Since the first reported case in 1912 of cocaine-induced perforation of the palate, an additional 7 cases have been reported describing extensive palatal destruction. The clinical presentation shares similarities with nasal-type natural killer/T-cell lymphoma, Wegener's granulomatosis, and infectious diseases. We describe a 50-year-old woman with a progressively destructive midfacial process that initially appeared as a small, localized palatal defect. Over time, the lesion caused bilateral deformity of the ala, extensive loss of the palate, maxillary and sinonasal complexes, ethmoids, and ulceration of adjacent tissue. Clinical laboratory tests showed elevated cytoplasmic-antineutrophil cytoplasmic antibodies, but the histopathology did not support the diagnosis of Wegener's granulomatosis. Special stains and cultures were negative for infectious organisms. Flow cytometry and T-cell gene rearrangement studies ruled out lymphoma. Because of the inability to diagnose this worrisome process, the presence of polarizable foreign material in the original biopsy, and the patient's admission to past cocaine use, a urine drug screen was performed, which was positive for cocaine and marijuana.