What causes nasal ulceration?

Causes of Nasal Ulceration

Nasal ulceration results from systemic immunologic diseases (Wegener granulomatosis, sarcoidosis), chronic infections (tuberculosis, syphilis, fungal), malignancy, self-induced trauma (trigeminal trophic syndrome, factitious disorder), and drug reactions, with granulomatous diseases and infections being the most common serious causes requiring tissue biopsy for definitive diagnosis. 1

Systemic Immunologic and Granulomatous Diseases

The most critical causes to identify are systemic diseases that produce ulcerative nasal lesions:

• Wegener granulomatosis (granulomatosis with polyangiitis), sarcoidosis, relapsing polychondritis, and midline granuloma are primary systemic immunologic diseases affecting the nose, often presenting with ulceration before systemic symptoms become apparent 1
• These conditions typically produce ulcerative lesions with crust formation that may lead to nasal obstruction or bleeding 1
• Patients with uremia develop thinning of the nasal epithelium that can predispose to ulceration 1

Infectious Causes

Chronic infections are a major category requiring exclusion:

• Tuberculosis, syphilis, leprosy, sporotrichosis, blastomycosis, histoplasmosis, and coccidiomycosis all cause granulomatous nasal lesions that are usually ulcerative 1
• Rhinoscleroma, caused by Klebsiella rhinoscleromatis, presents as a polypoid mass with epistaxis and nasal obstruction, endemic in tropical and subtropical regions 1
• Deep fungal infections, particularly in patients with hyperglycemia, can cause persistent nasal ulcers 2
• HIV infection and syphilis should be tested for in persistent cases requiring HIV antibody and syphilis serology examination 2

Malignancy

Tumors must be excluded in any persistent nasal ulceration:

• Both benign and malignant tumors may cause nasal symptoms, with lesions generally causing unilateral occlusion 1
• Rapidly growing nasal malignancies cause nasal obstruction early and may present with bleeding, hyposmia/anosmia, pain, and otalgia 1
• Prolonged occupational exposure to chemicals such as nickel and chrome have been associated with nasal carcinoma 1

Self-Induced Ulceration

A frequently overlooked but important category:

• Trigeminal trophic syndrome (TTS) occurs after peripheral or central damage to the trigeminal nerve, characterized by anesthesia, paresthesias, and ala nasi ulceration 3, 4, 5
• TTS most commonly occurs in older women following therapy for trigeminal neuralgia, with ulcers usually involving the nasal ala and paranasal areas 3
• Factitious disorder presents with self-induced nasal lesions distinguished from TTS by normal trigeminal nerve function and frequent patient denial of lesion manipulation 4
• Appearance of nasal ulcer after trigeminal ablation for neuralgia is diagnostic of TTS 4

Drug-Induced Ulceration

Medications can rarely cause nasal ulceration:

• Nicorandil, an anti-anginal medication, is known to cause oral ulceration and skin lesions, though facial ulcers are rare 6
• Drug-related ulcers require a high index of clinical suspicion, especially in patients with complex medical backgrounds taking multiple medications 6

Diagnostic Approach

For any nasal ulcer persisting over 2 weeks or not responding to 1-2 weeks of treatment, perform tissue biopsy and comprehensive laboratory evaluation 2:

• Blood tests should include full blood count, coagulation studies, fasting blood glucose, HIV antibody, and syphilis serology 2
• Tissue biopsy is essential to differentiate between malignancy, infection, vasculitis, and self-induced causes 3, 4, 5
• Special tests including direct immunofluorescence, serum antibody tests, and microbiological cultures may be necessary 2
• Consider multiple biopsies if ulcers involve different sites with varying morphological characteristics 2

Critical Pitfalls to Avoid

• Never assume a nasal ulcer is benign without biopsy, as malignancy and serious systemic diseases can present similarly 1, 3
• Do not overlook systemic causes, as persistent nasal ulcers may be the first sign of underlying systemic conditions 2
• In patients with trigeminal nerve procedures or neuralgia history, strongly consider TTS before extensive immunosuppressive workup 5
• Inadequate or superficial biopsies may miss important diagnostic features 2
• For suspected self-induced ulceration (TTS or factitious disorder), surgical reconstruction often results in recurrence and should be delayed until the underlying condition is addressed 4