Case report: regression of aspiration pneumonitis after nasal endoscopic repair of traumatic cerebrospinal fluid nasal leak.

Am J Transl Res 2023;15(9):5778-5784 www.ajtr.org /ISSN:1943-8141/AJTR0149958 Case Report Case report: regression of aspiration pneumonitis after nasal endoscopic repair of traumatic cerebrospinal fluid nasal leak Fangwei Zhou1*, Peng Zhang2*, Tian Zhang1, Yifei Ma1, Jianyao Li1, Mengting Zeng1, Bingxi Yu3, Guodong Yu1 Department of Otorhinolaryngology-Head and Neck Surgery, Affiliated Hospital of Guizhou Medical University, Guiyang 550004, Guizhou, China; 2Department of Respiratory and Critical Care Medicine, Fengdu People’s Hospital, Fengdu County, Chongqing 408200, China; 3Department of Otolaryngology, Xingyi People’s Hospital, Xingyi 562400, Guizhou, China. *Equal contributors. 1 Received March 3, 2023; Accepted August 8, 2023; Epub September 15, 2023; Published September 30, 2023 Abstract: Aspiration pneumonitis is an inflammatory lung disease caused by the inhalation of oropharyngeal secretions colonized by pathogenic bacteria. Accurate diagnosis of aspiration pneumonitis can be challenging, and cerebrospinal fluid (CSF) rhinorrhea is often overlooked as a rare cause of aspiration. In this case report, we present the case of a 48-year-old male patient who experienced right-sided nasal flow of clear watery secretions for 6 months, accompanied by a dry cough as the major symptom. Through comprehensive assessment of clinical symptoms, sinus imaging, nasal endoscopy, and relevant laboratory testing, a presumptive diagnosis of traumatic cribriform plate fracture with CSF rhinorrhea was made. Chest imaging revealed flocculent ground glass shadows in the bilateral lungs. After ruling out viral pneumonia, nasal endoscopic repair of the skull base defect was performed. The patient’s dry cough and rhinorrhea symptoms resolved within 1 week after surgery, and the pneumonia showed significant improvement and complete resolution within 2 weeks postoperatively. Despite the absence of characteristic symptoms and evident inhalation factors, chronic CSF rhinorrhea caused by the cribriform plate fracture was ultimately identified as the primary etiology of the patient’s aspiration pneumonitis. This rare case highlights the importance of considering traumatic CSF rhinorrhea as an uncommon cause of aspiration, which can enhance physicians’ awareness and focus on the less-common etiologies of aspiration. Such awareness can contribute to more accurate diagnosis and early operative intervention, particularly in the context of the coronavirus disease 2019 pandemic. Keywords: CSF rhinorrhea, aspiration pneumonitis, endoscopic sinus surgery, skull base defect, COVID-19 era Introduction Cerebrospinal fluid (CSF) rhinorrhea refers to a CSF leak into the nasal cavity or sinuses due to defective dura mater and through sites such as a broken, ruptured, or thinned anterior or middle cranial fossa base, which may be caused by trauma or other congenital or spontaneous reasons [1]. These skull base injuries primarily originate from tumor invasion, head trauma, or intranasal or intracranial surgery [2]. Although some patients with CSF nasal leaks need only conservative treatment, others with persistent symptoms often require surgical intervention. Continuous CSF nasal leakage can lead to problematic symptoms such as headaches, nasal discharge, olfactory disorders, and visual disturbances [3]. Moreover, spinal fluid leakage from the intracranial space into the upper respiratory tract may lead to grave consequences due to the risk of ascending infection that may cause life-threatening fulminant meningitis [4]. Early repair and intervention are therefore vital. The emergence and spread of coronavirus disease 2019 (COVID-19) was a global public health crisis that threatens healthcare, education, tourism, and business [5]. Patients with high nasal virus titers and the potential for aerosol production during intranasal instrumentation present a high risk of COVID transmission to medical personnel performing skull base surgeries [6]. The cuneiform plate lateral lamella is the thinnest bone of the anterior skull base and Pulmonary involvement by CSF rhinorrhea Figure 1. Preoperative CT images of sinus showing a defect in the left roof of the ethmoid sinuses (yellow arrow). the most vulnerable part of the skull base [7]. Skull base fractures are typically caused by high-impact head trauma. Such fractures may be associated with severe intracranial complications, particularly CSF rhinorrhea, due to the inherent anatomic structure of the skull base [8]. Persistent CSF nasal leakage necessitates surgical treatment due to the risk of fulminant meningitis. In the COVID-19 era, endonasal endoscopic filling with nasal autogenous material is an effective treatment for CSF rhinorrhea, as skull base defects are localized [9]. Typically, the term “pneumonitis” refers to lung tissue inflammation unrelated to intracranial lesions and may manifest with symptoms such as wheezing, coughing, and shortness of breath [10]. Common etiologies include chemical exposure, infectious agents, inhalation, or radiation [11]. Aspiration pneumonitis is an infectious lung disorder caused by massive aspiration of the upper gastrointestinal or oropharyngeal contents. It is more common among people with risk factors such as dysphagia and disorder of consciousness [12]. However, due to the uncertain etiology and atypical clinical characteristics, the prompt diagnosis of aspiration pneumonitis can be challenging. Pulmonary involvement associated with CSF nasal leaks is rare; to our knowledge, only a few cases have been reported to date [13-15]. Here, we present a case of aspiration pneumonitis resulting from traumatic CSF rhinorrhea. The patient’s CSF leakage was controlled after surgical repair by nasal endoscopy, leading to the resolution of most pneumonia symptoms and imaging features. 5779 Case description A 48-year-old man presented with a 6-month history of right-sided watery rhinorrhea. The spontaneous clear, salty nasal discharge stemmed from a closed head injury sustained in a traumatic motor vehicle accident 6 months earlier. After initial management involving bed rest and observation, the patient was discharged from a local hospital after 7 days. He denied any history of recurrent sinusitis, obstructive sleep apnea hypopnea syndrome, meningitis, or sinus surgery, and any recent symptoms of headaches or elevated intracranial pressure. Four months later, he developed a frequent dry cough due to rhinorrhea, which gradually worsened, specifically when recumbent, which led to poor sleep quality. Furthermore, the patient recently developed mild olfactory disorders. Despite receiving antibiotic treatment at the local community hospital, his symptoms did not significantly improve. The patient sought further treatment at our outpatient department, where he underwent sinus computed tomography (CT) scan and nasal endoscopy. The sinus CT revealed a defect in the right roof of the ethmoid sinuses (Figure 1). Nasal endoscopy revealed s (...truncated)