Rare case of Sneezing Suppression leading to Spontaneous CSF Leak, a Report
Saudi Arabia: A 45-year-old woman developed a spontaneous cerebrospinal fluid (CSF) leak and air entry into the skull, possibly triggered by suppressing a sneeze, despite no history of trauma or surgery. She presented with mild, persistent headaches for 3 months that improved when lying down, along with intermittent clear nasal discharge from the left nostril, especially when leaning forward.
The unusual case, published in the American Journal of Case Reports by Khalil I. Kariri from the Department of Otolaryngology–Head & Neck Surgery, Armed Forces Hospital, Jazan, Saudi Arabia, and colleagues, highlights a rare but important complication associated with sneeze suppression. The report underscores how sudden increases in intranasal pressure can force air or fluid through weak areas of the skull base, potentially resulting in CSF leakage and pneumocephalus.
The patient, previously healthy, had no history of head injury, sinus disease, or prior surgery. Clinical evaluation revealed largely normal neurological findings, though nasal examination showed structural variations such as turbinate enlargement and septal deviation. Imaging played a key role in diagnosis. High-resolution CT scans identified small pockets of air within the cranial cavity and a tiny defect in the left cribriform plate, while MRI confirmed the presence of intracranial air without other abnormalities.
Further history revealed a habit of repeatedly suppressing sneezes, particularly in social settings. This behavior likely contributed to the pressure changes responsible for the skull base defect and subsequent complications. Initially, as the patient had no signs of infection or neurological deterioration, a conservative approach was adopted. She was advised to avoid activities that increase nasal pressure, such as forceful sneezing or straining, and to seek immediate care if symptoms worsen.
Despite these precautions, the patient experienced recurrent episodes of clear nasal discharge over the following weeks, particularly when bending forward. Medical management with acetazolamide was initiated to reduce CSF pressure, but symptoms persisted. Endoscopic evaluation later confirmed an active CSF leak.
Given the persistence of symptoms, a multidisciplinary team proceeded with surgical intervention. The patient underwent endoscopic repair of the skull base defect along with correction of nasal structural abnormalities. Intraoperative findings included a small encephalomeningocele and an active CSF leak at the cribriform plate. The defect was successfully repaired using grafting techniques, and the patient was closely monitored postoperatively.
Recovery was uneventful, with no recurrence of symptoms during follow-up over one year. The patient remained free of headaches, nasal discharge, or neurological complications. She was counseled on avoiding behaviors that increase intranasal pressure, particularly suppressing sneezes, and advised to sneeze with an open airway to reduce risk.
This case draws attention to sneeze suppression as an underrecognized cause of spontaneous CSF leaks and pneumocephalus. In patients presenting with unexplained nasal discharge or intracranial air without a history of trauma, this mechanism should be considered. Early imaging and timely diagnosis are essential to prevent complications. The authors emphasize that greater awareness among clinicians, along with patient education on safe sneezing practices, could help avoid such potentially serious outcomes.
Reference:
DOI: 10.12659/AJCR.951643
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