Pass Me a Tissue…

Do you consider yourself to be open-minded or closed-minded? Open-minded people are considered to be more willing to embrace change and generally have a higher level of curiosity. They try new things, live in the present, and often times seem less judgmental. While it is often perceived as a good thing to have an open mind, you don’t want to be so open-minded that your brains leak out of your nose! In today’s culture, it is possible that our thoughts leak too freely; however, there is a true medical condition in which your mind lubricant literally drips out of your nose… cerebrospinal fluid rhinorrhea or CSF rhinorrhea. It’s important to know when to dive for a tissue and when to call your nearest ENT.

Most of us have suffered the embarrassment of talking to a close friend or loved one only for your nose to begin running like a sieve. Perhaps triggered by a blooming Bradford pear tree, the outdated perfume of the sweet elderly lady who sits close to you in church, or even a hot bowl of your favorite chicken noodle soup. We quickly dart our eyes around the room to make sure no one is watching, then hightail it to the nearest box of tissues before our sleeve is saturated. Clear nasal dripping can be one of the most aggravating and embarrassing issues to deal with. Each year, millions of Americans are seen at walk-in clinics, primary care offices, and by otolaryngologists and allergists for nasal discharge.

Common causes of nasal drainage include seasonal or non-seasonal allergies, upper respiratory tract infections such as rhinovirus and cold temperatures. Crying (or trying not to cry) during your favorite Nicholas Sparks book can sometimes cause a drippy nose. Rebound congestion after prolonged use of topical decongestant drugs such as Afrin, chronic sinusitis, nasal polyps and cluster headaches can also be to blame. However, cerebrospinal fluid rhinorrhea is a rare and potentially life-threating condition that also presents with clear nasal discharge. CSF rhinorrhea occurs when the meninges (the membrane barrier that lines the skull and vertebrae to protect the brain and spinal cord) is torn and cerebrospinal fluid drips down the nose. Ascending infection can lead to meningitis and in some cases death.

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The cause of common rhinorrhea or drippy nose is characterized by overabundance of mucin produced by mucous membranes that line our nasal cavities. With rhinorrhea, mucus is created faster than the body is able to process it, leading to clogging in the nasal cavities. Gravity takes over, causing nasal discharge. Accompanying symptoms generally vary based on the underlying cause, but can include nasal congestion, facial pain, headache, nosebleeds, sneezing, ear pressure, sometimes ear infection and even sinusitis. As excess mucus drips down the back of the throat, excoriation can occur causing sore throat and coughing.

Generally, nasal drainage is evaluated by medical providers with a thorough history to elicit the exact cause so that they can treat you accordingly. Many cases are self-limiting, such as the common cold, and do not require treatment. For allergic and non-allergic rhinitis, medications can be helpful including cortisone nasal sprays, antihistamines, vasoconstrictors, and sometimes antibiotics if a bacterial infection is suspected. Many claim that natural treatments like saline sprays and herbal oils can also be helpful. New in-office treatment options are available to alleviate nasal drainage. And then of course there’s honkin’ your schnoz (nose blowing) for which the Kleenex family greatly appreciates your business. Allergy testing and immunotherapy are helpful for some.

Evaluation by an Ear, Nose, and Throat provider can be valuable to rule out underlying co-morbidities such as sinusitis, nasal polyps, and additional upper respiratory disease.
Sometimes what you may think is good-old-fashioned snot can actually be something far more deadly. Cerebrospinal fluid rhinorrhea is a rare malady that can occur traumatically or spontaneously. Classic nasal CSF leak presents with unilateral (one-sided) clear nasal drainage that often worsens when bending forward. Sufferers sometimes complain of a metallic or salty taste. Predisposing conditions include obesity causing increased intracranial pressure, severe sleep apnea, congenital skull bone malformations, hyper-pneumatization of the sphenoid sinus, and a condition called empty sella turcica. Accompanying symptoms can include headache, lack of smell, nasal congestion, weakness, dehydration, and night cough. Severely symptomatic patients present with symptoms of meningitis including nuchal rigidity, sudden high fever, altered mental status, photophobia, phonophobia, and even seizures. Traumatic CSF rhinorrhea is a sign of basal skull fracture related to head trauma and can have devastating complications. CSF leak is also a very rare complication of sinus surgery.

 

Evaluation and diagnosis are centered around a thorough history, sampling of collected nasal discharge which is sent for β-2-transferrin assay, nasal endoscopic examination to visually identify the place of leak, and radiological diagnosis with skull CT scans. MRI helps in detecting hernial protrusion of the brain in the skull found in encephalocele.
Treatment options include watchful waiting as some CSF leaks will heal spontaneously. Surgical intervention includes a type of bypass surgery in which an overlay lumbo-peritoneal shunt is placed. Moderate failure rate is expected and surgeons then perform transcranial and trans-nasal approach surgery with osteoplastic craniotomy with closing of the defect using the patient’s own donor tissue.

Timing is critical. Risk of meningitis in patients with persistent CSF rhinorrhea may be as high as 20%. Meningitis is a life-threatening condition in which the meninges becomes infected leading to fever, headache and neck stiffness. Untreated meningitis is almost always fatal. If you or a loved one suspect you may have CSF rhinorrhea, don’t delay evaluation by an otolaryngologist (ENT).

Most of the time, clear nasal drainage is a nuisance rather than a life-threating situation. But it’s important to know the warning signs of CSF rhinorrhea and seek immediate medical help. While I would normally encourage everyone to “keep an open mind”, please don’t keep it so open that your thoughts (or spinal fluid) leak out on to your shirt. 🙂

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This article was written for and published by Inside Medicine.

 

Kari and Dr. Dang photo for IM

Kari Kingsley, MSN, CRNP works as an otolaryngology nurse practitioner in collaboration with Dr. Neeta Kohli-Dang. Together they share nearly forty years of ENT experience. They treat dizziness, ear infections, hearing loss, nasal congestion, sinus infections, thyroid nodules, tonsillitis, neck masses, hoarseness, trouble swallowing, and a multitude of other ear nose and throat conditions. Please call 256-882-0165 to schedule an appointment with Dr. Neeta Kohli-Dang and Kari Kingsley or visit Huntsville ENT.

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