Cocaine‐Induced Midline Destructive Lesions: A Historical Review of Diagnostic Mimicry
Anna Onderková, Marlene M. Speth, Hesham A. SalehABSTRACT
Objective
To review the historical evolution of cocaine‐induced midline destructive lesions (CIMDL), from cocaine's medical introduction to contemporary diagnostic classification.
Data Sources
PubMed/MEDLINE, Embase, Scopus and Google Scholar were searched from inception to April 2026, supplemented by hand‐searching of reference lists. Source material comprised published historical and clinical accounts of cocaine's introduction as a local anesthetic, its dissemination and regulation, and later otolaryngology and multidisciplinary reports characterizing cocaine‐associated sinonasal injury, destructive midline syndromes, and ANCA‐associated disease.
Review Methods
A non‐systematic narrative review was organized chronologically around major historical and clinical milestones.
Results
Following Koller's 1884 introduction of topical cocaine anesthesia, increasing exposure led to recognition of destructive sinonasal complications and progressive refinement of CIMDL as a distinct diagnostic entity. Late‐20th‐century otolaryngology literature established CIMDL as a distinct clinicopathological entity that frequently mimics granulomatosis with polyangiitis (GPA) and other midline destructive disorders. Contemporary literature recognizes overlap between CIMDL and levamisole‐associated vasculitis, with human neutrophil elastase‐directed ANCA aiding serological discrimination and extent‐based grading standardizing anatomical severity.
Conclusion
The diagnostic complexity of CIMDL reflects three converging historical forces: the rapid adoption of cocaine without adequate safety surveillance infrastructure; five decades of unresolved nosological debate surrounding midline destructive disease; and the emergence of levamisole as a ubiquitous adulterant, which has confounded the serological tools developed to differentiate these conditions. Extent‐based staging provides a serologically agnostic framework despite the reduced specificity of ANCA testing. Diagnosis should integrate a non‐judgmental exposure history with histological, radiological and toxicological findings.
Level of Evidence
Not applicable.