Differential Diagnosis for Non-Healing Erosion in the Nasal Septum after Years of Nasally Inhaled Drug Abuse

• Single Most Likely Diagnosis
  • Nasal septal perforation due to chronic cocaine or other drug abuse: This is the most likely diagnosis because long-term inhalation of drugs like cocaine can cause vasoconstriction, leading to tissue necrosis and perforation of the nasal septum. The chronic nature of the condition and the history of drug abuse strongly support this diagnosis.
• Other Likely Diagnoses
  • Chronic rhinosinusitis: Prolonged drug abuse can lead to chronic inflammation and infection of the nasal passages and sinuses, contributing to non-healing erosions.
  • Granulomatosis with polyangiitis (formerly known as Wegener's granulomatosis): This autoimmune disorder can cause destruction of the nasal passages and sinuses, although it is less directly linked to drug abuse.
  • Relapsing polychondritis: An autoimmune condition that can cause cartilage destruction, including in the nose, but it's less common and not as directly associated with drug abuse.
• Do Not Miss Diagnoses
  • Squamous cell carcinoma or other nasal cavity malignancies: Although less likely, the possibility of a malignancy arising in the setting of chronic irritation and inflammation cannot be overlooked, as it would have significant implications for treatment and prognosis.
  • Infectious diseases such as syphilis or leprosy: These can cause nasal destruction and are important to consider, especially if the patient has been exposed to these pathogens or has risk factors for them.
• Rare Diagnoses
  • Sarcoidosis: A condition that can cause granulomatous inflammation in various parts of the body, including the nose, but it's rare and less directly linked to drug abuse.
  • Midline destructive lesions (e.g., midline granuloma): These are rare conditions that can cause destruction of the nasal tissues and sinuses, often due to an abnormal immune response or a specific type of lymphoma.