A 35-year-old woman comes to the office due to persistent rhinorrhea. The patient has clear drainage from the right side of her nose that increases when she has a bowel movement or bends over to pick something off the floor. On examination, the external nose appears normal, the turbinates are pink, and the septum is straight. There is a small amount of clear fluid from her right nostril. The remainder of the examination is normal. Which of the following additional history is most important for establishing a diagnosis in this patient?

Question

A 35-year-old woman comes to the office due to persistent rhinorrhea.  The patient has clear drainage from the right side of her nose that increases when she has a bowel movement or bends over to pick something off the floor.  On examination, the external nose appears normal, the turbinates are pink, and the septum is straight.  There is a small amount of clear fluid from her right nostril.  The remainder of the examination is normal.  Which of the following additional history is most important for establishing a diagnosis in this patient?

Quizplus · Accepted Answer

11ec25c8_d21b_63da_bc81_852391172f43_MD0003_00 Clear, unilateral rhinorrhea that increases at times of relatively increased intracranial pressure (eg, bending over, bowel movements) is suspicious for cerebrospinal fluid (CSF) rhinorrhea. Patients also often report a salty or metallic taste. Most cases occur after head trauma, especially with fracture of the skull base (eg, cribriform plate, temporal bone). CSF rhinorrhea can be evident immediately after the trauma or may have a delayed presentation (days to months) in which rhinorrhea is noted after acute edema resolves. Testing the nasal discharge for CSF-specific proteins (eg, beta-2 transferrin, beta-trace protein) is diagnostic. Imaging or endoscopic nasal examination can be used to localize the precise site of the defect. Patients typically require inpatient management for bed rest, head-of-bed elevation, and frequent neurologic evaluation because they are at risk for meningitis due to nasal flora contamination of the CSF. If the CSF rhinorrhea does not resolve with these measures, further interventions (eg, lumbar drain, operative repair) are necessary. (Choices A and D) A personal or family history of atopy may suggest allergic rhinitis, which would present with bilateral (rather than unilateral) rhinorrhea and pale or bluish, boggy, edematous turbinates. Accompanying symptoms of sneezing, itching, and watery eyes are also typically present. (Choices B and F) Intranasal cocaine and nasal decongestants cause vasoconstriction. Overuse can result in bilateral (rather than unilateral) rhinorrhea and severe "rebound" nasal congestion (eg, rhinitis medicamentosa). Examination often shows swollen, erythematous turbinates. Tissue destruction from vasoconstriction caused by intranasal cocaine typically occurs at the septum (resulting in septal perforations) rather than at the skull base. (Choice C) Patients can be exposed to a variety of substances at work that result in allergic, irritant-induced, or corrosive rhinitis, leading to rhinorrhea. However, such rhinorrhea would be bilateral, and symptoms would increase during times of exposure (ie, at work) rather than with head positioning or straining. Educational objective: Clear, unilateral rhinorrhea that increases at times of relatively increased intracranial pressure (eg, bending over, bowel movements) is suspicious for cerebrospinal fluid rhinorrhea, which is most often caused by head trauma and can result in meningitis. References: Traumatic CSF leaks of the anterior skull base. (http://www.ncbi.nlm.nih.gov/pubmed/29558573)

A 35-Year-Old Woman Comes to the Office Due to Persistent