What is the evaluation and treatment for a nasal ulcer?

Evaluation and Treatment of Nasal Ulcers

For nasal ulcers, perform a thorough nasal examination with speculum or endoscopy to document ulcer characteristics (location, size, borders, perforation), obtain tissue biopsy if the ulcer persists beyond 2 weeks or appears atypical, and test ANCA and ACE levels to rule out Wegener's granulomatosis and sarcoidosis before attributing the ulcer to idiopathic or traumatic causes. 1, 2

Initial Clinical Evaluation

History Taking

• Document ulcer duration, triggers, and associated symptoms including epistaxis (most common presenting symptom), nasal obstruction, crusting, pain, and systemic manifestations 2, 3
• Obtain detailed medication history to identify potential causative drugs including topical decongestants (rhinitis medicamentosa), cocaine, ACE inhibitors, and anti-anginal medications like nicorandil 1, 4
• Assess for occupational and environmental exposures, trauma history (including nasal picking or self-manipulation), and history of prior nasal surgery or trigeminal nerve procedures 1, 5
• Screen for systemic disease symptoms suggesting granulomatous disease, autoimmune conditions, or immunodeficiency 1, 2

Physical Examination

The nasal examination should specifically assess for: 1

• Septal deviation, perforation, spurs, or ulcers with documentation of exact location (anterior vs posterior, unilateral vs bilateral)
• Ulcer characteristics: size in centimeters, shape (well-circumscribed vs irregular), borders (smooth vs undermined), depth, and presence of bleeding points 2, 6
• Surrounding mucosa: edema, pallor, erythema, crusting, prominent vessels, or excoriation 1
• Associated findings: nasal polyps, turbinate hypertrophy, discharge characteristics, and presence of tumors or foreign bodies 1

Use rigid or flexible nasopharyngoscopy for complete visualization of the middle meatus, posterior septum, and nasopharynx, as standard nasal speculum examination may miss posterior lesions 1

Diagnostic Workup

Laboratory Testing

Order the following tests based on clinical suspicion: 2

• ANCA (anti-neutrophil cytoplasmic antibody) - essential for identifying Wegener's granulomatosis, which successfully diagnosed 6 of 74 patients in one series 2
• ACE (angiotensin converting enzyme) - supports diagnosis of sarcoidosis 2
• Complete blood count - to rule out hematologic disorders in persistent ulcers 1, 7
• Syphilis serology - mandatory for all genital ulcers but consider for atypical nasal ulcers with systemic features 1

Note: ESR, CRP, chest radiograph, biochemistry panels, and coagulation screens did not contribute to diagnosis in a 74-patient series and should not be routinely ordered unless specific clinical indications exist 2

Tissue Biopsy Indications

Biopsy is indicated when: 1, 7, 2

• Ulcer persists beyond 2 weeks despite treatment 1, 7
• Malignancy is suspected based on appearance (irregular borders, induration, rapid growth) 2
• ANCA or ACE tests are abnormal 2
• Granulomatous disease, fungal infection, or neoplasia is in the differential 1

Important caveat: In a retrospective review of 71 biopsied septal lesions, 55% showed non-specific or non-diagnostic findings, and biopsy rarely changed management unless supportive tests were abnormal or malignancy was suspected 2

Differential Diagnosis by Etiology

Traumatic (39% of cases) 2

• Iatrogenic: nasal surgery, nasogastric tube placement, nasal oxygen cannula 2
• Self-induced: digital trauma (nose picking), trigeminal trophic syndrome (requires history of trigeminal ablation for neuralgia), factitious disorder 5
• Mechanical: sharp food, foreign bodies 7

Inflammatory/Autoimmune (11% of cases) 2

• Wegener's granulomatosis: presents more commonly with nasal obstruction than epistaxis; ANCA positive 2
• Sarcoidosis: elevated ACE levels 2
• Relapsing polychondritis: saddle nose deformity may be present 1

Drug-Induced 1, 4

• Rhinitis medicamentosa: rebound congestion from overuse of topical α-adrenergic decongestants or cocaine 1
• Nicorandil: can cause facial ulceration (previously unreported location) requiring drug discontinuation 4

Infectious (3% of cases) 2

• Fungal: Aspergillus species causing invasive sinonasal disease in immunocompromised patients, with potential for perforation into oral cavity or CNS extension 1
• Bacterial: secondary infection of existing ulcers 1

Idiopathic (47% of cases) 2

• Diagnosis of exclusion after comprehensive workup

Treatment Approach

Conservative Medical Management (First-Line)

Initiate for all non-emergent nasal ulcers: 3

• Nasal saline irrigation twice daily to reduce crusting and promote healing 1, 3
• Topical emollients (petroleum jelly, antibiotic ointment) to maintain moisture 3
• Discontinue causative medications if drug-induced etiology identified 1, 4
• Treat underlying systemic disease (systemic corticosteroids for Wegener's, antimicrobials for infections) 1

Surgical Intervention

Consider surgical options when conservative management fails after several months: 3

For chronic septal ulceration without perforation:

• Extracellular matrix scaffold repair (MatriStem® or similar) provides framework for healthy mucosal in-growth; all 3 patients in one series achieved complete symptom relief 3
• Septal dermoplasty or flap reconstruction - traditional options with variable success 3

Important surgical caveats: 5

• Trigeminal trophic syndrome: Delayed ulcer recurrence is common (4 of 5 patients in one series); reconstruction should only be attempted in highly motivated patients, with average 43-month delay from presentation to surgery 5
• Factitious disorder: Strongly discourage surgical repair; one patient developed recurrence 2 weeks post-operatively. Nasal prosthetic devices are preferred for aesthetic correction 5

Invasive Fungal Sinusitis (Immunocompromised Patients)

Requires aggressive combined medical-surgical approach: 1

• Voriconazole is the preferred agent based on randomized trial data in pulmonary aspergillosis 1
• Amphotericin B deoxycholate historically recommended, continued minimum 6 weeks post-surgery 1
• Urgent surgical debridement to prevent embolic complications and CNS extension 1
• CT imaging with bone windows essential for defining extent of soft tissue and bony disease 1

Specialist Referral Criteria

Refer to otolaryngology when: 1

• Ulcer persists beyond 2 weeks despite treatment 1, 7
• Significant septal deviation compressing middle turbinate or obstructing ostiomeatal complex 1
• Suspected neoplasia, granulomatous disease, or invasive fungal infection requiring endoscopic evaluation and biopsy 1
• Recurrent ulceration despite appropriate medical management 1

Refer to allergy/immunology when: 1

• Chronic/recurrent sinusitis with associated otitis media, bronchitis, or pneumonia suggesting immunodeficiency 1
• Need for quantitative immunoglobulin levels and specific antibody response assessment 1

Refer to psychiatry when: 5

• Factitious disorder or trigeminal trophic syndrome suspected, particularly if patient denies lesion manipulation despite evidence 5

Critical Pitfalls to Avoid

• Do not assume all anterior septal ulcers are traumatic - 47% remain idiopathic after full workup, and serious conditions like Wegener's can present similarly 2
• Do not routinely biopsy without clinical indication - 55% yield non-diagnostic results and rarely change management unless ANCA/ACE abnormal or malignancy suspected 2
• Do not overlook medication review - drug-induced ulcers require high clinical suspicion, especially in patients on multiple medications 4
• Do not surgically reconstruct self-induced ulcers prematurely - address underlying psychiatric condition first, as recurrence rates are extremely high 5
• Do not delay imaging in immunocompromised patients - invasive fungal sinusitis can rapidly extend to CNS with devastating consequences 1