Suppressing a Sneeze May Have Led to Cerebrospinal Fluid Leak

Suppressing a sneeze may have led to a spontaneous leak of cerebrospinal fluid (CSF) and air entering the skull of a woman with no history of trauma or surgery.

A 45-year-old woman was referred to an otorhinolaryngology–head and neck surgery outpatient clinic after having mild holocephalic headaches for 3 months, which were somewhat alleviated when she laid flat. She had also experienced intermittent clear, watery discharge on the left side of her nose three times — most recently 3 weeks before she showed up at the clinic — that was provoked when she leaned forward, reported Abdulrahman A. Otaif, MBBS, of Jazan University in Saudi Arabia, and colleagues in the American Journal of Case Reports.

The woman’s initial neurological and general examinations were normal. However, both bilateral inferior turbinate hypertrophy and a septal spur were observed on the left side during anterior rhinoscopy, though no active leak was present.

A CT scan revealed several small intracranial air locules consistent with pneumocephalus within the interhemispheric fissure and left frontal lobe. It also showed a 2-mm bony dehiscence of the left anterior cribriform plate with mucosal thickening, as well as a leftward C-shaped septal deviation and bilateral inferior turbinate hypertrophy. An MRI also suggested the presence of intracranial air without parenchymal abnormalities.

The patient didn’t have any signs of meningitis nor did she have any symptoms the day she was in the clinic, so she was discharged and told to return if her symptoms worsened or if she developed a fever. She also was advised not to do Valsalva maneuvers, a type of breathing exercise where the breath is pushed out against a closed mouth and nose.

In the following 6 weeks, the patient had two more episodes of the clear nasal discharge. Both episodes lasted less than 30 minutes and were triggered by bending forward. There were two occasions where she resisted sneezing in a social setting, which didn’t cause new symptoms or neurological deficits.

At her 6-week follow-up visit, nasal endoscopy revealed a clear fluid leak going to the left choana. Doctors prescribed her 500 mg of acetazolamide to be taken twice daily to reduce CSF pressure and counseled her on sneeze hygiene. About 2 weeks later, the woman reported persistent nasal discharge despite this treatment.

The patient then underwent bilateral inferior turbinate reduction, septoplasty, and skull base repair of the left cribriform defect, which involved cauterizing the encephalomeningocele and removal of the surrounding mucosa. The patient spent 24 hours under observation and continued taking acetazolamide. The packing was removed on day 3, and upon discharge, she was instructed to avoid heavy lifting and blowing her nose, and to sneeze freely.

Suppressing a sneeze usually doesn’t cause any problems, but it can dramatically increase intranasal pressure — up to 20 times more than a normal sneeze, Otaif and colleagues explained. They called it a “rare but clinically significant cause of pneumocephalus and spontaneous cerebrospinal fluid leak.”

Christian Ferreira, MD, a cerebrovascular neurosurgeon at Northwell’s Phelps Hospital in Sleepy Hollow, New York, told MedPage Today that most of the time, sneeze suppression will not cause a CSF leak.

“Holding in a sneeze is usually harmless,” Ferreira said. “But in rare cases it can act like a sudden pressure spike and if … the patient already has a weak point on the skull base, that pressure may be enough to trigger a spinal fluid leak.”

Ferreira said it’s important to pay attention if a patient already has symptoms and if they have any risk factors or predispositions to elevated pressure in their head. A held-in sneeze could be a trigger for them.

The nasal cavity is full of bacteria and is also one of the thinner membranes near the brain where CSF could leak, he explained. Meningitis or bacterial infection is a dangerous risk, which is why repairing a leak is crucial.

“I’ve seen patients with a leak for months, and they never had an infection. And I know patients that have the leak for 3 to 5 days, and they develop a meningitis,” Ferreira said.

When identifying a CSF leak versus a regular runny nose, Ferreira said the discharge is clear, watery, and usually from just one side of the nose. It may even taste salty. If the patient says the discharge gets worse when they bend over or presents with meningitis, those are both clues it may be a CSF leak. A CSF leak can also lead to intracranial hypotension, which can cause symptoms like severe headache, brain fog, and sometimes even visual disturbance.

“You’re not going to do a CT scan for all the patients having a runny nose in the [emergency department] … but if the patient has a specific type of headache and this specific type of drainage, you should definitely rule out this type of condition,” Ferreira said.