Objectives Cocaine and cocaine mixed with levamisole are increasingly used in the UK and result in significant direct nasal damage in addition to promoting vasculitis. Our aims were as follows: (1) to identify the main symptoms and presentation of cocaine-induced vasculitis; (2) to provide evidence regarding the best practice for the investigation and diagnosis of cocaine-induced vasculitis; and (3) to analyse the clinical outcomes of patients in order to understand the optimal management for the condition. Methods We performed a retrospective case series analysis of patients presenting with cocaine-induced midline destructive lesions or vasculitis compatible with granulomatosis with polyangiitis (GPA) from two large tertiary vasculitis clinics between 2016 and 2021. Results Forty-two patients (29 Birmingham, 13 London) with cocaine-induced midline lesions or systemic disease were identified. The median age was 41 years (range 23–66 years). Current cocaine use was common, and 20 of 23 samples provided were positive when routine urine toxicology was performed; 9 patients who denied ever using cocaine were identified as using cocaine based on urine toxicology analysis, and 11 who stated they were ex-users still tested positive. There was a high incidence of septal perforation (75%) and oronasal fistula (15%). Systemic manifestations were less common (27%), and only one patient had acute kidney injury. Fifty-six per cent of our patients were PR3-ANCA positive, with none testing positive for MPO-ANCA. Symptom remission required cocaine discontinuation even when immunosuppression was administered. Conclusion Patients with destructive nasal lesions, especially young patients, should have urine toxicology performed for cocaine before diagnosing GPA and considering immunosuppressive therapy. The ANCA pattern is not specific for cocaine-induced midline destructive lesions. Treatment should be focused on cocaine cessation and conservative management in the first instance in the absence of organ-threatening disease.

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Tumour seeding along the needle tract following core needle biopsy of the parotid is a recognised complication. We present a unique case of mucoepidermoid carcinoma of the parotid in an 18-year-old patient with associated tumour seeding within the core needle biopsy tract. Tumour seeding was confirmed both histologically and radiologically on magnetic resonance imaging as early as 35 days post-biopsy. The patient was treated successfully with a combination of surgery and adjuvant proton beam therapy. This case also visually demonstrates a surgical approach to en-block excision of the mass and tract.

The mandible is the most commonly fractured bone in the maxillofacial region following trauma. Severe infections are rare, and so we highlight an unusual presentation of Ludwig’s angina following a late presentation of a mandibular fracture in a 68-year-old gentleman with significant medical co-morbidities. The recovery process was prolonged and involved multi-disciplinary input. This case makes a recommendation for early recognition of mandibular fractures, antibiotic therapy where appropriate, and hypervigilance when caring for patients with systemic illnesses.

Most impacted fish bones in the aerodigestive tract are easily removed or managed in the emergency department. Occasionally, they present as a diagnostic and surgical challenge. We present a case of a submucosal intraglossal fish bone extraction in a 38-year-old male who presented with localized pain in his tongue. This case highlights several key factors contributing to the successful outcome, including multidisciplinary input from anaesthesiology, radiology, and the oral and maxillofacial surgical team. The use of a pre-operative computed tomography (CT) scan, nasal intubation, and intra-operative ultrasound scan potentially minimised the risk of associated complications.

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