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This woman’s runny nose turned out to be a brain leak
Shemika Rodriguez thought she had a cold until headaches and dizziness led her on a journey that ended in surgery to fix a cerebrospinal fluid leak
At first, Shemika Rodriguez, 44, food deliverer and aspiring pop singer, didn’t think much of her running nose. After weeks of dripping, though, she noticed that she wasn’t congested and her nose only ran from her left nostril. Then it got weirder: “I noticed that any time I would bend over to pick something up, my nose would drip more.”
Rodriguez consulted several physicians, eventually reaching Northwell internist Zachary Bregman, MD. Rodriguez’s nasal and sinus issues had been severe and unrelenting for months. They hadn’t responded to standard treatments, like antihistamines and antibiotics — and she was experiencing concurrent dizziness and headaches. “This led me to consider unusual diagnoses,” says Dr. Bregman, who suspected something called a cerebrospinal fluid leak, also called CSF rhinorrhea.
Cerebrospinal fluid leak: a rare condition
Cerebrospinal fluid (CSF) is a clear, thin liquid that surrounds and cushions your brain and spinal cord to help protect them from injury. Your body makes about 500 milliliters of the fluid a day (about eight ounces); it’s contained by three layers of membranes. If there is a tear in the outermost membrane layer, called the dura mater, some of the fluid may escape — that’s a cerebrospinal fluid leak. The condition is rare, thought to occur in about 5 of 100,000 people. Left untreated, it can lead to serious, or even fatal, complications.
What causes cerebrospinal fluid leak?
In most cases, a cerebrospinal fluid leak is caused by a head trauma from an injury or surgery; other times, the leak occurs spontaneously.
Charles (Ching Lick) Tong, MD
Ching Lick Tong, MD, a highly skilled otolaryngologist specializing in the treatment of chronic sinusitis, nasal obstructions, and skull base neoplasms, is dedicated to providing comprehensive care for complex ENT conditions.
Cerebrospinal fluid leak symptoms
If you have a cerebrospinal fluid leak in your nose, there are a few potential signs:
- Heightened sensitivity to light and sound
- Dizziness
- Confusion
- Memory loss
- Headache
Because cerebrospinal fluid protects your spinal cord, a leak can also leave it vulnerable to injury and infection, including, in severe cases, meningitis. This is a potentially fatal bacterial or viral infection of the spinal cord with symptoms of its own, including seizures, high fever and neck stiffness.
Finding the cerebrospinal fluid leak
Dr. Bregman sent Rodriguez to ear, nose and throat physician Charles C.L. Tong, MD, for a comprehensive evaluation. To confirm his and Dr. Bregman’s suspicions, Dr. Tong took a sample of fluid to have it tested for a protein that is present in cerebrospinal fluid but not in nasal mucus.
Cerebrospinal fluid leak can also be detected with CT and/or MRI scans; Dr. Tong ordered both. Rodriguez was able to get the imaging that same day at Lenox Health Greenwich Village, and on-site neuroradiologists read the scans immediately. And there it was: a tiny hole in the bones that support the bottom of the brain, called the skull base. Part of her brain had pushed through the opening. Dr. Tong called Rodriguez the next morning to share the findings and his plan.
Findings on the imaging suggested idiopathic intracranial hypertension, or increased pressure in the brain, had led to her leak. (“Idiopathic” means that there wasn’t an obvious reason for the increase.) When the heart beats, the brain pulsates. If the brain is under pressure, that repeated pulsation can wear down the bone of the skull base, which is located right behind the nose and eyes. Over time, a hole may develop, and brain tissue and the lining of the brain (the dura) may herniate through. If you also have a tear in the dura, fluid will leak into the nasal tract. Repairing the hole is crucial.
There was no time to waste. Rodriguez was scheduled for surgery just two weeks later.
Dr. Tong reached out to his neurosurgical partner, John Boockvar, MD, vice chair of the department of neurosurgery at Lenox Hill Hospital, to review the scans. They decided on a minimally invasive approach: The surgery and repair would be accomplished through her nostrils, with no incisions on her head at all.
Cerebrospinal fluid leak surgery
To fix a cerebrospinal fluid leak, surgeons must first reach it. This can be done via several methods, including:
- Mastoidectomy: A surgical procedure to reach and repair the source of a cerebrospinal fluid leak. Surgeons remove a small portion of the temporal bone (called the mastoid process) behind the ear to reach the dura, where the leak is often located.
- Craniotomy: A surgical procedure that involves removing a portion of the skull (bone flap) to access the brain. This approach is typically used for leaks located higher up in the skull or those that are more complex.
Once the leak is exposed, surgeons will patch it with a graft made from muscle or fat.
On September 22, Rodriguez checked into Lenox Hill Hospital for surgery. Her nose was still pouring fluid. “Dr. Tong and Dr. Boockvar had explained each step to me, from start to recovery,” says Rodriguez. “I was nervous, but I was ready.”
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Once Rodriquez was prepped, Dr. Tong used a surgical navigation system (akin to the GPS in your car) and an endoscope — a long thin tube fitted with a light and a high-definition camera — to map the corridor from the nostrils to the defect. Using Dr. Tong’s light, Dr. Boockvar removed the brain matter protruding through the hole in the skull base; it had become nonviable after losing its blood supply, so the removal had no impact on Rodriguez. Then he used a synthetic patch to repair the hole in the brain lining.
Next Dr. Tong got to work fixing the nasal lining. Borrowing a portion of tissue covering the nasal septum (the structure that separates the right and left nostril), he rotated it over to repair the hole. Four hours after the surgery began, it was over. Rodriguez’s leak was gone.
Rodriguez spent the first few days after the operation in the intensive care unit with splints in her nose and drainage tubes in her lumbar spine. The tubes drained her spinal fluid, so the seals stayed dry while they set and settled. “Just like you wouldn’t run the shower right after you caulk a tub, the same holds true for a CSF repair,” says Dr. Boockvar.
About a week after surgery, Rodriguez was discharged.
Recovering from cerebrospinal fluid leak surgery
Minimally invasive cerebrospinal fluid leak surgery offers many benefits, including shorter hospital stays and a faster, smoother recovery, but it’s still a major operation. After surgery, patients typically spend two days in the hospital. Recovery times vary significantly depending on the individual, the severity of the leak and the surgical approach.
Rodriguez had scabbing and swelling in her nose for a few weeks, and it took about two months for her sense of smell and taste to fully return. She followed her doctors’ advice to ease into activity slowly, and now takes a diuretic to help decrease the pressure in her brain. Her risk of developing another cerebrospinal fluid leak is low, says Dr. Tong.
Rodriguez is grateful to Dr. Tong, Dr. Boockvar and her Northwell team, who took the time to get her the care and answers she needed.
“Their spirit and professionalism, and the way they treat people, is truly divine,” says Rodriguez. “They are a gift to the world, and I’m forever thankful.”
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