A clue in the nose.

A morbidly obese 50-year-old woman presented with two episodes of septic meningitis over a 4-month period. The patient admitted having a watery discharge from her right naris for a year; she could not recall a history of head trauma. The glucose level of the discharge was 65 mg/dl. The authors diagnosed cerebrospinal fluid (CSF) rhinorrhoea. A second inspection of the brain CT showed flattening of the pituitary gland suggestive of empty sella, and a right posterior wall sphenoid sinus defect. Our patient had many features suggestive of spontaneous nasal CSF leak. Elevated intracranial pressure is a common finding; it increases the hydrostatic forces exerted at anatomically weakened sites of the skull and eventually produces a bone defect. Endoscopic exploration of the sphenoid sinus showed a bony defect which was repaired. When the patient was last seen 6 months after her surgery, she was doing well and her rhinorrhoea had stopped.