Persistent runny nose caused by undiagnosed cerebrospinal fluid (CSF) leak
Head and face infections pose a risk of spreading to the brain
The Washington Post recently published a story about Kendra Jackson, a woman who went to doctor after doctor to try to find out why her nose was running constantly.
When Ms. Jackson used the word “constantly,” she was speaking literally. She described her nose as running “like a waterfall, continuously, and then it would run to the back of my throat.”
Her runny-nose symptom persisted for years. Some doctors told her that she had a cold. Other doctors concluded that she was suffering from seasonal allergies. The medications and treatments that these doctors offered did not work and, for years, her nose kept running, causing her to sneeze, blow her nose, have headaches, and lose sleep every day.
In early 2018, Ms. Jackson went to see specialists in the Nebraska Medicine hospital system. There, she was finally correctly diagnosed with a cerebrospinal (CSF) fluid leak. Instead of having drainage from a cold or allergies, brain fluid was leaking out through her nose.
Cerebrospinal fluid is a clear liquid that acts as a mechanical and immunological buffer for the brain and spinal cord, and also plays an important role in regulating blood flow to the brain. The choroid plexuses in the brain produce about 500 mL of CSF per day. Most people have about 125 mL of CSF at any given time. When there is a CSF leak, the patient has an increased risk of developing meningitis and other brain or spinal infections.
A surgical team took her to the operating room to repair a tiny hole between her skull and nostrils. They successfully plugged the leak and Ms. Jackson is now doing fine.
As a Houston, Texas medical malpractice attorney, this reminds me of a case that I handled several years ago. A healthy, active teenager started having symptoms of a bad head cold. Over a few days, the cold symptoms got worse and she started to have nausea and vomiting.
Her parents took her to a northwest Houston emergency room, where they did a brain scan. Doctors there thought she might have a brain tumor. They transferred her to a hospital in the Texas Medical Center, where doctors quickly figured out that she had a golf ball-sized abscess in the right frontal lobe area of her brain.
An abscess is an accumulation of pus caused by an infection. A surgeon took her to the operating room, did a craniotomy (drilled a small hole in her skull), and drained fluid from the abscess. She immediately felt better.
Unfortunately, her hospitalization did not end well. After saving her life, the hospital nurses and physicians failed to monitor her serum sodium levels. This is important to do after any surgery on the brain. Her sodium levels dropped so low that she developed hyponatremia, causing her brain to swell. By the time the healthcare providers figure this out, she almost died.
Through the process of the surgery, we learned that my client’s brain abscess formed because of a defect in the cribriform fossa. This anatomical structure is part of the skull, roughly beneath the eyes and above the nose. This defect allowed the infection from her head cold to pass through the skull and spread to the brain.
Every time I think about this case, my mind wanders back to a gross human anatomy professor that I had in my first year of medical school. (I started my graduate academic work in medicine, before migrating to health law). He described the face’s triangle of danger.
You can locate the triangle of danger by creating a triangle with both of your thumbs and index fingers, locating the triangle apex at the top of your nose. Any infection in the triangle of danger has a risk of spreading to the brain, in that this area of the face shares a blood supply with the brain.
The triangle of danger is worrisome enough, but, of course, any defect or hole in the skull makes matters even more concerning because it provided direct access to the brain.
Both of these stories illustrate the importance of seeking specialized medical care for ongoing symptoms that you might be tempted to think are merely related to a cold or allergies. Even after getting to a specialist, I recommend patients to be persistent in providing information, asking questions, and obtaining follow-ups until there is a final diagnosis and treatment plan.
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Robert Painter is a medical malpractice attorney at Painter Law Firm PLLC, in Houston, Texas. He is a former hospital administrator who represents patients and family members in medical negligence and wrongful death lawsuits against hospitals, physicians, surgeons, anesthesiologists, and other healthcare providers. In 2017, H Texas magazine named him one of Houston’s top lawyers. In May 2018, the Better Business Bureau recognized Painter Law Firm PLLC with its Award of Distinction.
Robert Painter is a medical malpractice lawyer at Painter Law Firm PLLC.
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Published in the July/August 2018 edition of "The Houston Lawyer" magazine