testing results, other less common snorting substances can be assessed (e.g., methamphetamine, heroin) | 7.89 | 8 | 5 | 9 | 1 | consensus | 1 |
2.1 | Destructive midline lesions due to nasal administration of non-cocaine recreational drugs (e.g., amphetamine, acetaminophen–oxycodone) can be clinically managed as CIMDLs | 7.83 | 9 | 1 | 9 | 1 | consensus | 3 |
2.11 | Patients presenting with a potential CIMDL and confirming a cocaine-snorting habit should be considered de facto CIMDL patients and receive adequate care and follow-up, though biopsies might still be discussed with the patient to rule out differentials | 8.06 | 9 | 3 | 9 | 1 | consensus | 3 |
2.12 | Enlarging isolated septal perforations in non-CIMDL patients should undergo a complete workup including serology (ESR, ANA, C-ANCA—with immunofluorescence for NPO and PR3 if positive—IgG4, and rheumatoid factor) and nasal biopsy (for histological and microbiological analysis), considering rheumatology, internal medicine, or infectious disease referral according to results | 8.67 | 9 | 7 | 9 | 0 | strong consensus | 3 |
2.13 | Patients reporting complete cessation of RNCU with an increase in CIMDL involvement at follow-up should undergo a complete workup including serology (ESR, ANA, C-ANCA, and rheumatoid factor), rheumatology/internal medicine/infectious disease consultation, and nasal biopsy (both for histological and microbiological analysis) | 8.56 | 9 | 7 | 9 | 0 | strong consensus | 3 |
2.14 | In case of an increase in CIMDL involvement at follow-up in patients reporting stopping recreational cocaine use, a drug test can be considered | 8.22 | 9 | 5 | 9 | 1 | consensus | 1 |
2.15 | Patients with potential CIMDLs, especially with negative workup, can be offered a nasal mucosal biopsy under local or general anesthesia to assist with diagnosis | 7.94 | 9 | 3 | 9 | 1 | consensus | 3 |
Item No. | Statement | Mean | Median | Min | Max | Outliers | Result | Delphi Round |
---|---|---|---|---|---|---|---|---|
3.1 | CIMDL patients could be encouraged to meet a specialist in addiction medicine | 8.39 | 9 | 3 | 9 | 1 | consensus | 2 |
3.2 | Pain management in CIMDL patients should avoid strong opioids and rely on an addiction medicine service and/or pain medicine services in case of uncontrolled pain potentially requiring strong opioids | 8.67 | 9 | 7 | 9 | 0 | strong consensus | 3 |
3.3 | CIMDL patients must be advised that the only known method for halting lesion development is ceasing recreational nasal cocaine administration | 8.61 | 9 | 7 | 9 | 0 | strong consensus | 1 |
3.4 | Patients with CIMDL should be correctly informed that no “safe threshold” of cocaine usage prevents further CIMDL evolution | 8.89 | 9 | 8 | 9 | 0 | strong consensus | 1 |
3.5 | After proper information, any CIMDL patient can be offered a complete workup including serology (ESR, ANA, C-ANCA—with immunofluorescence for NPO and PR3 if positive—IgG4, and rheumatoid factor), rheumatology, internal medicine and/or infectious disease consultation, and nasal biopsy for increasing compliance to medical advice and therapies | 8.22 | 8.5 | 7 | 9 | 0 | strong consensus | 3 |
3.6 | Grade II or higher CIMDL patients should always be assessed for signs of rhinosinusitis even in asymptomatic cases | 8.50 | 9 | 6 | 9 | 1 | consensus | 2 |
3.7 | Grade III or higher CIMDL patients should be counseled for signs and symptoms of orbital or skull base complications and instructed to report to emergency department or specialty services promptly for evaluation | 8.17 | 9 | 3 | 9 | 1 | consensus | 1 |
3.8 | Potential CIMDL extension and signs of secondary rhinosinusitis should be assessed with a CT scan, with the use of contrast medium limited to cases with suspected osteitis or osteonecrosis | 8.00 | 9 | 3 | 9 | 1 | consensus | 1 |
3.9 | A baseline plain CT of the sinus (including the orbits and skull base) is recommended in patients presenting with CIMDL stage II or higher | 8.56 | 9 | 7 | 9 | 0 | strong consensus | 2 |
3.1 | The use of MRI in CIMDLs should be limited to the evaluation of orbital, skull base, intracranial, or other soft tissue involvement | 8.44 | 9 | 7 | 9 | 0 | strong consensus | 2 |
3.11 | The impact of CIMDLs on sinonasal health should preferably be investigated with general nasal health questionnaires, though sinusitis-specific questionnaires may have a clinical and investigational role | 8.39 | 9 | 5 | 9 | 1 | consensus | 3 |
3.12 | CIMDL patients should be instructed to employ daily saline nasal lavages for nasal toilette and can employ nasal emollients for reducing crusting | 8.44 | 9 | 3 | 9 | 1 | consensus | 1 |
3.13 | Antibiotic therapy (systemic and/or topical) should be reserved for bacterial superinfections or osteitis, obtaining bone cultures in the latter scenario whenever possible | 8.72 | 9 | 7 | 9 | 0 | strong consensus | 3 |
3.14 | Endoscopic debridement of crusting and necrotic tissues during outpatient follow-up and/or high-volume nasal lavages can be offered to improve symptoms such as nasal obstruction and cacosmia | 8.72 | 9 | 7 | 9 | 0 | strong consensus | 3 |
3.15 | CIMDL patients with palatal perforation can be offered palatal obturator prostheses as first-line management | 8.11 | 9 | 3 | 9 | 1 | consensus | 1 |
3.16 | Grade IV CIMDL patients should be proposed pneumococcal, haemophilus and meningococcal vaccine administration | 8.22 | 9 | 3 | 9 | 1 | consensus | 3 |
3.17 | Initial follow-up should be personalized and planned according to the CIMDL stage, considering more frequent visits to encourage RNCU cessation; in stable patients, a 6–12 month follow-up can be proposed up to 2–5 years after stopping cocaine snorting | 8.28 | 9 | 7 | 9 | 0 | strong consensus | 3 |
Item No. | Statement | Mean | Median | Min | Max | Outliers | Result | Delphi Round |
---|---|---|---|---|---|---|---|---|
4.1 | CIMDL patients with symptoms and signs of rhinosinusitis should be proposed adequate medical and/or surgical treatment as per EPOS/ICAR:RS guidelines | 8.44 | 9 | 5 | 9 | 2 | consensus | 2 |
4.2 | Patients with signs and symptoms of osteitis or osteonecrosis should be offered debridement of necrotic tissue and adequate systemic antibiotic treatment guided by culture biopsy of a bony specimen and planned together with an infectious disease consultation | 8.39 | 9 | 4 | 9 | 1 | consensus | 2 |
4.3 | In patients with intraorbital complications from CIMDL, culture-guided antibiotic therapy should represent the first-line management, while endoscopic transnasal surgical debridement and drainage should be reserved for cases with sudden visual acuity reduction or loss of color perception, large or superior/lateral orbital abscesses, or failing medical therapy | 8.44 | 9 | 7 | 9 | 0 | strong consensus | 3 |
4.4 | Grade IV CIMDL without CSF leaks or intracranial complications should be managed conservatively (nasal toilette, antibiotics for superinfections, vaccine recommendarions) | 8.72 | 9 | 7 | 9 | 0 | strong consensus | 3 |
4.5 | In fit-for-surgery grade IV CIMDL patients with ascertained CSF leaks, thorough debridement of necrotic tissues and prompt skull base reconstruction are recommended, and a neurosurgical consultation should be considered | 8.67 | 9 | 7 | 9 | 0 | strong consensus | 3 |
4.6 | Patients with intracranial complications should be managed with culture-guided antibiotic therapy and/or surgical toilette via an endonasal or combined endonasal/craniotomy route, in a multidisciplinary rhinological and neurosurgical team, according to the specific complication | 8.72 | 9 | 7 | 9 | 0 | strong consensus | 2 |
4.7 | Septal, nasal, and palatal reconstructions should not be performed in CIMDL patients unless the patient provides adequate motivation and proves cocaine use stopping by providing toxicological analyses covering at least 12 months | 8.61 | 9 | 5 | 9 | 1 | consensus | 2 |
Item No. | Statement | Mean | Median | Min | Max | Outliers | Result | Delphi Round |
---|---|---|---|---|---|---|---|---|
1.4 | CIMDLs are due to RNCU only, while they are not related to medical nasal cocaine administration | 7.61 | 9 | 1 | 9 | 2 | near-consensus | 3 |
2.7 | Patients with suspected CIMDLs denying RNCU and with negative workup results should undergo a cocaine drug test for cocaine to adjust follow-up and treatment | 7.83 | 9 | 3 | 9 | 3 | no consensus | 3 |
2.8 | RNCU can be identified via urinary metabolites (3 to 15 days after use, also according to the administered dose) or hair analysis (up to 3 months after use) | 8.28 | 9 | 3 | 9 | 2 | near-consensus | 3 |
4.8 | Reconstructions for CIMDL patients should be tailored to the patients; though pedicled flaps and vascularized free flaps usually represent the first option, autografts can still be considered, and allografts are usually adequate for a minority of patients | 7.94 | 9 | 4 | 9 | 2 | near-consensus | 3 |
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Saibene, A.M.; Nitro, L.; Carsuzaa, F.; Alexandru, M.; Bedarida, V.; Di Bari, M.; Fath, L.; Garcia-Lliberos, A.; Legré, M.; Lobo-Duro, D.; et al. Comprehensive Management of Cocaine-Induced Midline Destructive Lesions: A Young-IfOS Consensus. J. Pers. Med. 2025, 15, 231. https://doi.org/10.3390/jpm15060231
Saibene AM, Nitro L, Carsuzaa F, Alexandru M, Bedarida V, Di Bari M, Fath L, Garcia-Lliberos A, Legré M, Lobo-Duro D, et al. Comprehensive Management of Cocaine-Induced Midline Destructive Lesions: A Young-IfOS Consensus. Journal of Personalized Medicine. 2025; 15(6):231. https://doi.org/10.3390/jpm15060231
Chicago/Turabian StyleSaibene, Alberto Maria, Letizia Nitro, Florent Carsuzaa, Mihaela Alexandru, Vincent Bedarida, Matteo Di Bari, Léa Fath, Ainhoa Garcia-Lliberos, Margaux Legré, David Lobo-Duro, and et al. 2025. "Comprehensive Management of Cocaine-Induced Midline Destructive Lesions: A Young-IfOS Consensus" Journal of Personalized Medicine 15, no. 6: 231. https://doi.org/10.3390/jpm15060231
APA StyleSaibene, A. M., Nitro, L., Carsuzaa, F., Alexandru, M., Bedarida, V., Di Bari, M., Fath, L., Garcia-Lliberos, A., Legré, M., Lobo-Duro, D., Maniaci, A., Radulesco, T., Sowerby, L., Tan, N., Tucciarone, M., Vandersteen, C., Favier, V., & Fieux, M. (2025). Comprehensive Management of Cocaine-Induced Midline Destructive Lesions: A Young-IfOS Consensus. Journal of Personalized Medicine, 15(6), 231. https://doi.org/10.3390/jpm15060231