DRIP DROP FROM THE NOSE, IT IS NOT RHINITIS, IT WILL NOT STOP

Abstract

Introduction Cerebrospinal fluid (CSF) rhinorrhea occurs due to an abnormal communication between the subarachnoid space and the nasal cavity. Spontaneous CSF (sCSF) leaks are those not explained by traumatic injury, previous surgery, or secondary causes. We present a case of sCSF leak misdiagnosed as allergic rhinitis. Case Description A 64-year-old Hispanic woman with past medical history of hypertension, renal cell carcinoma, hypothyroidism and no prior surgery presented with a one-year history of continuous clear rhinorrhea from her left nostril. The patient had persistent cough and postnasal drip despite multiple courses of antibiotics, intranasal steroids, and oral antihistamines. Rhinoscopy and CT of the temporal bones were negative, but sample of the nasal fluid tested positive for beta-2 transferrin. A brain MRI revealed bilateral cribriform meningocele as a most likely site of CSF leak (Figure 1). There were also meningoceles of Meckel cave and jugular foramina along with increased optic nerve sheath diameter suggesting elevated intracranial pressure. Endoscopic sinus surgery with intrathecal fluorescein showed an active CSF leak on the left side and meningocele on the right. The leak was repaired with a nasal septal flap. On clinical follow-up 3 months after surgery, the patient reported no rhinorrhea or post-nasal drip. Discussion sCSF leaks are responsible for 6-23% cases of CSF rhinorrhea. The clinical diagnosis can be challenging because of their resemblance to chronic rhinitis. Failed response to medical management should raise suspicion. sCSF should be repaired to prevent meningitis and intracerebral infection, therefore early identification with β-2 transferrin testing is crucial. Figure. A. Right cribriform meningocele (red arrow), however, the leak can be seen as a linear fluid signal in the nasal roof on the left side from a cribriform plate defect (white arrow). B. Dilated optic nerve sheath diameter (8.4 mm, normal C. Dural diverticula arising from Meckel's cave (arrows)