Efficacy of Normalising Serum Zinc Level for Patients with Olfactory Dysfunction and Zinc Deficiency.

INTRODUCTION: Zinc deficiency may worsen the severity of olfactory dysfunction; however, the relationship between serum zinc levels and therapeutic effects on olfactory dysfunction remains uncertain. This study investigated the relationship between normalising serum zinc levels and the therapeutic effects on olfactory dysfunction. METHODS: Forty-two patients diagnosed with post-infectious, post-traumatic, and idiopathic olfactory dysfunction, with serum zinc levels <70 µg/dL, were included in the study. All patients were treated with mecobalamin, tokishakuyakusan, and polaprezinc. The patients were divided into 2 groups: the zinc-normalised (≥70 µg/dL) and zinc-deficient (<70 µg/dL) groups, based on their post-treatment serum zinc levels. Olfactory test results were compared in each of the 2 groups. RESULTS: The patients were treated for a median of 133 days. The zinc-normalised group had significantly better results in all olfactory tests (detection/recognition thresholds of the T&T olfactometer, odour identification test (Open Essence), Visual Analogue Scale for olfactory dysfunction, and self-administered odour questionnaire). In contrast, only the self-administered odour questionnaire showed a significant improvement in the zinc-deficient group, with no significant differences observed in the other olfactory tests. When comparing the changes in the olfactory test scores between the 2 groups, significant differences were observed in the detection/recognition thresholds of the T&T olfactometer test and Open Essence results. CONCLUSION: These findings suggest that patients with olfactory dysfunction may have difficulty improving their olfactory function if they also have zinc deficiency. Furthermore, normalisation of zinc deficiency may contribute to the improvement of olfactory dysfunction with general treatment.

Comparison of Patient Characteristics and Olfactory Sensitivity for Trigger Odorants in Parosmia and Phantosmia.

OBJECTIVES: This study aimed to determine the characteristics of patients with qualitative olfactory dysfunction (qualOD) and whether individuals with parosmia exhibit increased olfactory sensitivity to previously reported odorous triggers of parosmia. METHODS: This study included individuals aged ≥18 years, divided into quantitative OD only, parosmia, and phantosmia groups. Data collected included: clinical-demographic data, "Sniffin' Sticks" scores, questionnaires (depression scale, importance of olfaction), and information about parosmia and phantosmia. A proportion of patients underwent trigger odor threshold testing for 2-Furfurylthiol [FFT] found in coffee and 2,6-nonadienal [Nonadienal] found in cucumber. RESULTS: Those with parosmia were typically younger women, with shorter OD duration due to post-viral OD (PVOD), hyposmic/normosmic, and experienced parosmia more severely. Parosmia was 3.5 times more likely in PVOD. Those with phantosmia were older, with longer OD duration due to idiopathic OD, hyposmic/anosmic, and experienced phantosmia less severely. There were no significant differences between FFT and Nonadienal threshold scores in patients with parosmia, phantosmia, or only quantitative OD, but all groups had significantly increased olfactory sensitivity for trigger odors compared to phenyl ethyl alcohol (PEA). CONCLUSION: Parosmia and phantosmia patients have distinct characteristics. This may provide clinicians with a better understanding of possible olfactory outcomes in these patients. The higher olfactory sensitivity of all groups to trigger odors compared to PEA raises interesting points about parosmia triggers and odors in the context of warning for danger, in relation to the pathophysiology of parosmia that may be worth exploring in future studies. LEVEL OF EVIDENCE: 3 Laryngoscope, 134:3277-3285, 2024.

Characteristics of higher depressive tendency in the patients with olfactory disorder.

OBJECTIVE: Most patients with olfactory dysfunction experience stress and anxiety because of the inconvenience and changes caused by the loss of olfaction. However, psychological assessment is not performed routinely in patients with olfactory dysfunction, and the characteristics of these patients with psychological depression are unclear. METHODS: In this study, we used the Self-rating Depression Scale to evaluate the degree of depression in patients who visited our clinic with olfactory dysfunction and examine the characteristics of these patients with strong depressive tendencies. Patients who visited our clinic between April 2019 and March 2020 with complaints of olfactory dysfunction were included in the study. RESULTS: A total of 180 patients (79 male and 101 female) underwent olfactory examination and completed the Self-rating Depression Scale. Eighty-six and 94 patients were included in the low depression and high depression groups, respectively. Binomial logistic regression analysis showed significant positive associations of Self-rating Depression Scale scores with female sex and the presence of parosmia/phantosmia (p < 0.05). CONCLUSION: In our study, approximately half of the patients with olfactory dysfunction had depressive tendencies especially in female and parosmia/phantosmia patients. We believe that psychological assessments, such as that with the SDS, can help identify patients with olfactory dysfunction who may be at a greater risk of developing depression.

A Nationwide survey of safety protocols and chemosensory assessments by Japanese clinicians pre- and post-COVID-19 pandemic.

OBJECTIVE: There has been an increase of attention and awareness of smell and taste loss due to the impact of COVID-19. However, little is known about the influence of COVID-19 on the number of psychophysical tests performed, the timing of these tests, or the protection protocols employed to protect against virus transmission. This study aimed to explore the changes in examination approaches, types of tests employed, and safety measures adopted by clinicians before and after the COVID-19 pandemic. METHODS: A survey was distributed to 404 institutes of the Oto-Rhino Laryngological Society of Japan, consisting of otolaryngologists working in university hospitals, general hospitals, and private clinics. The anonymous online survey contained questions related to safety measures and chemosensory assessments performed before and after the COVID-19 pandemic. Specifically, participants were queried on the number and types of examinations conducted, the type of examiners who performed them, the timing of tests in suspected and non-suspected COVID-19 cases, modifications made due to the pandemic, and the protective measures adopted during chemosensory examinations. RESULTS: Of the 201 respondents, representing a 50 % response rate, 49 % were from general hospitals, 48 % from university hospitals, and 3 % from private clinics. The study found a slight decrease in the overall number of chemosensory tests conducted post-COVID-19. In terms of who performed the test, there were no differences pre- and post- COVID-19. Most examinations (52-68 %) for suspected COVID-19 cases were performed 1-2 months after the onset of symptoms. Modifications in testing rooms and personal protective equipment (PPE) were reported by the majority of institutions post-pandemic. While different examination rooms or PPE were not commonly used based on a patient's previous COVID-19 diagnosis, changes were observed in testing practices. Most examinations were conducted in rooms with windows or fans, and PPE usage was high; surgical masks, eye visors or face shields, and disposable gloves being commonly used. Virus transmission from patient to examiner was reported in only one case during T&T olfactometer examination. CONCLUSION: We investigated the impact of the COVID-19 pandemic on the number of olfactory and gustatory tests performed, the type of examiner, the examination room, and the use of PPE and found no significant difference before and after the COVID-19 pandemic on these factors. Adherence to a protection protocol involving the proper use of PPE in controlled environments enabled the continuation of olfactory and gustatory tests during the pandemic.

Practical guide for the diagnosis and management of primary ciliary dyskinesia.

OBJECTIVE: Primary ciliary dyskinesia (PCD) is a relatively rare genetic disorder that affects approximately 1 in 20,000 people. Approximately 50 genes are currently known to cause PCD. In light of differences in causative genes and the medical system in Japan compared with other countries, a practical guide was needed for the diagnosis and management of Japanese PCD patients. METHODS: An ad hoc academic committee was organized under the Japanese Rhinologic Society to produce a practical guide, with participation by committee members from several academic societies in Japan. The practical guide including diagnostic criteria for PCD was approved by the Japanese Rhinologic Society, Japanese Society of Otolaryngology-Head and Neck Surgery, Japanese Respiratory Society, and Japanese Society of Pediatric Pulmonology. RESULTS: The diagnostic criteria for PCD consist of six clinical features, six laboratory findings, differential diagnosis, and genetic testing. The diagnosis of PCD is categorized as definite, probable, or possible PCD based on a combination of the four items above. Diagnosis of definite PCD requires exclusion of cystic fibrosis and primary immunodeficiency, at least one of the six clinical features, and a positive result for at least one of the following: (1) Class 1 defect on electron microscopy of cilia, (2) pathogenic or likely pathogenic variants in a PCD-related gene, or (3) impairment of ciliary motility that can be repaired by correcting the causative gene variants in iPS cells established from the patient's peripheral blood cells. CONCLUSION: This practical guide provides clinicians with useful information for the diagnosis and management of PCD in Japan.

Translation, cultural adaptation, and validation of the Standardized Cosmesis and Health Nasal Outcomes Survey in Japanese (J-SCHNOS).

BACKGROUND: Rhinoplasty is one of the most popular plastic surgery techniques. The evaluation of both functional and cosmetic aspects of rhinoplasty is essential for planning and assessing surgery results. The Standardized Cosmesis and Health Nasal Outcomes Survey (SCHNOS) is a validated questionnaire used to assess both functional and aesthetic symptoms in patients with nasal problems, and it has been translated into several languages. The purpose of this study was to translate, culturally adapt, and validate the SCHNOS in Japanese among patients undergoing rhinoplasty. METHODS: This was a prospective validation study of the Japanese version of the SCHNOS (J-SCHNOS). The first phase involved translation and cross-cultural adaptation of the SCHNOS. The second phase included validation of the J-SCHNOS among native Japanese speakers. RESULTS: In total, 357 participants completed the final version of the J-SCHNOS (219 males and 138 females; mean age 43.4 years). The J-SCHNOS showed high internal consistency with excellent Cronbach's alpha values for both obstruction (SCHNOS-O) (0.96) and cosmetic (SCHNOS-C) (0.93) domains. The reproducibility was high, with an excellent intraclass correlation coefficient (ICC) >0.9 for all items. Exploratory factor analysis showed unidimensional structures in both the SCHNOS-O and the SCHNOS-C. CONCLUSION: The J-SCHNOS is a reliable and valid tool to assess the severity of nasal problems in patients undergoing rhinoplasty.

A case of recurrent chronic eosinophilic pneumonia after switching from benralizumab to dupilumab.

Dupilumab inhibits interleukin-4Rα and suppresses type 2 inflammation. Careful administration of dupilumab is required because it increases the blood eosinophil count secondary to a decrease in local eosinophil counts, sometimes resulting in eosinophilic complications. We herein report a case of recurrent chronic eosinophilic pneumonia after switching from benralizumab to dupilumab. A 54-year-old man with a history of eosinophilic pneumonia presented to our hospital with symptoms of cough, fever, and phlegm production six months after beginning dupilumab administration for recurrent chronic rhinosinusitis. When using dupilumab, it is essential to carefully monitor patients' eosinophil trends and pulmonary symptoms.

Efficacy of tokishakuyakusan and mecobalamin on post-infectious olfactory dysfunction: A prospective multicenter study.

OBJECTIVE: To determine if tokishakuyakusan (TSS) is effective for treating post-infectious olfactory dysfunction (PIOD) compared with vitamin B12 (mecobalamin). METHODS: We conducted a randomized, nonblinded clinical trial. Patients with PIOD enrolled in 17 hospitals and clinics from 2016 to 2020 were randomly divided into two groups, and we administered TSS or mecobalamin for 24 weeks. Their olfactory function was examined using interviews and T&T olfactometry. The improvement of olfactory dysfunction was assessed following the criteria of the Japanese Rhinologic Society. RESULTS: Overall, 82 patients with PIOD were enrolled in this study. In the TSS and mecobalamin groups, 39 patients completed the medication regimen. In the TSS and mecobalamin groups, olfactory dysfunction was significantly improved based on self-reports and olfactory test results. The improvement rate of olfactory dysfunction was 56% in the TSS group and 59% in the mecobalamin group. Early intervention within 3 months produced a better prognosis than the treatment initiated after 4 months. Furthermore, age and sex differences were not observed. Both medications produced no severe adverse events. CONCLUSION: The present study showed that TSS and mecobalamin might be useful for treating PIOD.

International clinical assessment of smell: An international, cross-sectional survey of current practice in the assessment of olfaction.

OBJECTIVES: Olfactory dysfunction (OD) is common and carries significant personal and societal burden. Accurate assessment is necessary for good clinical and research practice but is highly dependent on the assessment technique used. Current practice with regards to UK/international clinical assessment is unknown. We aimed to capture current clinical practice, with reference to contemporaneously available guidelines. We further aimed to compare UK to international practice. DESIGN: Anonymous online questionnaire with cross-sectional non-probability sampling. Subgroup analysis according to subspeciality training in rhinology ('rhinologists' and 'non-rhinologists') was performed, with geographical comparisons only made according to subgroup. PARTICIPANTS: ENT surgeons who assess olfaction. RESULTS: Responses were received from 465 clinicians (217 from UK and 17 countries total). Country-specific response rate varied, with the lowest rate being obtained from Japan (1.4%) and highest from Greece (72.5%). Most UK clinicians do not perform psychophysical smell testing during any of the presented clinical scenarios-though rhinologists did so more often than non-rhinologists. The most frequent barriers to testing related to service provision (e.g., time/funding limitations). Whilst there was variability in practice, in general, international respondents performed psychophysical testing more frequently than those from the UK. Approximately 3/4 of all respondents said they would like to receive training in psychophysical smell testing. Patient reported outcome measures were infrequently used in the UK/internationally. More UK respondents performed diagnostic MRI scanning than international respondents. CONCLUSIONS: To our knowledge, this is the most comprehensive UK-based, and only international survey of clinical practice in the assessment of OD. We present recommendations to improve practice, including increased education and funding for psychophysical smell testing. We hope this will promote accurate and reliable olfactory assessment, as is the accepted standard in other sensory systems.

Evaluating tooth extraction as a stand-alone treatment for odontogenic sinusitis.

BACKGROUND: There are multiple treatment methods for odontogenic sinusitis (OS); however, the optimal treatment remains unclear. AIMS/OBJECTIVE: To determine the cure rate of OS after tooth extraction and the factors contributing to the cure. MATERIAL AND METHODS: We prospectively identified 37 patients diagnosed with OS with an indication for causative tooth extraction. Before and three months after tooth extraction, the patients were assessed using sinus computed tomography and classified as either cured or uncured based on the absence or presence of soft tissue shadow in the maxillary sinus. The prognostic factors were analysed by comparing the two groups. RESULTS: There were ten patients for whom all data could be obtained. The mean age of the patients at the time of tooth extraction was 53.8 ± 12.9 years (range, 34-75 years). In seven patients, the soft tissue shadow in the maxillary sinus disappeared; these patients were classified as cured. Uncured patients were significantly younger than cured patients (59.9 vs. 39.7 years). CONCLUSIONS AND SIGNIFICANCE: Tooth extraction effectively treated OS in 70% of patients. However, even after tooth extraction, OS may not improve, particularly in younger patients.

Olfactory dysfunction in Japanese children with moderate-to-severe allergic rhinitis.

OBJECTIVE: Detailed quantitative studies on olfaction remain inadequate in patients with paediatric allergic rhinitis (AR). This study examined olfactory dysfunction in children with AR. METHODS: From July 2016 to November 2018, children aged 6-9 years were recruited and grouped as AR (n = 30) or without AR (control group, n = 10). Odour identification was evaluated by the Universal Sniff (U-Sniff) test and the Open Essence (OE). The results were compared between the AR and control groups. Intranasal mucosa findings, nasal smear eosinophil counts, blood eosinophil counts, total immunoglobulin E (IgE) levels, Japanese cedar-specific IgE and Dermatophagoides pteronyssinus-specific IgE were evaluated in all participants. Additionally, the presence of sinusitis and adenoid hypertrophy in patients with AR was also evaluated by sinus X-ray examinations. RESULTS: The median U-Sniff test scores were not significantly different between the AR and control groups (9.0 vs. 10.0, respectively; p = 0.107). The OE score was significantly lower in the AR group than in the control group (4.0 vs. 8.0; p = 0.007, respectively), especially in the moderate-to-severe AR group versus the control group (4.0 vs. 8.0; p = 0.004). Furthermore, in the OE, the correct answer rates for 'wood', 'cooking gas' and 'sweaty socks' were significantly lower in the AR group than in the control group. CONCLUSIONS: Paediatric AR patients can reduce olfactory identification ability, and the degree may be associated with the severity of AR in nasal mucosal findings. Furthermore, olfactory dysfunction may slow down the response to 'emergency situations', such as gas leak.

Characteristics of Extranodal NK/T-Cell Lymphoma, Nasal Type, Compared with Nasal Diffuse Large B-cell Lymphoma.

Background: Extranodal NK/T-cell lymphoma, nasal type (ENKL), is an aggressive tumour with poor prognosis. Its early diagnosis may improve the prognosis of patients; however, it is often overlooked in many cases and misdiagnosed as an inflammatory sinus disease during its initial stage. Identifying the clinical characteristics of ENKL may aid otorhinolaryngologists in indicating cases early for a pathologic examination. In this study, we aimed to investigate the clinical characteristics of ENKL compared with that of diffuse large B-cell lymphoma (DLBCL), which is the most common nasal malignant lymphoma. Methods: The backgrounds, clinical symptoms, blood test results, and computed tomography images of patients with nasal/paranasal malignant lymphoma in our hospital between 2012 and 2017 were investigated. The characteristics of ENKL and nasal DLBCL were compared to differentiate them. Results: A total of 27 patients with nasal cavity and/or paranasal sinus lymphoma were included. Extranodal NK/T-cell lymphoma, nasal type, was diagnosed in 10 patients, while DLBCL was diagnosed in 17 patients. The median age of patients with ENKL was significantly lower than that of patients with DLBCL. All patients with ENKL had a unilateral lesion in the nasal cavity, with most located at the inferior turbinate. They also experienced nasal symptoms with significantly higher incidence of nasal obstruction and tendency of bleeding. Conclusion: ENKL was often unilateral and caused nasal obstruction, unlike DLBCL. Those who are younger in age and have sinonasal tumour with unilateral nasal obstruction and bleeding should be considered for early and repeated biopsies at multiple sites, with ENKL taken into consideration.

Relationship between the severity of olfactory dysfunction and serum zinc levels.

PURPOSE: Although the association between zinc deficiency and olfactory dysfunction is inconclusive, zinc deficiency causes apoptosis of the olfactory ensheathing cells which is involved in olfactory nerve turnover and axon regeneration, thereby suggesting a possible relationship. We investigated the relationship between serum zinc levels and olfactory function in patients with olfactory dysfunction. METHODS: Ninety patients who had been diagnosed with post-infectious, posttraumatic, drug-induced, neurological and idiopathic olfactory dysfunction were included. Patients were divided into zinc normal group and zinc deficiency groups according to three reference values for serum zinc levels (60, 65, 70 µg/dL). The results of olfactory tests and patient backgrounds were used to compare the differences between the two groups. RESULTS: There were significantly worse detection and recognition thresholds in the T&T olfactometer and Open Essence (odor identification test) results in the zinc deficiency group (< 60 µg/dL). In addition, significant correlations between olfactory tests (detection/recognition thresholds in the T&T olfactometer and Open Essence results) and serum zinc levels < 65 µg/dL were observed. The zinc deficiency group < 70 µg/dL with idiopathic olfactory dysfunction had significantly worse olfactory tests (detection/recognition thresholds in the T&T olfactometer and Open Essence). In addition, there was a significant correlation between the detection/recognition thresholds in the T&T olfactometer and serum zinc levels in idiopathic olfactory dysfunction. CONCLUSIONS: Our findings suggest that zinc deficiency may exacerbate the severity of olfactory dysfunction. Furthermore, idiopathic olfactory dysfunction may be partly caused by zinc deficiency.

Insight into the mechanisms of olfactory dysfunction by COVID-19.

One of the unique symptoms of COVID-19 is chemosensory dysfunction. Almost three years since the beginning of the pandemic of COVID-19, there have been many studies on the symptoms, progress, and possible causes, and also studies on methods that may facilitate recovery of the senses. Studies have shown that some people recover their senses even within a couple of weeks whereas there are other patients that fail to recover chemosensory functions fully for several months and some never fully recover. Here we summarize the symptoms and the progress, and then review the papers on the causation as well as the treatments that may help facilitate the recovery of the symptoms. Depending on the differences in the levels of severity and the locations where the main pathological venues are, what is most effective in facilitating recovery can vary largely across patients and thus may require individualized strategies for each patient. The goal of this paper is to provide some thoughts on these choices depending on the differences in the causes and severity.

Assessment of postviral qualitative olfactory dysfunction using the short SSParoT in patients with and without parosmia.

PURPOSE: To examine if the short formed Sniffin Sticks Parosmia Test (SSParoT), a test for parosmia can distinguish cases with parosmia from cases without parosmia. METHODS: In this study, 63 patients with postviral olfactory dysfunction were investigated including both COVID and non-COVID cases. The age, symptom duration, degree of parosmia/phantosmia was collected. For olfactory function, the Sniffin Sticks olfactory score was obtained including scores for odor threshold, discrimination and identification. For assessment of parosmic changes, the short SSParoT was adopted and both hedonic range (HedRang) and direction (HedDir) was calculated. RESULTS: The mean HedRang of patients with parosmia (2.35, standard deviation, SD = 1.40) and without parosmia (2.78, SD = 1.09) was smaller than that in controls (4.5, SD = 2.15). However, the mean HedDir of both parosmia (- 0.32, SD = 0.98) and non-parosmia patients (0.04, SD = 1.07) was similar to controls (- 0.1, SD = 1.55). When considering that the 10th percentile of the distribution of SSParoT score should distinguish between patients with and without parosmia, the sensitivity of the HedRang was 29% and specificity was 67%. For HedDir, the sensitivity was 6% and specificity was 100%. Only the odor identification score (r = 0.34, p = 0.01) discriminated parosmia and non-parosmia while other measures including HedRang and HedDir did not. CONCLUSION: The present study showed that the short SSParoT score could not distinguish patients with parosmia from patients without parosmia. Although the SSParoT represents an innovative approach to assess parosmia, and could be useful in the tracking of parosmic changes, the development of measures to diagnose parosmia in an objective way remains a challenge.

MRI tractography reveals the human olfactory nerve map connecting the olfactory epithelium and olfactory bulb.

The olfactory nerve map describes the topographical neural connections between the olfactory epithelium in the nasal cavity and the olfactory bulb. Previous studies have constructed the olfactory nerve maps of rodents using histological analyses or transgenic animal models to investigate olfactory nerve pathways. However, the human olfactory nerve map remains unknown. Here, we demonstrate that high-field magnetic resonance imaging and diffusion tensor tractography can be used to visualize olfactory sensory neurons while maintaining their three-dimensional structures. This technique allowed us to evaluate the olfactory sensory neuron projections from the nasal cavities to the olfactory bulbs and visualize the olfactory nerve maps of humans, marmosets and mice. The olfactory nerve maps revealed that the dorsal-ventral and medial-lateral axes were preserved between the olfactory epithelium and olfactory bulb in all three species. Further development of this technique might allow it to be used clinically to facilitate the diagnosis of olfactory dysfunction.

A comparison between sniffing and blowing for olfactory testing before and after laryngectomy.

PURPOSE: Olfactory dysfunction occurs after laryngectomy due to the loss of nasal airflow and inability to sniff. However, the reason for the loss of olfactory function after laryngectomy is unclear on evaluation with sniffing type tests performed individually. It is expected that the sensorineural olfaction remains, and the results of the sniffing test would be negative, while that of the odour-blowing test would be positive. Therefore, the aim of this study was to investigate both tests and prove normal olfaction in the patients. METHODS: Patients who had undergone laryngectomy were evaluated using the T&T olfactometer for odour-sniffing tests, Jet Stream Olfactometer (JSO) for odour-blowing tests, and visual analogue scale (VAS). Evaluations were performed pre-operatively, and 1 month, 6 months, and 1-year post-laryngectomy. RESULTS: Thirty-two patients were included in the study. The median recognition thresholds using the T&T and JSO were 1.4 and 2.2 before surgery, 5.8 and 5.4 at 1 month, 5.8 and 5.2 at 6 months, and 5.8 and 5.0 at 1 year after surgery, respectively. Results of the olfactory threshold test in both T&T and JSO and VAS score were significantly worse after surgery compared to that before laryngectomy (p < 0.05). The degree of increase was significantly smaller with JSO than with T&T (p < 0.05). CONCLUSION: While we could not prove normal olfaction in patients after laryngectomy, the odour-blowing test was superior to the odour-sniffing test in detecting patients with residual olfaction. Simply blowing a scent is insufficient to obtain good olfaction; active airflow is crucial for recognizing odours.

Aspiration of Cerebrospinal Fluid Rhinorrhea as a Cause of Non-resolving Pneumonia.

We herein report two cases of cerebrospinal fluid (CSF) rhinorrhea associated with lung infiltrates. One patient presented with symptomatic non-resolving pneumonia, while the other was asymptomatic. In both cases, the lung infiltrates completely resolved when CSF leakage had subsided. Pulmonary involvement in CSF rhinorrhea is under-recognized, and despite being the definitive treatment, surgery for CSF rhinorrhea is typically postponed due to the presence of lung infiltrates. However, meningitis is a serious complication due to a delay in surgical management. Physicians should be made aware that CSF rhinorrhea is a potential cause of intractable lung infiltrates.