Rhinorrhea treatment reveals cerebrospinal fluid leak

LOUISVILLE, Ky. — Imagine a patient who has been treated for rhinorrhea, but then fluid begins to leak out of their ear. Now imagine that you are a medical student encountering this puzzle on the first day of your allergy elective.

Kelly Cronin, DO, a second-year internal medicine resident at The University of Texas Medical Branch in Galveston, presented this unusual case at the American College of Allergy, Asthma & Immunology Annual Scientific Meeting.

“My attending told me that this case wasn’t typical for the kinds of cases we would be seeing,” Cronin told Healio.

A woman aged 63 years presented to the allergy clinic after 6 months of rhinorrhea, post-nasal drip and sneezing. Clinicians prescribed intranasal fluticasone propionate after negative environmental testing.

Also after the allergy evaluation, the otolaryngology team implanted bilateral tympanostomy tubes to address the patient’s history of chronic middle ear effusions. The patient then had a follow-up appointment with the allergy department 6 weeks later.

“She came and said, ‘My rhinorrhea is 70% better, but now I have this fluid coming out of my ear’,” Cronin said, adding that the patient’s rhinorrhea primarily was triggered by foods and temperatures at that point.

“We examined her and saw it was pulsatile,” Cronin said. “Then we tested the ear fluid for beta-2-transferrin because we were a little concerned about a cerebrospinal fluid (CSF) leak. It was positive.”

A CT scan of the temporal bone revealed that the patient had a right tegmen tympani defect with right eustachian tube communication. Meanwhile, Cronin and her colleagues referred the patient back to otolaryngology team to remove the tympanostomy tube.

The otorrhea resolved once the tube was removed. However, the rhinorrhea got worse.

“She said she was back to her baseline again with the rhinorrhea, even on fluticasone,” Cronin said.

The neurosurgery team then performed a tympanomastoidectomy to correct the tegmen tympani defect, and the rhinorrhea significantly improved, although the patient continued to experience rhinorrhea triggered by various foods and temperatures. The clinicians prescribed intranasal ipratropium to ameliorate the rhinorrhea.

“It was like a plumbing issue,” Cronin said. “It was like a CSF leak coming out of her nose, actually. And then it was coming out of her ear. And then when the ear tube was removed, [it started] coming out of her nose again.”

The clinicians hypothesized that the tube placement had provided an alternative outlet for the CSF to drain via the ear canal, resulting in the rhinorrhea with pulsatile otorrhea development. The resolution of the otorrhea with the tube removal corresponding with the worsening rhinorrhea was consistent with their theory, they added.

According to Cronin, only “a couple” of other, similar cases have been reported. These cases involved patients with risk factors for tegmen tympani defects such as trauma or previous infections.

“But this patient didn’t have any of those,” she said.

Cronin reported that the patient continues to follow up with the allergy clinic and that her symptoms are now controlled. Still, Cronin said, there are lessons for medical students and veteran practitioners alike.

“Common things being common, a lot of times it will be just allergic or nonallergic rhinitis,” she said.

“But keep in mind that there can be more rare or multifactorial reasons that people can have rhinorrhea when all the symptoms aren’t matching or the patient is not getting better,” she continued. “It might be something a little bit atypical.”

The challenges that this case and others presented inspired Cronin to pursue allergy as a career path.

“I just really enjoyed the elective a lot, so this is what I’m planning on going into,” she said.