A 38-year-old man complains of a whistling sound during inspiration and recurrent crusting in the nose. Examination reveals a well-defined perforation in the anterior cartilaginous nasal septum. He has a long history of habitual intranasal cocaine use. The most likely cause of the perforation is:

• A Caseous necrosis from tuberculous osteitis
• B Granulomatous vasculitis of the septal vessels
• C Syphilitic periostitis of the bony septum
• D Ischaemic necrosis of the cartilage from vasoconstriction ✓

Explanation

Cocaine produces intense local vasoconstriction, and repeated application causes ischaemic necrosis of the anterior cartilaginous septum, the classical site of traumatic and chemical perforations because this region has the poorest blood supply. Granulomatous vasculitis suggests granulomatosis with polyangiitis, which usually brings systemic features and a positive PR3-ANCA. Syphilitic perforation characteristically involves the bony posterior septum rather than the cartilage.

Reference: Scott-Brown's Otorhinolaryngology and Head and Neck Surgery, 8th ed.

High-yield for: NEET PGINI-CETNExTFMGEUSMLEPLABMRCP

Written and medically reviewed by the StethoPrep medical team.