Clinical Practice and Cases in Emergency Medicine

Introduction: Sternutation is a physiological reflex that clears the upper respiratory tract through forceful air expulsion. Although it is typically considered benign, sternutation can generate substantial pressure and airflow that can result in barotrauma, including pneumocephalus.

Case Report: A 67-year-old female presented with shortness of breath, rhinorrhea, and a headache following sneezing. Physical exam revealed no signs of trauma or neurological deficits but did note clear rhinorrhea bilaterally. Computed tomography (CT) of the head revealed extensive extra-axial intracranial gas bilaterally, and the patient was admitted for further management. While admitted, otolaryngology was consulted and surgically corrected a right cribriform meningoencephalocele with an active cerebrospinal fluid leak. At follow-up the patient had no residual rhinorrhea symptoms or focal neurological findings.

Conclusion: One proposed mechanism of sternutation-induced pneumocephalus involves the “one-way-ball-valve” effect, whereby elevated sinus pressure during sternutation forces air through
a dural defect, trapping it within the cranial cavity. Diagnosis is typically made with non-contrast CT and treatment depends on severity, ranging from conservative oxygen therapy to urgent surgical intervention. Indications on CT, such as the Mount Fuji sign, air bubble sign, and the peaking sign, help differentiate tension pneumocephalus from less severe forms. This case adds to the growing literature on sternutation-induced pneumocephalus and highlights the importance of recognizing sternutation as a potential source for serious intracranial pathology.
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