International Rhinologic Society Rhinology 0300-0729 2026 05 20 Is routine cocaine testing justified in patients with septal perforation? EN R.A. Algazlan Department of Otolaryngology, Imperial College Healthcare NHS Trust, London, United Kingdom T. Soares Department of Otolaryngology, Imperial College Healthcare NHS Trust, London, United Kingdom T. Ross Department of Otolaryngology, Imperial College Healthcare NHS Trust, London, United Kingdom C. Rennie Department of Otolaryngology, Imperial College Healthcare NHS Trust, London, United Kingdom Letter 3382 10.4193/Rhin25.055 Nasal septal perforation occurs when both mucoperichondrial layers surrounding the septal cartilage are compromised. While richly vascularized, this tissue is particularly vulnerable to ischaemic injury caused by intranasal cocaine use. Cocaine inhibits catecholamine reuptake, leading to vasoconstriction, tissue necrosis, and, ultimately, septal damage. Furthermore, the adulterant levamisole, present in up to 80% of seized cocaine in Germany, is a known trigger for vasculitis, compounding this effect.