Images of Memorable Cases: Case 123 This 42-year-old cocaine addict complained of longstanding nasal stuffiness and recurrent epistaxis. On examination, he had crusting and ulceration of the nasal mucosa, perforation of the nasal septum, and a hole in his soft palate. 123. Cocaine-induced midline destructive lesion Compulsive nasal insufflation of pulverized cocaine can damage the nasal mucosa and lead to ischemic necrosis of the septal cartilage and ultimate perforation of the nasal septum. The same mechanism presumably accounts for the palatal abnormality shown in the image. Differentiating these cocaine-induced lesions from those of limited Wegener’s granulomatosis can be difficult, particularly if the patient does not readily admit to substance abuse.