A 54-year-old male patient presented to oral and maxilla-facial surgery department for management of a large naso-oral fistula. A computed tomography (CT) scan revealed extended necrosis of hard and soft palates, nasal septum and medial maxillary sinus walls (Fig. 1). The patient's file contained a CT scan that had been performed six years earlier; it showed intact intranasal structures and a deviated septum (Fig. 2).

Fig. 1 Coronal (a) and axial (b) planes of the current CT-scanner; large endonasal and palatal necrosis.

Fig. 2 Coronal (a) and axial (b) planes of the first CT-scanner, 6 years ago; highlighting intact oral and endo-nasal structures.

Many different diagnoses could explain this local necrosis: autoimmune diseases (especially granulomatosis with polyangiitis, e.g., Wegener's granulomatosis), infections such as syphilis or leishmaniasis, iatrogenic causes and malignant lesions. The full investigation did not explain the large necrosis.

The patient ultimately revealed using cocaine by nasal insufflation for several months. Extended necrosis is not a common complication of cocaine abuse, as the most frequent alteration is a simple septal perforation. Cocaine-induced necrosis is another plausible diagnosis, but it should be selected only after eliminating other aetiologies.

Funding

This research did not receive any specific funding.

Conflicts of interest

The authors declare that they have no conflict of interest.

Data availability statement

Data available on request from the authors. The data that support the findings of this study are available from the corresponding author upon reasonable request.

© The authors, 2025

All Figures

	Fig. 1 Coronal (a) and axial (b) planes of the current CT-scanner; large endonasal and palatal necrosis.
In the text

	Fig. 2 Coronal (a) and axial (b) planes of the first CT-scanner, 6 years ago; highlighting intact oral and endo-nasal structures.
In the text