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You are seeing a 6-year-old boy with 1 month of clear nasal discharge from the right nares only. His vital signs are: temp 37.6 C, HR 90, RR 20, BP 115/75. Physical exam shows only clear nasal discharge from his right nares. He was seen in urgent care 6 weeks ago for a fall from his e-bike. At that time, he had no LOC, a normal neurologic and physical exam, and no vomiting. He had not been wearing a helmet. Using shared decision-making with the parents, no imaging was done and he was discharged with return precautions. His little brother was seen in urgent care 2 days ago and tested positive for RSV. PMH includes high-functioning Autism Spectrum Disorder and a history of frequent otitis media.
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February 24, 2026 at 11:11 am
A) Skull fracture
CSF rhinorrhea can be a sign of basilar skull fracture with a CSF leak. Post-traumatic CSF leak usually is present immediately after the trauma or within a few days, but presentation can be delayed; almost all present within 3 months of the traumatic event. It can also occur as a result of penetrating trauma, post-cranial surgery, or spontaneously (often due to increased intracranial pressure). The rhinorrhea is clear and unilateral. Although testing the fluid for presence of glucose using a urine dipstick test strip can suggest the diagnosis, false positives may occur. Definitive testing is by laboratory identification of CSF-specific proteins such as Beta-2 transferrin. Nasal septal hematoma would be visible on exam. Nasal foreign body typically results in unilateral purulent malodorous discharge. Sinusitis and RSV URI would result in bilateral nasal discharge.