Extensive pneumocephalus after nose blowing: an unusual cause of severe headache

Abstract

A 54-year-old Afro-Caribbean woman presented to the emergency department with a 1-day history of severe headache and general malaise. The pain started suddenly after blowing her nose, was frontal in location and became rapidly severe and throbbing in nature. There were no symptoms that would suggest orthostatic headache, no dizziness or vertigo, no visual or auditory disturbance and no neurological weakness. The pain was worse on movement, coughing and bending and was associated with photophobia, nausea and the development of a clear nasal discharge. Previous medical history was unremarkable; there was no history of sinus or nasal problems, no recent headaches or migraines, no visual abnormalities and no life history of head injury or nasal trauma. Examination was largely unremarkable; on arrival her Glasgow Coma Scale was 15 and she was apyrexial with no meningism or photophobia. No evidence of intracranial hypertension was found. There was slight skull tenderness on palpation over the frontal sinus, but the remainder of her neurological (including cranial nerve) examination and general examination was unremarkable. Biochemical (electrolytes, liver function, glucose, calcium) and haematological tests revealed a mild neutrophilia (12.5×109cells/litre) but were otherwise normal. Over the course of the admission, she became increasingly unwell with increasing nausea, further vomiting and fluctuant levels of consciousness. A computed tomography scan of the head showed an extensive pneumocephalus extending to the foramen magnum with marked sulcal and basal cistern effacement (Figure 1 and 2). Bone windows revealed a hole in the roof of the right sphenoid sinus. The clear discharge was found to be CSF and sent for microbiology analysis. Prophylactic cefotaxime and metronidazole antibiotics were commenced and she underwent endoscopic endonasal exploration. The bony defect in the roof of the right sphenoid and the CSF leak were identified. The dural defect was closed with a fascia lata graft and fat harvested from the thigh. Four days after the operation, she became increasingly confused and a repeat computed tomography scan showed new hydrocephalus. A lumbar puncture was performed and showed an opening pressure of 43 cm (5–20 cm). Two days later she underwent ventricular-peritoneal shunting. She eventually made a full recovery. It is still uncertain whether the hydrocephalus was secondary to a disruption of the sinus by the air pressure in the skull or whether there was hydrocephalus before the events leaking through the ethmoidal bone, suggesting the possibility of spontaneous CSF leak syndrome complicated with pneumocephalus (Schievink, 2000).