IngentaConnect Rhinorrhea not responding to nasal corticosteroids

Authors: Patel, Parag N.¹; Oyefara, Benjamin¹; Aarstad, Robert²; Bahna, Sami L.¹

Source: Allergy and Asthma Proceedings, Volume 28, Number 6, November-December 2007 , pp. 735-738(4)

Publisher: OceanSide Publications, Inc

Abstract:

A woman with multiple illnesses including allergic rhinitis presented for a follow-up visit at our clinic with constant rhinorrhea for 2 weeks despite regular use of nasal corticosteroids. Two weeks earlier, after alcohol drinking and doubling some of her medications for missed doses, she fell on her face. The Emergency Department records documented headache, bradycardia, hypotension, dehydration, and right infraorbital swelling. She was admitted for hydration and observation, and was discharged after two days without radiologic evaluation of the head. At our clinic, physical examination revealed pale turbinates bilaterally and clear watery discharge from the right nostril. Cerebrospinal fluid (CSF) rhinorrhea was suspected, but glucose testing was not available at our clinic. The patient was immediately admitted into the hospital. A beta-2-transferrin test confirmed CSF from the right nostril. High resolution sinus CT revealed fluid in the right sphenoid sinus, a large cyst in the left maxillary sinus, a cribriform plate dehiscence on the right side, and fluid collection adjacent to the middle turbinate. A lumbar drain was placed to release the pressure and antibiotic prophylaxis was started. Nasal endoscopy revealed CSF leak from the cribriform plate with bone dehiscence and a dural tear. A graft from nasal septal cartilage and temporalis fascia was applied using Tisseal fibrin glue. The persistent rhinorrhea resolved and on follow-up visits, the patient remained asymptomatic. Thinking of CSF rhinorrhea in the differential diagnosis of rhinitis would lead to early diagnosis and prevention of serious medical complications and potential legal liabilities.

Keywords: Cerebrospinal fluid; cribriform plate fracture; head trauma; nasal discharge; rhinitis; differential diagnosis; rhinorrhea

Document Type: Case report

DOI: 10.2500/aap.2007.28.3061

Affiliations: 1: Allergy and Immunology Section, Department of Pediatrics, Louisiana State University Health Sciences Center, Shreveport, Louisiana 2: Department of Otolaryngology, Louisiana State University Health Sciences Center, Shreveport, Louisiana