Patient with runny nose that never stops for 3 years despite ipratropium nose spray - consider CSF leak

A 62-year-old male is evaluated for runny nose nose that never stops for 3 years despite using ipratropium nose spray. There are clear secretions, and no congestion. It responds to Atrovent, 2 sprays bid for the last 3 years. No history of head trauma, falls, accidents, headache or other history or symptoms suggestive of CSF leak.

The runny nose is worse in the morning when he stands up.

What would you suggest?

CFS leak, also called Brain Fluid Leak, is still in the differential diagnosis. SPT test was negative.

ENT evaluation as suggested.

Summary

Rhinitis and rhinorrhea are common clinical complaints that may be allergic or nonallergic in etiology. Distinguishing between allergic and nonallergic etiologies can be difficult but necessary for treatment. It is essential that no symptom, especially that which persists and resists treatment, is trivialized.

People with CSF rhinorrhea might complain of a runny nose that gets worse with a change in position (such as standing up) or with Valsalva maneuver (straining or lifting heavy objects)

Spontaneous CSF Rhinorrhea/CSF leaks occur in patients without any previous trauma. Spontaneous CSF leaks are probably due to elevated intracranial pressure (ICP). Ultimately, the bone is weakened until a defect if formed and a leak begins. The dura or part of the brain (encephalocele) may actually protrude through the weakened part of the bone.

The presentation of a CSF leak is typical: Clear, watery discharge that often occurs only on one side of the nose. Often the discharge is continuous, but it may be sporadic and related to certain activities. This drainage may be reproducible by bending over or by straining. Patients may report a metallic or salty taste. Many patients with spontaneous leaks often are diagnosed with allergies or sinus infections and are unsuccessfully treated, often for many months, with antihistamines, nose sprays, and antibiotics.

References:

Cerebrospinal fluid leak mimicking allergic rhinitis. Ricketti AJ1, Cleri DJ, Porwancher RB, Panesar M, Villota FJ, Seelagy MM. Allergy Asthma Proc. 2005 Mar-Apr;26(2):125-8.
http://www.ncbi.nlm.nih.gov/pubmed/15971471

CSF Rhinorrhea - Medscape http://buff.ly/1vLuZhE

Runny Nose Caused By Brain Fluid Leak - About.com http://buff.ly/1vLuXGl

Cerebrospinal Fluid Leak — NEJM http://buff.ly/1vLvQio

CSF Leaks http://buff.ly/1vLw88K