Septal perforation—a hole in the nasal septum—is an increasingly common problem seen by ENT specialists in NSW. One of the leading causes today is intranasal cocaine use, particularly cocaine that is adulterated with toxic additives such as levamisole.
Many patients are unaware they have a septal perforation until symptoms become severe. Others are shocked to learn that even intermittent cocaine use can permanently damage the nose. This article explains how cocaine causes septal perforation, why adulterants make it worse, and why NSW patients are at particular risk.
What Is a Septal Perforation?
The nasal septum is the wall that separates the left and right sides of the nose. It is made of cartilage and bone, covered by a thin lining with a delicate blood supply.
A septal perforation occurs when this tissue dies and a hole forms. Once cartilage is lost, it does not regenerate.
Common symptoms include:
- Whistling noise when breathing
- Crusting inside the nose
- Recurrent nosebleeds
- Nasal blockage despite an open hole
- Dryness, pain, or infection
- Collapse of the nasal bridge in severe cases
Small perforations can progress silently. Large perforations can cause permanent nasal deformity.
Septal perforation showing a hole in the nasal septum caused by cocaine use
How Cocaine Causes Septal Perforation
Cocaine is one of the most powerful vasoconstrictors known. When applied inside the nose, it:
- Shuts down blood flow
- Causes repeated ischaemia (lack of oxygen)
- Leads to ulceration of the lining
- Results in cartilage death
- Ends in a septal perforation
This damage is dose-independent. Some patients develop septal perforation after relatively short periods of use, particularly when cocaine is repeatedly applied to the same area.
Why Cocaine Today Is More Dangerous Than Before
In Australia, and especially in NSW, cocaine is rarely sold in a pure form.
- Border-level cocaine purity commonly exceeds 70–80%
- Street-level cocaine purity in NSW is typically 25–45%
- Many samples contain multiple adulterants
- Some contain little or no cocaine at all
This means users are not just exposing their nose to cocaine—but to a chemical mixture with unpredictable effects on blood vessels and tissue healing.
Levamisole: The Adulterant That Accelerates Septal Perforation
One adulterant deserves special attention: levamisole.
Levamisole is a veterinary drug with toxic effects in humans. It is now commonly found in cocaine in Australia, including NSW.
Why levamisole worsens septal perforation
Levamisole:
- Promotes tissue inflammation and necrosis
- Impairs blood vessel repair
- Triggers immune-mediated damage
- Reduces the body’s ability to fight infection
When combined with cocaine’s vasoconstriction, levamisole creates a perfect storm for nasal tissue destruction.
Endoscopy showing levamisole adulterated cocaine and nasal tissue damage
This is why ENT surgeons are seeing:
- Larger septal perforations
- Faster progression
- More extensive midline damage
- Poor healing even after stopping cocaine
Septal Perforation vs “Cocaine Nose”
- A septal perforation is often the first stage of what can progress to cocaine-induced midline destructive lesions, where damage spreads to:
- Turbinates
- Nasal floor
- Hard palate
- Nasal bridge (saddle nose deformity)
Early septal perforation is a warning sign, not a benign finding.
Why NSW Patients Are Seeing This More Often
NSW has:
- High cocaine availability
- High demand
- Repeated downstream cutting
- High prevalence of levamisole adulteration
This combination leads to greater variability and toxicity at the point of use. From a clinical perspective, NSW ENT specialists now see septal perforation in:
- Younger patients
- Social or “weekend” users
- Patients without other risk factors (e.g. surgery, nasal sprays, autoimmune disease)
Can a Septal Perforation Heal?
No. Once cartilage is lost, it does not regenerate.
Management depends on:
- Size of the perforation
- Symptoms
- Ongoing exposure (cocaine use must stop)
Options include:
- Conservative care (saline, ointments)
- Septal buttons (i dont recommend these as then often still cause crusting, become infected and can have a malodour)
- Surgical reconstruction (not always possible)
Continued cocaine use—even occasionally—dramatically worsens outcomes.
4 weeks post septal perforation surgical repair
Red Flags That Should Prompt ENT Review
Seek assessment if you have:
- Recurrent crusting or bleeding
- A whistling sound from the nose
- Nasal pain or dryness that won’t settle
- Change in nasal shape
- A known history of cocaine use and new nasal symptoms
Early intervention can prevent progression to irreversible deformity.
permanent scarring from cocaine levamisole injury to nose
same patient as above 6 months earlier
Key Take-Home Messages
- Septal perforation is a common and serious complication of cocaine use
- NSW cocaine is frequently adulterated
- Levamisole significantly increases nasal tissue destruction
- Damage can occur even with intermittent use
- Once established, septal perforation is permanent
- Unfortunately, the first step to fixing the issue is the hardest – giving up intra-nasal drug
Summary
Cocaine-related septal perforation is no longer rare. It is increasingly seen in otherwise healthy adults who did not expect permanent damage from recreational use.
If you are concerned about nasal symptoms—or worried about the long-term effects of cocaine use—early specialist review matters. The nose often shows damage first, but the consequences can extend well beyond it.
“author”: {
“@id”: “https://richardharvey.sydneyentclinic.com/about/#prof-richard-harvey”
}