自发性脑脊液鼻漏误诊误治临床探讨

Clinical Exploration of Misdiagnosis and Mistreatment for Spontaneous Ce⁃rebrospinal Fluid Rhinorrhea

目的分析自发性脑脊液鼻漏误诊误治的原因,总结避免误诊误治的措施。方法回顾性分析2008年12月至2023年8月被误诊的11例自发性脑脊液鼻漏患者的临床资料。结果8例流清水样涕、鼻腔黏膜色泽苍白或淡红,被误诊为过敏性鼻炎。1例左侧鼻腔流水、中鼻道半透明荔枝肉状肿物,副鼻窦CT示“左上颌窦、筛窦炎,左中鼻道软组织密度影”,被误诊为左慢性鼻窦炎伴鼻息肉。1例上呼吸道感染后,头部不适,流清水样涕,被误诊为急性鼻炎。1例睡觉时鼻腔有液体流向喉部,鼻窦CT示“右侧上颌窦卵圆形肿物、边界清晰,考虑囊肿”,被误诊为右上颌窦囊肿。11例患者经对症治疗后症状无缓解,进一步行影像学及鼻流出液葡萄糖定量检查后确诊为自发性脑脊液鼻漏。误诊时间10~60(24.09±13.5)d。11例均行经鼻内镜脑脊液鼻漏修补术后痊愈。结论自发性脑脊液鼻漏起病隐匿、临床少见、多为单侧发病、鼻流出液多呈持续性且清亮无色,可因体位改变、咳嗽、喷嚏、便秘等致颅内压增加而加重。完善鼻窦CT和磁共振成像,可为该病的诊断提供证据,确诊需要鼻流出液葡萄糖定量检查。

Objective To analyze the causes of clinical misdiagnosis and mistreatment of spontaneous cerebrospinal fluid(CSF)rhinorrhea,and to summarize the measures to avoid misdiagnosis and mistreatment.Methods The clinical data of 11 patients with spontaneous CSF rhinorrhea who were misdiagnosed from December 2008 to August 2023 were retrospectively analyzed.Results Eight patients were misdiagnosed as allergic rhinitis due to runny watery nose and pale or reddish nasal mucosa.One patient had translucent lychee fleshy masses in the left nasal passages and middle nasal passages.CT scan of the paranasal sinuses showed"left maxillary sinus,ethmoid sinusitis,and soft tissue density shadow in the left middle nasal passages",which was misdiagnosed as left chronic sinusitis with nasal polyps.One patient was misdiagnosed as acute rhinitis due to head discomfort and watery nose after upper respiratory tract infection.A patient with fluid flowing from the nasal cavity to the larynx during sleep was misdiagnosed as a cyst of the right maxillary sinus after sinus CT showed"ovoid mass of the right maxillary sinus with clear boundary which was considered to be a cyst".After symptomatic treatment,the symptoms of 11 patients were not relieved,and further imaging and quantitative determination of glucose in rhinorrhea were confirmed as spontaneous CSF rhinorrhea.The misdiagnosis lasted 10-60(24.09±13.5)d.All 11 patients recovered after endoscopic repair of CSF rhinorrhea.Conclusion The onset of spontaneous CSF rhinorrhea is insidious,rare in clinical settings,and mostly unilateral,and the rhinorrhea are mostly persistent,clear and colorless,which can be aggravated by increased intracranial pressure caused by changes in body position,cough,sneezing,and constipation.Sinus CT and magnetic resonance imaging can provide evidence for the diagnosis of this disease,and the final diagnosis requires quantitative determination of glucose in rhinorrhea.