BMJ Case Reports 2016; doi:10.1136/bcr-2016-216393

Snorting the clivus away: an extreme case of cocaine-induced midline destructive lesion

  1. Alberto Maccari
  1. Otolaryngology Unit, ASST Santi Paolo e Carlo, Department of Health Sciences, Università degli Studi di Milano, Milan, Italy
  1. Correspondence to Professor Alberto Maccari, bmjotorinosanpaolo{at}
  • Accepted 7 October 2016
  • Published 20 October 2016


Cocaine is a drug with relevant socioeconomic and clinical implications, which is usually recreationally used for its stimulant effects. It is widely known that the habit of snorting cocaine is associated with a peculiar type of drug-induced chronic rhinitis, which leads to inflammation of the sinonasal mucosa, slowly progressing to a destruction of nasal, palatal and pharyngeal tissues. These characteristic lesions due to cocaine abuse are commonly called cocaine-induced midline destructive lesions (CIMDL). Diagnosis is not always straightforward, since various conditions, mainly vasculitis, might mimic this acquired condition. The extent of pharyngeal involvement varies, although often a prolonged abuse can trigger a progressive destruction of oral and nasal tissues, with development of infections and recurrent inflammation. Our article focuses on cocaine as a world health problem with important ear, nose and throat implications and discusses the difficulties in diagnosing and treating CIMDL, through a case report.


  • Contributors AM did the surgery and took the biopsies. AMS helped in taking the biopsies and did the nasal endoscopy. He also helped in writing the article. KL helped in following up the patient. MM wrote the article and helped in doing the endoscopies.

  • Competing interests None declared.

  • Patient consent Obtained.

  • Provenance and peer review Not commissioned; externally peer reviewed.

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