Sir, you published a highly insightful article Cocaine and oral health in 2008 (BDJ 2008; 204: 365-369). We detail a case of this unusual presentation here with a brief literature review. A 48-year-old female presented with both nasal septal and hard palate perforation secondary to cocaine misuse (Fig. 1). Her history consisted of nasal congestion and obstruction which had deteriorated. She also developed facial pain, foul odour and sensation of food debris and fluids in her nasal cavity. Clinical examination demonstrated an obvious saddle nose deformity due to loss of nasal structural support. Intra-oral examination revealed partial anterior hard palate destruction leading to an oro-nasal fistula. On further questioning the patient admitted to a ten-year history of daily nasal cocaine use in addition to alcohol misuse.

Fig. 1
figure 1

Oro-nasal fistula showing a defect in the anterior hard palate extending to the nasal septum

Due to raised inflammatory markers and severe facial pain the patient was admitted to the ENT/maxillo-facial inpatient ward. She received a course of IV antibiotics and nasal douching. She was reviewed by the maxillofacial team and fitted with a cover plate to prevent passage through the oro-nasal fistula. The GP was asked to arrange substance misuse support for the patient to help with cocaine/alcohol cessation. The patient failed to engage with rehabilitation services and surgery was not advised due to the high risk of recurrence.

Cocaine is one of the most commonly used narcotics and is a central nervous stimulant resulting in a short term increase in dopamine release.1,2 Well known for its uses of anaesthetic and pain relief its chemical structure has been altered to produce commonly used preparations such as lidocaine, one of the most frequently used topical and injectable local anaesthetics.

There are three common routes of cocaine administration: intravenous, insufflation and smoke inhalation.3 Prolonged misuse of cocaine can lead to a myriad of complications which can vary based on the route of administration. Nasal septal perforation is an uncommon presentation and is more commonly associated with trauma and previous septal surgery.4

Upon presentation of ulcerative lesions of the face, differential diagnoses must be considered including trauma, infection and neoplastic disease. Ulceration secondary to substance misuse is an uncommon occurrence but sadly the trend is on the rise. Orofacial lesions and destructive midline perforation is not exclusive to abusers of cocaine and physicians who are involved in the diagnosis and treatment of these lesions should be aware that a number of agents and pathophysiological causes can be associated with this appearance.