Doctors in Saudi Arabia had already found pockets of air inside a 45-year-old woman's skull and a 2-millimeter gap in the bone beneath her brain. They told her to avoid straining. Over the next six weeks, she still held back sneezes on two occasions at social gatherings.
That detail, recorded in a case report in the American Journal of Case Reports published in April, helps explain an unusual choice her surgeons made. When they finally operated to seal the leak, they did not stop at the hole in her skull base. They also straightened the wall between her nostrils and shrank swollen tissue inside her nose, in part to lower the pressure a future blocked sneeze could build.
A Leak That Medication Could Not Stop
The patient was previously healthy, with no head injury and no sinus surgery. She was referred to an ear, nose and throat clinic after three months of mild headaches that eased somewhat when she lay flat. She also had watery drainage from her left nostril that appeared when she leaned forward, a pattern clinicians call a reservoir sign. Only when asked more questions did she mention that she often suppressed sneezes, especially in public.
A high-resolution CT scan showed small collections of air inside her head, a condition called pneumocephalus. It also revealed a 2-millimeter gap in the left cribriform plate, the thin, sieve-like bone that separates the nasal cavity from the brain. The same scan showed a C-shaped bend in her nasal septum and enlarged inferior turbinates on both sides, structures that can narrow the airway. An MRI confirmed the air and found no other brain abnormalities.
Because she had no symptoms on the day of review and no signs of meningitis, a team that included otolaryngologists at King Fahd Central Hospital in Jazan sent her home. She was told to avoid straining and to return if her symptoms worsened or she developed a fever.
The drainage came back twice over the next six weeks, each episode lasting less than half an hour. At the six-week visit, a nasal endoscope showed clear fluid running toward the back of her left nasal passage, and doctors started acetazolamide, a drug used to lower spinal fluid pressure. About eight weeks after her first visit, the leak was still there.
Surgery Aimed at the Skull and the Airway
Neurosurgery, anesthesia, and ENT teams met before the operation. Inside, surgeons found an active leak and a small encephalomeningocele, a pouch of brain lining and tissue pushing through the defect. They repaired the opening using a graft taken from her own turbinate tissue. In the same session, they performed a septoplasty and reduced both inferior turbinates.
The authors wrote that correcting her nasal anatomy, a step they said is not frequently mentioned in earlier reports, may have contributed to the good result by lowering chronic nasal resistance and the risk of future pressure buildup during sneezing. That is their interpretation, and one case cannot prove it.
What the report does document is the outcome. At checkups 1, 2, 4, 6, 9 and 12 months after surgery, she had no symptoms, and endoscopy showed the repair site had healed with no sign of leakage.
Her discharge instructions were blunt: avoid heavy lifting, avoid blowing her nose and, most important, do not suppress a sneeze. When she was formally released from joint ENT and neurosurgery follow-up, she was advised to sneeze with her airway open.
The authors also offered an explanation for the habit itself. They suggested her public sneeze suppression was probably driven by a desire to follow post-pandemic etiquette.
How a Blocked Sneeze Can Find a Weak Spot
A sneeze is built to release pressure fast. Pinch the nose and clamp the mouth shut, and that pressure has nowhere to go. A 2019 review of sneezing injuries estimated that closing the airway during a sneeze can produce more than 20 times the usual airway pressure. The same review counted 52 unique reports of sneeze-related injuries in the medical literature, most in people with no known risk factor and 81% in men.
That is a small number, and the evidence consists almost entirely of individual case reports. Still, the Saudi patient is not alone. In a 2023 report in Radiology Case Reports, a 72-year-old woman developed pneumocephalus and a ruptured olfactory bulb after suppressing a sneeze and needed emergency surgery. A 2024 case in BMJ Case Reports described a woman in her 60s whose air inside the skull, attributed to repeated sneezing, cleared without surgery.
The Jazan patient did not have obesity or idiopathic intracranial hypertension, two typical risk factors for spontaneous spinal fluid leaks, which the authors took as support for a mechanical cause. Still, a single case cannot establish that suppressing sneezes created the defect, how long it had existed, or whether her crowded nasal anatomy made her more vulnerable.
The Rarity, and the Warning Signs Worth Knowing
The authors describe the complication as rare but clinically significant, and most people who stifle a sneeze will never experience anything like it. Their main message is for clinicians: when a patient with no trauma or prior surgery has unexplained nasal drainage or air inside the skull, ask about sneezing habits.
For everyone else, the practical points are modest. The CDC advises covering sneezes with a tissue, or sneezing into an elbow when no tissue is handy, which addresses the germ concern without trapping the pressure. Clear, watery drainage from one nostril that keeps coming back, especially when bending forward, and alongside headaches that change with position, deserves a medical evaluation.
Nasal drainage accompanied by fever, a stiff neck, or confusion calls for urgent care.
Key Questions Answered
Why did surgeons operate on her nose as well as her skull?
She had a deviated septum and enlarged turbinates. The authors believe correcting them may lower nasal resistance and future pressure spikes during sneezing, though one case cannot prove it.
Did she keep suppressing sneezes after the diagnosis?
Yes. The report says she resisted sneezing on two occasions at social gatherings during the six weeks after her first visit.
Did holding in sneezes definitely cause the skull defect?
No. The authors consider sneeze suppression the likely mechanism, but a single case report cannot establish cause.
How common are injuries from holding in a sneeze?
Rare. A 2019 review found 52 unique reports of sneeze-related injuries in the medical literature.
What symptoms can point to a spinal fluid leak from the nose?
Clear, watery drainage from one nostril, often when leaning forward, and headaches that improve when lying down. Fever or a stiff neck with these symptoms needs urgent care.
Published by Medicaldaily.com
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