Unseen Risks: A Case Report on Drug-induced Nasal Septal Perforation

Nasal septal perforation is an uncommon condition caused by several aetiologies. The recent trend in the increased use of Tapentadol intra-nasal analgesic spray has led to various systemic and local complications. This is one of the first few case reports on Tapentadol-induced nasal septal perforation. A 34-year-old female presented to the Otorhinolaryngology clinic with a two-week history of a painful non-healing ulcer in the palate associated with pus discharge.She also had bilateral nasal obstruction and foul-smelling discharge. The patient had used Tapentadol nasal spray (22.5 mg/spray) 4-5 times daily for two years to manage her lumbar disc prolapse pain.Oral cavity examination showed a 0.5 × 0.5 cm fistula at the junction of the hard and soft palate. Diagnostic nasal endoscopy exhibited extensive dried crusting and pus discharge, along with a perforation in the cartilaginous part of the septum, and eroded bilateral inferior turbinates. Patient was worked up for granulomatous disease of nose / malignancy. Biopsy showed acute on chronic inflammation with necrotic tissue.Bood investigations included cANCA, pANCA, and Rheumatoid factor, which was negative. Treatment involved the cessation of the Tapendalol nasal spray, local debridement, and a regiment of antibiotics and steroids. Upon follow-up, endoscopy demonstrated improved symptoms and the regeneration of normal mucosa. Drug-induced septal perforation is recognized as a rare condition, but it should be taken into account in all cases of septal perforation. Meticulous history and clinical examination is essential for accurate diagnosis.