The patient: Jia, a 39-year-old defense attorney*
The symptoms: A non-stop runny nose
The doctor: Dr. Satish Govindaraj, an ear, nose, and throat specialist at Mount Sinai Hospital in New York City
Jia was at her office working one afternoon in May 2014 when her nose suddenly started running. At first she thought it was just a cold, or maybe seasonal allergies, but the fluid seemed to be coming from only her left nostril—and it wouldn’t stop. Worse, whenever she bent down or exerted herself in any way, the flow increased significantly.
After four days, she went to her family doctor, who told her the symptoms weren’t typical of a sinus infection; she didn’t have a headache, cough, or sinus pressure, and the fluid was clear, as opposed to yellow or green. Still, he prescribed an antibiotic and a corticosteroid nasal spray, just in case. Two weeks later, Jia’s nose was still running. She had no history of allergies and was otherwise symptom-free, so her doctor ordered a CT scan.
The radiologists didn’t highlight anything out of the ordinary in the results, but Jia’s GP was concerned she might have a cerebrospinal fluid (CSF) leak. He referred her to Dr. Satish Govindaraj, who confirmed those suspicions. The CT had actually revealed a small bone gap in Jia’s skull, and brain fluid was leaking from her nose.
The patient was fortunate that her physician picked up on the symptoms, says Govindaraj, who took on Jia’s case after the leak was confirmed. In cases of runny noses caused by colds or allergies, mucus is usually present in both nostrils and at some point decreases (or even disappears). In contrast, “because CSF fluid is continuously produced,” he says, “it’s usually more of a steady drip.” Your mucus can reveal a lot about your health, so be on the lookout for these 8 things that your mucus is trying to tell you.
Jia had a spontaneous leak, meaning she had no preceding trauma that might have caused it. The condition is rare and, though it tends to occur most often in obese or overweight middle-aged women (weight around the abdomen puts pressure on the veins, and that pressure is transmitted to the brain), Jia didn’t fit the profile. However, the CT scan indicated that the lining of her brain had herniated into her sinus cavity. A tiny tear had developed in the lining, leaking fluid from her brain into her nose.
A sample of the fluid confirmed the presence of beta-2 transferrin, a protein found only in the eyes, liver, and brain fluid. “If you encounter it coming out of the nose, you know it’s from the brain,” Govindaraj says.
Without surgery to repair the leak, Jia was at risk of meningitis or a brain abscess—infection could be easily passed from her nose to the vulnerable tissue poking into her sinus area. After a second CT scan to guide the procedure, Govindaraj performed endoscopic surgery through her nostrils. He removed the exposed area of the brain, patched the gap in her skull with bone and tissue from her nose, bolstered the graft with dissolvable packing and inserted a sponge to keep pressure on the area. “Because the patient had such a high-flow leak, we had to get it sealed fast.” If you’re preparing for surgery, here’s what you need to do to make it go as smoothly as possible.
Five days after the surgery, Jia returned to Govindaraj’s office to have the sponge removed. While the leak is fixed, there’s still a risk a new one could develop. Govindaraj prescribed acetazolamide, a diuretic that also decreases brain-fluid pressure, and recommended a neuro-ophthalmologist to monitor her for signs of elevated intracranial pressure in her eyes.
*Name changed to protect patient privacy