A 10-year-old Emirati male presented to the emergency department (ED) on 12th of November 2020 complaining of unilateral clear, watery nasal discharge from the left nostril for 14 days. His symptoms started immediately after he presented to the ED 14 days ago complaining of low grade fever (38 deg C), dry cough, nasal congestion and body aches, was found to have congested throat, otherwise unremarkable physical examination. COVID PCR nasopharyngeal swab was done in this ED visit and the patient was discharged home on symptomatic treatment.
As per the patient, the clear nasal discharge was started immediately after COVID swab was done in the same nostril, whenever he bends his neck forward the discharge increases. He started to feel dizzy recently but denies headache, fever, nausea, vomiting, neck stiffness, blurred vision or rash.
The patient is a known case of 3MC syndrome (autosomal recessive disorder characterized by distinctive facial features like hypertelorism, blepharophimosis, blepharoptosis, highly arched eyebrows and cleft lip and palate. Other findings include growth deficiency, cognitive impairment, and hearing loss) (3).
He underwent surgical repair for cleft lip when he was 3 months old and cleft palate when he was 6 months old (stage 1). The second stage of surgery was done on October 2019 where he underwent alveolar bone grafting.
On physical examination, the patient was lying on bed comfortably, vitals were as follows: heart rate of 76 beats/minute, respiratory rate of 23 breaths/minute, blood pressure of 90/55 mmhg, oxygen saturation 99% on room air and a temperature of 36.4 degree C.
Facial dysmorphic features were noted, he had a broad forehead, low set ears and hypertelorism. The patient was alert and oriented to self, time and place. His GCS was 15. No focal neurological deficit, negative Kernig and Brudzinski signs. Focused exam showed active clear watery discharge from the left nostril as shown in the picture (Picture 1). The rest of the physical exam was unremarkable.
Cerebrospinal fluid leak was highly suspected from the history and physical examination. Labs drone were unremarkable, including normal WBC count and inflammatory markers. CT brain without contrast was done and reported as following “No intracranial abnormality identified. Poor definition of the cribriform plate and with significant rightward deviation of the nasal septum warrants further assessment with high-resolution MRI scan” (Picture 2 and 3). However, MRI was not done for unknown reason.
The patient was started on prophylactic antibiotics and he got admitted under pediatrics neurosurgery. He underwent surgical repair on the second day of admission by ENT and neurosurgery teams. Nasal endoscopy was done and showed medial lamella cribriform defect about 1 mm with meningocele in the left side. An Endoscopic Endonasal repair of CSF leak was done.
After the surgical repair, the patient reported complete resolution of his symptoms. The patient was kept for observation for five days post surgery, no complication were observed during this period. One week post discharge, he was followed up in the clinic and no complications were reported.