rss
BMJ Case Reports 2018; doi:10.1136/bcr-2017-222296
  • Images in…

Recurrent meningitis caused by idiopathic cerebrospinal fluid rhinorrhoea from the sphenoid sinus

Open Access
  1. Yasuhiro Tanaka3
  1. 1 Department of Otorhinolaryngology, Asahi General Hospital, Chiba, Japan
  2. 2 Department of Otorhinolaryngology, The Jikei University School of Medicine, Tokyo, Japan
  3. 3 Department of Otorhinolaryngology, Dokkyo Medical University Saitama Medical Center, Saitama, Japan
  1. Correspondence to Dr Kazuhiro Omura, kazuhiro.omura{at}jikei.ac.jp
  • Accepted 12 December 2017
  • Published 11 June 2018

Description

A 41-year-old woman with 7 days of fever and headache had loss of consciousness 1 day prior to presentation. Despite the absence of trauma or other significant medical history, she had two episodes of meningitis in the previous 6 months. Physical examination showed no nuchal rigidity or abnormal findings on nasal endoscopy. Lumbar puncture showed a cerebrospinal fluid cell count of 750/μl. CT showed a bony defect of the posterior wall of the sphenoid sinus, which was filled with a soft tissue density. MRI showed fluid intensity in the same area (figure 1A, B). The diagnosis was recurrent meningitis due to possible idiopathic cerebrospinal fluid rhinorrhoea. Although a cisternogram is normally recommended, emergency drainage of the sphenoid sinus with antibiotic treatment was prioritised because of her deteriorating condition. With various possible diagnoses, an experienced surgeon operated on the patient. 

Figure 1

A bony defect of the posterior wall of the sphenoid sinus (arrows): (A) CT with sagittal view and (B) CT with axial view.

Endoscopic sinus surgery was performed emergently under general anaesthesia for drainage and reconstruction of the bony defect, 6mm below the sella floor (online supplementary video 1) in the sphenoid sinus.

Supplementary file 1

The exact site of the submucosal defect was identified and reconstructed with nasoseptal mucosal flap with fat (online supplementary video 2)   watery rhinorrhoea stopped soon after the operation. She was treated with cefotaxime 6 g/day for 2 weeks, made good progress and was discharged. At 38 months postoperatively, there is no evidence of recurrence based on both endoscopic evaluation and radiographic analysis.

Supplementary file 2

Learning points

  • Idiopathic cerebrospinal fluid rhinorrhoea (ICFR) is seen most often among middle-aged obese women. These patients tend to experience rhinorrhoea as the primary symptom, but meningitis is also often an initial symptom.

  • The typical cause of ICFR in the sphenoid sinus appears to involve a congenital bone union disorder of the posterior and lateral walls of the sinus, sometimes with meningoencephalocele. CT in this case showed a bony defect on the posterior wall of the sphenoid sinus, 6 mm below the sella floor. The exact site of the submucosal defect must be identified to achieve close approximation for reconstruction with abdominal fat, and sometimes a nasoseptal mucosal flap.

  • In cases of recurrent meningitis with cerebrospinal fluid rhinorrhoea, transnasal reconstruction with endoscopic sinus surgery is the first choice. Early consultation with otolaryngology and surgical reconstruction lead to a good outcome.

Footnotes

  • Contributors MH and KO experienced this case. MH drafted the manuscript, and KO designed the figures and videos and did critical revision of the article. NO and YT gave final approval of the version to be published.

  • Funding The authors have not declared a specific grant for this research from any funding agency in the public, commercial or not-for-profit sectors.

  • Competing interests None declared.

  • Patient consent Obtained.

  • Provenance and peer review Not commissioned; externally peer reviewed.

This is an Open access article distributed in accordance with the Creative Commons Attribution Non Commercial (CC BY-NC 4.0) license, which permits others to distribute, remix, adapt, build upon this work non-commercially, and license their derivative works on different terms, provided the original work is properly cited and the use is non-commercial. See: http://creativecommons.org/licenses/by-nc/4.0/

Open Access

Register for free content

The full text of all Editor's Choice articles and summaries of every article are free without registration

The full text of Images in ... articles are free to registered users

Only fellows can access the full text of case reports (apart from Editor's Choice) - become a fellow today, or encourage your institution to, so that together we can grow and develop this resource

Don't forget to sign up for content alerts so you keep up to date with all the case reports as they are published, and let us know what you think by commenting on the Editor's blog

Navigate This Article