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Nasolacrimal Duct Obstruction and Orbital Cellulitis Associated with Chronic Intranasal Cocaine Abuse

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Nasolacrimal Duct Obstruction and Orbital Cellulitis Associated with Chronic Intranasal Cocaine Abuse CLINICAL SCIENCES Nasolacrimal Duct Obstruction and Orbital Cellulitis Associated With Chronic Intranasal Cocaine Abuse George Alexandrakis, MD; David T. Tse, MD; Robert H. Rosa, Jr, MD; Thomas E. Johnson, MD Objective: To report the association of acquired naso- ture, opacification of the sinuses, and the presence of an lacrimal duct obstruction and orbital cellulitis in pa- intraorbital tissue mass. Histopathologic examination of tients with a history of chronic intranasal cocaine abuse. the nasolacrimal duct in 2 patients and of the orbital mass in a third patient revealed marked chronic inflamma- Methods: Retrospective, consecutive case series. Re- tion with fibrosis causing secondary nasolacrimal duct sults of imaging, histopathologic examinations, and clini- obstruction. Six patients were treated with systemic an- cal courses of these patients were studied. tibiotics followed by dacryocystorhinostomy in 3 pa- tients, and a pericranial flap to insulate the exposed or- Results: Five women and 2 men (mean age, 41 years) bit in 1 patient. with a history of chronic intranasal cocaine abuse (mean, 11 years; range, 5-20 years) presented with epiphora and Conclusions: Chronic intranasal cocaine abuse can re- in some cases acute onset of periorbital pain, edema, and sult in extensive bony destruction of the orbital walls with erythema associated with fever. The suspicion of intra- associated orbital cellulitis, and should be included in the nasal cocaine abuse was made on anterior rhinoscopy with differential diagnosis of acquired nasolacrimal duct ob- the detection of an absent nasal septum and inferior tur- struction. Anterior rhinoscopy is very helpful in estab- binate. Computed tomographic and magnetic reso- lishing the correct diagnosis in these patients. nance imaging findings in 4 patients included extensive bony destruction of the normal orbital wall architec- Arch Ophthalmol. 1999;117:1617-1622 OCAINE IS a naturally oc- the delicate upper respiratory tract mucosa. curringalkaloidofthecoca Cocaineinducesintensevasoconstrictionand plantErythroxyloncoca.Its anesthesiaoftherespiratorymucosa;thismay pharmacological proper- lead to mucoperichondrial ischemia, necro- tiesaresecondarytostimu- sis, and nasal septum perforation.2,5 Many in- Clation of the central and sympathetic ner- tranasal cocaine abusers develop rebound vous systems by augmenting the effects of nasal stuffiness, which is self-treated with norepinephrine.Theuseofcocaineasatopi- over-the-counter nasal inhalants contain- cal anesthetic in ophthalmology was de- ing vasoconstrictors that contribute to fur- scribed by Koller1 in 1884. Topically applied ther nasal mucoperichondrial necrosis. Re- cocaine causes mydriasis by blocking the petitive cycles of vasoconstriction lead to reuptake of norepinephrine and is used in marked destruction and result in osteo- evaluating anisocoria. In a higher concen- lytic sinusitis with total bony and cartilage tration, cocaine may cause cycloplegia and necrosis or saddle nose deformity.2,5,6 upper eyelid retraction.2 We describe 7 consecutive cases of ac- Cocaine abuse is an ongoing public quired nasolacrimal duct obstruction health concern and its prevalence and effects (NLDO) associated with chronic intrana- continuetodrawattention.AUSgovernment sal cocaine abuse. Three of the patients also report estimated that 28.7% of young adults presented with concomitant orbital cellu- aged 18 to 25 years have used cocaine at least litis secondary to the chronic sinusitis and once.3 When used illicitly, cocaine is usually destruction of the orbital bony walls. His- taken intranasally, intravenously, or by in- topathological studies are presented and the halation. Depending on the route of admin- management of these patients is dis- istration, several medical complications can cussed. Ophthalmologic complications as- occur.4 Intravenous use can result in myo- sociated with cocaine abuse are reviewed. cardial infarction, cardiac arrhythmia, rup- ture of the ascending aorta, cerebrovascular RESULTS accident, subarachnoid hemorrhage, hyper- From the Bascom Palmer Eye tensivecrisis,seizure,pulmonaryedema,and Seven consecutive patients (2 men and 5 Institute, University of Miami death.4 Theintranasalrouteisassociatedwith women) with a mean age of 41 years (age School of Medicine, Miami, Fla. complications related to chronic irritation of range, 36-58 years) were identified. Pre- ARCH OPHTHALMOL / VOL 117, DEC 1999 WWW.ARCHOPHTHALMOL.COM 1617 ©1999 American Medical Association. All rights reserved. Downloaded From: https://jamanetwork.com/ on 10/01/2021 opsy of a left medial orbital soft tissue mass disclosed dense fibrosis with chronic inflammation, partially involving SUBJECTS AND METHODS the skeletal muscle. Occasional Russell bodies were pres- ent (Figure 2). Cultures were negative for organisms. The study conformed to the policies outlined by the A course of oral prednisone (1 mg/kg per day) was started. Human Subjects Subcommittee of the University of Because of persistent orbital pain and minimal response Miami School of Medicine, Miami, Fla. The de- to steroids, a pericranial flap harvested from the fore- scribed patients were identified from a review of the head was used to insulate the exposed orbit from the ex- medical records of the Bascom Palmer Eye Institute ternal environment and air turbulence within the nasal for a 6-year interval (1993-1998). All patients un- cavity.7 The flap was secured into position within the or- derwent a complete history, physical examination, bit by wedging it between the posterior floor and peri- and ophthalmic evaluation. Diagnostic tests in- orbita.7 Postoperative anterior rhinoscopy revealed a cluded evaluation of the lacrimal system with the dye smooth, mucosalized tissue layer lining the medial wall disappearance test and Jones test, and evaluation of the sinuses and orbits with computed tomographic and orbital floor. Motility showed improved abduction (CT) or magnetic resonance imaging. of the left eye. The patient was able to breathe without orbital discomfort. Tearing persisted, but he declined sur- gery to relieve this symptom. He died 14 months later secondary to a myocardial infarction. senting signs and symptoms included epiphora or peri- orbital pain, edema, and erythema associated with fe- CASE 2 ver. The suspicion of intranasal cocaine abuse was made on anterior rhinoscopy with the detection of an absent A 40-year-old woman with a 20-year history of intranasal nasal septum and inferior turbinate. All patients had a cocaine inhalation had acutely decreased vision in the right history of chronic intranasal cocaine abuse with an av- eye and severe right periorbital pain with fever. Ocular his- erage of 11 years (range, 5-20 years). Lacrimal irriga- tory was notable for amblyopia of the left eye and chronic tion confirmed complete blockage. Computed tomo- right dacryocystitis secondary to complete NLDO. She had graphic and magnetic resonance imaging studies in 4 undergone uneventful right DCR 6 weeks prior to pre- patients disclosed extensive destruction of the orbital wall sentation. Her medical history was otherwise unremark- architecture, opacification of the sinuses, and the pres- able and she denied intravenous cocaine use. The visual ence of an intraorbital tissue mass. Findings from histo- acuity was 20/60 OD and 20/100 OS. Extraocular motil- pathologic examination of the nasolacrimal duct (NLD) ity of the right eye disclosed restricted upgaze and down- and orbital mass revealed marked chronic inflamma- gaze. External examination showed moderate right peri- tion with fibrosis causing secondary nasolacrimal duct orbital swelling, erythema, and a saddle nose deformity. obstruction. Six patients were treated with systemic an- The remainder of the ophthalmologic examination was un- tibiotics, followed by dacryocystorhinostomy (DCR) in remarkable. A large septal perforation was present on an- 3 patients and a pericranial flap in 1 patient. The cases terior rhinoscopy. Computed tomographic scan revealed are summarized in the Table. opacification of the right ethmoid sinus, right maxillary sinus, and both frontal sinuses with destruction of the nor- REPORT OF CASES mal ethmoidal and antral bony architecture (Figure 3). Treatment with intravenous antibiotics was started with CASE 1 rapid resolution of symptoms. Blood cultures were nega- tive for organisms. One month later, she denied perior- A 39-year-old man with a 12-year history of intranasal co- bital pain and visual acuity was 20/30 OD. Motility was caine abuse complained of severe left retrobulbar pain ag- unchanged. She later committed suicide. gravated by nasal breathing, diplopia, and constant tear- ing of the left eye for several months. His medical and ocular CASE 3 histories were otherwise unremarkable. He denied intra- venous cocaine use. Visual acuity was 20/20 OU. Motility A 58-year-old woman with a 5-year history of chronic showed decreased abduction and absent adduction of the intranasal cocaine abuse had acute onset of severe right left eye. External examination disclosed marked left peri- periorbital pain and fever. Her ocular history was unre- orbital swelling and erythema, inferior displacement of the markable. Her medical history was notable for morbid left globe, and saddle nose deformity. The remainder of obesity, non–insulin dependent diabetes mellitus, and the ophthalmologic examination was unremarkable. An- chronic obstructive pulmonary disease. She denied in- terior rhinoscopy disclosed that the nasal septum
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