When cocaine destroys more than the nasal septum: From the palate to the skull base

Cocaine did not stop after perforating the nasal septum of Juan, a man in his thirties who used the drug every day. It then ate through his palate and destroyed part of the bones separating his nose from his brain. Cerebrospinal fluid, which protects the central nervous system, was leaking through the resulting cavity when he was admitted to intensive care with a severe neurological condition. Surgeons managed to close the opening after removing the necrotic tissue, but he continued using cocaine and eventually died of aspiration pneumonia after material that should have gone into the digestive tract reached his lungs.Juan’s case (a fictitious name used to protect his privacy) was one of those presented at the latest National Congress of the Spanish Society of Otolaryngology and Head and Neck Surgery, held in Madrid in October. Several presentations highlighted some of the most extreme consequences of cocaine use, going far beyond a perforated septum: damage to the palate, the skin of the nose, the eye socket and even the base of the skull. Such complications are uncommon and generally occur in people with extremely heavy cocaine use, but extensive tissue loss may already have occurred by the time patients seek medical attention. The process begins with cocaine’s ability to constrict blood vessels, which reduces blood flow and deprives cells of oxygen and nutrients. “It’s the same process as in a heart attack or stroke, but in the tissues of the nose. The tissues die, the cartilage is destroyed and perforations appear,” explains Gonzalo Díaz Tapia, associate head of otolaryngology at Villalba General University Hospital, who has experience treating this type of damage.The first signs of tissue deterioration usually come with sensations “similar to a cold.” However, it is rare for people who are suffering damage to seek care at that stage. “They typically come to the clinic once there is already some kind of perforation in the septum,” the specialist continues.According to the Spanish Health Ministry’s EDADES survey, around 793,000 people aged 15 to 64 used cocaine in Spain over the past year, representing 2.5% of the population in that age group. When respondents are asked about cocaine use during the previous 30 days, a measure that better captures regular consumption, the figure falls by about half.Díaz Tapia stresses that perforations, especially the severe cases described at the otolaryngology congress, are generally associated with near-daily use of the drug.When the destruction reaches the palate, the consequences extend to basic functions such as eating and speaking. The perforation creates an opening between the mouth and the nasal cavity, allowing food and liquids to pass between the two. It also alters the resonance of the voice, giving speech a nasal quality.The damage is compounded by infections that proliferate in the nasal passages and sinuses when secretions cannot drain properly and become trapped. Together, these processes can significantly worsen the condition. In the most severe cases, such as that of the patient who developed a cerebrospinal fluid leak, the destruction can extend to the structures separating these cavities from the inside of the skull.The substances used to cut cocaine can also make symptoms worse. The drug is often adulterated with levamisole, a veterinary antiparasitic agent that carries additional risks, including damage to blood vessels and necrosis affecting the ears, fingers and other parts of the body.Another case presented at the congress involved a woman who had lost vision in one eye and was suffering from pain that could not be controlled with medication. Cocaine-related damage had spread to the eye socket. After several operations to remove dead tissue from her nose and sinuses, surgeons ultimately performed an orbital exenteration: they removed the eye, cleared the cavity and reconstructed it using tissue from her own body.The first step in rebuilding tissue damaged by cocaine is to stop using the drug. “Otherwise it makes no sense, because it will not heal and the tissue will die again,” says Díaz Tapia. “What’s more, a failed operation can exhaust options that would be useful later. It is best to consider surgery when you have a chance of success.” Sign up for our weekly newsletter to get more English-language news coverage from EL PAÍS USA Edition