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Otolaryngology-ENT Research

Case Report Volume 15 Issue 1

Case report: a rare presentation of nasal septal perforation due to pyoderma gangrenosum

Mohammed Al Tayyar, Abbad Toma

Department of Otolaryngology, Kingston Hospital Foundation Trust, England

Correspondence: Mohammed Al-Tayyar, Department of Otolaryngology, Kingston Hospital Foundation Trust, Kingston Upon, Thames, Surrey, London, KT2 7QB, England, Tel +44 07985292563

Received: March 13, 2023 | Published: March 30, 2023

Citation: Al-Tayyar M, Toma A. Case report: a rare presentation of nasal septal perforation due to pyoderma gangrenosum. J Otolaryngol ENT Res. 2023;15(1):44-46 DOI: 10.15406/joentr.2023.15.00526

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Background: Pyoderma gangrenosum (PG) is a rare dermatologic non-infectious neutrophilic disease that classically affects the lower extremities and is associated with inflammatory bowel disease. Rarely, it could affect the nasal septum, causing nasal septal perforation.

Methods: We reviewed the case of a 52-year-old male patient known to have PG with ongoing nasal septal perforation and reviewed his blood tests, computed tomography scan findings and histologic results.

Results: A diagnosis of nasal septal perforation due to PG was confirmed after exclusion of other common aetiologies. This was further supported by the presence of extensive ulceration of the nasal squamous mucosa with inflamed granulation tissue and abscess-like areas. These findings were consistent with the diagnosis of PG based on the histology report.

Conclusion: Although nasal septal perforation secondary to PG is considered rare, this presentation should still be kept in mind, especially when other possible causes of nasal septal perforation have been excluded and PG has been already well established.

Keywords: nasal septal perforation, neutrophilic dermatosis, pyoderma gangrenosum


Pyoderma gangrenosum (PG) is a reactive non-infectious inflammatory dermatosis falling under the neutrophilic dermatosis spectrum, which includes Sweet’s syndrome and Behcet’s syndrome.1,2 It was first described in 1930 by Drs. Brunsting, Goeckerman, and O’Leary, who described the typical lesions of PG as enlarging necrotic ulcers with erythematous to bluish undermined borders surrounded by spreading erythema.3,4

Six major variants of the skin condition have since been outlined, including (1) ulcerative or classic, (2) pustular, (3) bullous or atypical, (4) vegetative, (5) peristomal, and (6) post-surgical PG (Table 1).3

Pyoderma gangrenosum

Common location


Associated disease

Ulcerative (classic)

Lower extremities

Rapid progression Violaceous
undermined border Very painful

Inflammatory bowel disease (IBD)
Arthritis Myeloproliferative disease

Bullous (atypical)


Superficial bulla Blue-grey border

Myeloproliferative disease (i.e., acute
myeloid leukaemia)


Legs Upper trunk

Painful pustules Red halo




Superficial ulcer No violaceous



Near stoma site

Painful ulcer Violaceous
undermined border

IBD Enteric malignancies

Post-surgical (procedural)
(e.g., after nipple piercing)       

Surgery site (breast,
abdomen most common)       

Rapid progression Active and undermined
border Pain out of proportion to lesion            

Fewer cases of underlying systemic
disease (compared with classic form)

Table 1 Different clinical presentations of pyoderma gangrenosum and their associated systemic diseases

Case report

A 52-year-old male patient was recently diagnosed with the vegetative type of PG as he only had skin lesions in the back without any other systemic manifestations. After the diagnosis, he developed several non-specific nasal issues that were progressive in nature. These included nasal stiffness, nasal obstruction, crustation, and a dull ache.

Previously, he had tried different remedies, either over-the-counter medications or those prescribed by his primary health care providers. These drugs included saline nasal rinses, local steroid sprays5, and local antibiotics; however, despite the use of these medications, the patient’s nasal symptoms continued to deteriorate. Therefore, he was referred to the otolaryngology specialized clinic.

On examination at the clinic, nasal bridge broadening was noted with extreme tenderness at the alar cartilage area. Nasal endoscopy was performed that revealed nearly total nasal septal perforation as well as erosion of the anterior sphenoidal wall. Moreover, there was widespread granulation tissue inside the nasal cavity.

A thorough and detailed approach was used to determine the cause of the septal perforation. There was no history of nasal trauma or surgery, cocaine abuse, or any granulomatous6 diseases apart from PG. Various lab and imaging tests such as cytoplasmic and peripheral antineutrophil cytoplasmic antibodies (c-ANCA and p-ANCA), erythrocyte sedimentation rate (ESR), full blood count (FBC), and chest X-ray (CXR), among others, were ordered in order to arrive at a definitive diagnosis. The results of all these tests were inconclusive. In addition, a computed tomography (CT) scan was ordered, and the results were consistent with the clinical findings (Figure 1).

Figure 1 A coronal CT scan of the patients nose and paranasal sinuses.

At that stage, it was prudent to exclude malignancy; therefore, multiple biopsies were taken under general anaesthesia (Figure 2).

Figure 2 Intraoperative view of the nose.

The cytology assessment detected no malignant cells; however, there was noted extensive nasal squamous mucosa ulceration with inflamed granulation tissue and abscess-like areas consistent with PG.


Nasal septal perforation is considered reasonably common in otolaryngology consultations. The aetiologies vary greatly from one another, and there is a myriad of possibilities that could cause them. These can be summarized into the categories listed in Table 2.

Traumatic causes     

Surface irritants




Nasal surgery

Cocaine insufflation



Granulomatosis with

Nose picking

Fumes (chromic/sulphuric acid)      


Squamous cell carcinoma     


Bilateral septal cauterization

Lepromatous leprosy



Foreign bodies


Rhinoscleroderma Mucor       


Systemic lupus erythematosus

Table 2 Aetiologies of the nasal septal perforation

Because of the wide range of aetiologies for septal perforation, history-taking is crucial. Nasal perforations may be the first sign of various granulomatous disorders, including granulomatosis with polyangiitis (GPA) and systemic lupus erythematosus (SLE). Baseline work-up should include an FBC, ESR, serum urea, serum electrolytes,7–9 urinalysis, C-ANCA, treponemal tests, ACE titres, a CXR, and a nasal swab. Routine biopsy of septal perforations to exclude vasculitis has been suggested10–12 but biopsy rarely reveals anything other than chronic inflammation and is usually insufficient for a specific diagnosis.

Nasal septal perforation due to PG is considered rare; therefore, this diagnosis remains a diagnosis of exclusion.3 Head and neck manifestations of PG are known to have poor response to standard treatment.13 The patient mentioned in this study had already received extensive steroid therapy to treat his skin lesions, and yet his lesions still progressed until finally his nasal structures were destroyed.


Although nasal septal perforation secondary to PG is considered rare, this presentation should still be kept in mind especially when other possible causes of nasal septal perforation have been excluded and PG is already well established.



Conflicts of interest

Authors declare no conflict of interests.


This work was supported by the Kingston hospital foundation trust.


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