Treatment of an oronasal fistula in a patient on bisphosphonate therapy: A case study.

Bisphophonates (BPs) are a group of drugs used in treating bone diseases, which may lead to the development of the osteonecrosis of the jaw (ONJ). The negative impact of BPs on angiogenesis is among the causes of ONJ. The specific mechanisms of complications are unknown. What is taken into consideration is the trauma background, which, in combination with the implemented BP treatment, can induce bone necrosis. One of the possible consequences of necrotic change progression is the development of an oronasal fistula. Treatment generally requires a surgical intervention.The paper describes the course of treatment of an oronasal fistula in a patient with BP osteitis, currently using an upper denture. The fistula arose a year after the removal of a protruding sequestrum in the region of the hard palate. An attempt was made to treat the fistula by the mobilization of soft tissues from the palate and the bilayered closure of the fistula with the use of a pedicled connective tissue graft on the greater palatine artery, along with a Tinti-Parma-Benfenati (TPB) flap. The patient was subjected to appropriate post-procedural measures. Regular follow-ups did not reveal any abnormalities in the course of healing.The use of the abovementioned procedure proved to be an effective method of treatment of an oronasal fistula. The use of a pedicled connective tissue graft for the closure of the oronasal fistula caused by BP therapy had a significant effect on the treatment outcome.

Extranodal NK/T cell lymphoma, nasal type, with retrobulbar extraconal phlegmon and naso-oral fistula.

Extranodal natural killer (NK-)/T cell lymphoma, nasal type (ENKL), 1 is a rare disease that often mimics rheumatological and infectious conditions and can therefore be difficult to diagnose. The authors present a case of a 55-year-old Vietnamese woman who was misdiagnosed with severe atrophic rhinitis and chronic sinus osteitis. Over a period of 8 months from initial referral, she underwent multiple biopsies and was treated with various antimicrobial regimens until the histopathological diagnosis of ENKL was finally made. Her presentation was complicated by bacterial dacrocystitis, preseptal cellulitis and a retrobulbar extraconal phlegmon requiring surgical drainage. She also subsequently developed a naso-oral fistula on treatment. This case highlights the importance of repeated biopsies, in particular from non-necrotic regions of the sinonasal tract when a patient does not respond to therapy and clinical suspicion of neoplastic pathology remains. This is the first case of ENKL to describe significant orbital complication.

Case for diagnosis. Palate perforation due to cocaine use

Abstract: We report a 42-year-old cocaine addicted female patient referred for evaluation of hard palate ulceration resulting in oro-sinus communication with difficulties in swallowing and phonation, an rhino-sinusitis. Acrylic and removable silicone prosthesis was prescribed to relieve severe functional disorders. It is essential that the patient permanently abandons cocaine use to perform surgical reconstruction.

Case for diagnosis. Palate perforation due to cocaine use.

We report a 42-year-old cocaine addicted female patient referred for evaluation of hard palate ulceration resulting in oro-sinus communication with difficulties in swallowing and phonation, an rhino-sinusitis. Acrylic and removable silicone prosthesis was prescribed to relieve severe functional disorders. It is essential that the patient permanently abandons cocaine use to perform surgical reconstruction.

Lesión necrotizante de la línea media con fístula oronasal causada por inhalación de cocaína / Cocaine-induced midline destructive lesion and oronasal fistula

Los autores realizan una revisión bibliográfica de las perforaciones palatinas asociadas a lesiones necrotizantes de la línea media por inhalación de cocaína y, aportan un caso clínico propio con fístula oronasal. La frecuencia de las perforaciones palatinas asociadas a las lesiones necrotizantes de la línea media por inhalación de cocaína es muy superior a las encontradas en la granulomatosis de Wegener. La presencia de una perforación palatina es también un dato sugestivo de linfoma extranodal. La clave diagnóstica de todas las lesiones necrotizantes de la línea media es histopatológica pero obtener un diagnóstico inequívoco es más difícil de obtener de lo que podría suponerse (AU)

The authors perform a literature review of palatal fistulas present in midline necrotizing nasal lesions due to inhalation of cocaine and present a case report. The frequency of palatal fistulas associated with midline necrotizing lesions by inhalation of cocaine is superior to tose found in Wegener's granulomatosis. The presence of a palatal fistula is also suggestive of a extranodal lymphoma. Histopathology is the key to the differential diagnosis but getting an unequivocal diagnosis is more difficult to obtain than might be supposed (AU)

Repair of cocaine-related oronasal fistula with forearm radial free flap.

BACKGROUND: Cocaine snorting may cause significant local ischemic necrosis and the destruction of nasal and midfacial bones and soft tissues, leading to the development of a syndrome called cocaine-induced midline destructive lesion. A review of the English-language literature reveals only a few articles describing the treatment of hard and/or soft palatal perforation related to cocaine inhalation. Described here are 4 patients with a history of cocaine abuse showing palatal lesions. MATERIALS AND METHODS: From 2010 to 2013, a total of 4 patients affected by cocaine-related midline destructive lesions were referred to our department. They all presented signs of a cocaine-induced midline destructive lesion. They showed wide midfacial destruction involving the nasal septum as well as the hard and soft palates causing an ample oronasal communication. RESULTS: In 3 patients, oronasal communication has been treated successfully using a personal technique based on a partially de-epithelialized forearm free flap. The fourth patient had been treated only with local debridement because, when she came to our attention, her abusive habits were still unsolved. DISCUSSION: Different surgical options have been reported such as local, regional, and free flaps for hard and soft palate reconstruction. However, because of an unpredictable vascularization of the palatal tissues and owing to the scarceness of the local soft tissues, local flaps are at high risk for partial and complete failure. The transfer of free vascularized tissue, however, seems to be the most reliable and logical solution for medium- to large-sized fistulas. Among the various free flaps, we choose the radial forearm type because of the pedicle length and the flap thickness.

The head, neck, and systemic manifestations of levamisole-adulterated cocaine use.

Systemic complications of levamisole-adulterated cocaine (LAC) use have recently been described. The objective of this review is to increase awareness of these manifestations among oral and maxillofacial surgeons. LAC exposure through inhalation, nasal insufflation, or injection can induce cutaneous vasculopathy and hematologic abnormalities such as neutropenia or agranulocytosis. Unlike other vasculopathies involving the skin, LAC-induced vascular injury frequently manifests with purpuric and necrotic lesions that involve the face and ears. Oral manifestations have also been reported but are not yet well characterized. The aforementioned hematologic manifestations are not uncommon, and patients exposed to LAC are potentially at higher risk for infectious complications. When manifestations of LAC affect the head, neck, and oral cavity, oral and maxillofacial surgeons may be the first providers to encounter the patient. Early recognition of the clinical signs and laboratory abnormalities will better allow for distinguishing LAC-related effects from various clinical mimics, will facilitate appropriate patient management, and may further contribute to the understanding of the biological effects of LAC.

Unusual case of a conservatively treated pathological fracture after sequestrectomy in a patient with long-term oral bisphosphonate use.

Bisphosphonates are used in the management of metastatic bone disease, Paget's disease of bone and osteoporosis. A long-term complication of these drugs is bisphosphonate-related osteonecrosis of the jaws (BRONJ). Treatment of BRONJ can be quite challenging, and remains a topic of debate. We report the case of a 74-year-old woman who had used Fosamax(®) (alendronate sodium) orally for four years. After 3½ years she developed pain, swelling, and a fistula in the left mandible. After exploration and sequestrectomy in combination with antibiotic treatment, osteolysis with a pathological fracture developed. Given the extent of the disorder and a decrease in complaints after the surgery, a non-surgical approach was chosen with continuation of the antibiotic treatment for 10 weeks, a soft diet and not wearing of dentures. During follow-up complaints subsided, the intra-oral fistula disappeared and the fracture healed. This is the first report of healing of a BRONJ patient stage III with pathological fracture. It illustrates the remaining healing potential of the bisphosphonate-treated bone.

Diagnostic considerations and prosthetic rehabilitation of a cocaine-induced midline destructive lesion: A clinical report.

The intranasal inhalation of cocaine has numerous complications. In addition to its systemic effects, cocaine can cause extensive destruction of the osteocartilaginous midline structures of the palate, nose, and sinuses. Without an accurate social and clinical history, a cocaine-induced midline destructive lesion can cause diagnostic difficulties, because its clinical presentation closely mimics other diseases. This clinical report describes an oronasal defect caused by cocaine use, the diagnostic considerations of these lesions, and prosthetic management of the defect.

Cocaine and oral health.

In the UK almost one million individuals use cocaine on a regular basis, implying that dentists are likely to encounter individuals that use cocaine. Regular use of this drug may have several orofacial effects, such as perforation of the nasal septum and palate, gingival lesions and erosion of tooth surfaces. In addition, recent use of cocaine increases the risk of a medical emergency during dental treatment, especially when epinephrine-containing local anaesthetics or retraction cords are used. Therefore, dental treatment should be postponed for 6 to 24 hours after the use of cocaine.

An unusual oronasal fistula induced by prolonged cocaine snort. Case report and literature review.

In the last 50 years cocaine usage has had a growing incidence worldwide. Chronic nasal abuse of this drug can cause extensive oromaxillofacial destructive process as oronasal perforation. To author's knowledge the only type of oronasal fistula in cocaine abusers that has been reported to date has been perforation of the hard palate; a case of oronasal fistulas involving another region of oral cavity, the anterior gingival sulcus, has been reported only once. In this article authors present the first case of oronasal fistula involving hard palate and the right supero-lateral vestible induced by prolonged cocaine snort described in literature, review about the better surgical management for this lesion and the relationship between chronic cocaine abuse and elevated serum levels of c-ANCA.

[Effects of cocaine use on oral health and implications for dental treatment]. / Effecten van cocaïnegebruik op de mondgezondheid en de implicaties voor tandheelkundige behandelingen.

In The Netherlands, an increasing number of people use cocaine frequently, which may induce orofacial complications such as perforation of the nasal septum and palate, gingival lesions and dental erosion. In addition, recent use of cocaine increases the risk of cardiovascular complications during dental treatment, especially when local anaesthetics or adrenaline-impregnated retraction cords are used. Therefore, dental treatment should be postponed at least 6 to 24 hours after the use of cocaine.

Cocaine-induced oronasal fistulas with external nasal erosion but without palate involvement.

The effects of chronic cocaine abuse have been widely described in the literature. Common complications include nasal septal perforation, saddle-nose deformity, and palatal perforation. Erosion of the external structures of the face has not been as extensively described, nor have oronasal fistulas that involve structures other than the hard or soft palate. In this article, we present the first reported case of cocaine-induced external nasal erosion that included multiple oronasal fistulas in the anterior gingival sulcus but did not involve the hard or soft palate. We stress the importance of a thorough history in such patients and consideration of all possible diagnoses, including drug abuse.

Necrotizing granulomatous vasculitis associated with cocaine use.

Cocaine abuse may be associated with a destructive nasal and pharyngeal process felt to be due to ischemia secondary to vasoconstriction. This report is the first to document a necrotizing granulomatous vasculitis associated with nasal destruction and an oronasal fistula in a chronic cocaine user. Cocaine is an environmental insult that may play a role in triggering cerebral and non-cerebral vasculitis including a necrotizing granulomatous vasculitis of the respiratory tract.

Rare case of naso-oral fistula with extensive osteocartilaginous necrosis secondary to cocaine abuse: review of otorhinolaryngological presentations in cocaine addicts.

We report what we believe to be only the 10th case of palatal necrosis secondary to cocaine abuse in a 33-year-old female patient. Extensive necrosis also involved the cartilaginous and bony septum and paranasal sinuses. Following exclusion of other mid-line destructive diseases her treatment involved saline douches and cessation of cocaine. She remains under review within the department with no evidence of progressive disease. We present a review of the other nine cases of palatal necrosis reported in the world literature and demonstrate a greater incidence in female users. The various presenting conditions of cocaine abuse encountered within the head and neck region by the otorhinolaryngologist are then discussed.