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Creating Waves of Awareness

Mr M.A, a columnist in a regional news paper, consulted me during the initial days of my practice. He was very much troubled with a nasal discharge, with occasional sneezing, since many years. Initially, he had taken Allopathic and Ayurvedic remedies with no benefit. The discharge was watery, salty and hot. The flow used to get aggravated while straining and stooping, especially while performing Namaz. While taking that case, he said,
"doctor, I feel the discharge is coming from my brain." Immediately, I scolded him for "diagnosing" a rare condition. I told him that the discharge is from the mucus membrane of nose and para nasal sinuses. Considering his presenting totality, I prescribed Natrum mur 30. He again came with no special relief. I repeated the medicine and also suggested him to practice Pranayama. He continued my treatment for two months and stopped coming. After a long gap, he came to me with a file containing several investigation reports and a discharge summary. The report shows that the nasal discharge was Cerebro spinal fluid (CSF), leaking through the defect in the cribriform plate of the ethmoid bone. As per the discharge summary, a surgical repair was done using a graft, and the leak is now completely stopped.

I got ashamed of myself for missing the diagnosis, mainly because, he could diagnose it in-spite of being a non medical person. I had studied CSF rhinorrhea in 3rd year BHMS, but could not recollect my memory when a real patient came to me. If we are wisely attentive, we can definitely learn so many things for our patients!

Moral of the article: Do not miss the diagnosis by saying that it is very rare. Practically, there is no difference between 99% possibility and 1% possibility, because that one patient could be our patient!

Dr Muhammed Rafeeque, BHMS, PGNAHI.

CSF rhinorrhea:

EMedicine Article

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Comment by Dr Muhammed Rafeeque on March 21, 2011 at 5:40am
Comment by Veeraraghavan A.R. on March 19, 2011 at 1:05am
It is healthy. we should share our failure also.
Comment by Dr Muhammed Rafeeque on September 24, 2010 at 11:52pm
Comment by Dr.(Mrs) Amina Meer on September 24, 2010 at 1:16pm
nice case study..we often miss the diagnosis as it mimics the commonly found allergic rhinitis cases..our failures teach us to be more alert in case taking and listening attentively to patients narration.
Comment by Dr Muhammed Rafeeque on September 17, 2010 at 5:56am
Thank u doctor.
Comment by DR.GARGE PRADEEP RAMDAS on September 15, 2010 at 7:38am
dear dr ,that shows the importance of diagnosis.thanks for sharing such a valuable experience
Comment by Dr Muhammed Rafeeque on September 15, 2010 at 12:28am
Thanks for the comments.
This dictum is cent percent true: A good surgeon is one who knows when not to operate the patient! Surgery is not indicated for all cases of CSF rhinorrhea. When the defect is large with a higher risk of meningitis, it should be closed immediately. When the defect is small, we can give symptomatic treatment. Now this person is still my patient- with a list of diagnosis: HTN, DM, IHD etc. That surgery could only save him from meningeal infection, but still he is sick!
Comment by Dr. Poonam Batra on September 14, 2010 at 1:20pm
Thanks for sharing, many of us face this but daring like you mention at common platform, this is the way we learn.
Comment by Dr Neena Singla on September 14, 2010 at 9:51am
When I was working with Dr Jugal Kishore I had also seen a case of CSF rhinorrhoea, He was reluctant to go for surgery and we treated him symptomatically and he was better.
Comment by Dr Muhammed Rafeeque on September 14, 2010 at 7:06am
Thank you all for your valuable comments.

In order to diagnose CSF rhinorrhea, the CSF can be collected by asking the patient to do valsalva maneuver Laboratory tests of CSF helps to confirm the diagnosis.

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