On The Nose

By CodingStrategies on September 6th, 2018

In December 2017, the new British aircraft carrier HMS Queen Elizabeth sprung a leak. Big Liz (as she is affectionately known) first sailed during the summer of 2017, after a multi-year construction period in Scotland. According to reports, the warship was taking on around 52 gallons of water per hour thanks to a faulty propeller shaft gland packing. This means that the ship was acquiring nearly a gallon of sea water an hour, and the rate of flow is similar to water that exits from a normal residential faucet. Fixing this leaky gland involves stripping the existing packing around the propeller shaft where it enters the sea and replacing it to ensure that it is watertight. There is some contention over whether Liz will or will not require dry docking to accomplish this repair, but either way the Queen Elizabeth is scheduled to put to sea again in 2018. She will sail to the United States for flight trials with the F-38B fighters that she will transport during her British service life.

In May 2018, a Nebraska woman sought care for chronic allergies that made her nose leak almost continually, causing her to carry tissues with her everywhere. Kendra Jackson also had coughing, sneezing, difficulty sleeping and migraine headaches for nearly 2 ½ years, after hitting her face on the dashboard during a car accident. Her doctors assured her that her symptoms only represented allergies, or a bad cold. However, her misery did not resolve and Ms. Jackson would often wake up after sleeping upright in a chair with the front of her shirt saturated with fluid. In addition, at times she would gush liquid from her nose like a waterfall. In her quest for a diagnosis, Ms. Jackson visited multiple doctors and tried every kind of sinus medicine available in an attempt stop the deluge.

Finally, a rhinologist at Nebraska Medicine realized that her symptoms were likely due to something much more serious than the common cold. Laboratory analysis and a CT scan revealed that she had a rare condition, a cerebrospinal fluid leak caused by a tiny hole in the thin bone (less than the thickness of a potato chip) that separates her brain and nasal cavities. In fact, the CSF fluid leak was potentially causing her to lose nearly a half-pint of salty-tasting brain fluid every day through her nose and mouth.

Cerebrospinal fluid is a clear, colorless fluid that surrounds and protects the brain and spinal cord. This fluid also helps remove waste products from the brain and distribute nutrients and other substances throughout the central nervous system. Because the skull is rigid and the brain is soft and fragile, it needs to be protected by a cushion of liquid. CSF is produced continuously in the brain and is normally absorbed into the bloodstream through protrusions in the dura mater, the outer membrane of the brain.

A CSF leak results in a reduction of the cushioning effect and causes pressure, headaches that are worse when sitting upright, nausea and vomiting, neck pain or stiffness, a sense of imbalance, sensitivity to light and sound, and drainage from the nose or ear. It can also cause blurred or double vision, eye pain, hearing problems, tinnitus, spasms, seizures, and other symptoms. In severe cases, it can lead to significant infections such as meningitis, and become seriously debilitating. While this condition is rare, it is common enough that the CSF Leak Foundation has formed to raise awareness. Specialists estimate that a head injury is the most common cause, state that CSF leak is often misdiagnosed and add that this condition may affect about 5 of every 100,000 people worldwide each year.

Although CSF leaks were first documented in the 1930s, they are often misdiagnosed today -- generally as migraine headaches, sinusitis, or allergies. Often bed rest, increased fluids and caffeine will result in spontaneous healing. However, Ms. Jackson’s case required corrective surgery to plug the hole in her skull using tissue from her nose and abdomen. While Ms. Jackson still has migraines, she otherwise appears healthy and will have only routine monitoring in the future. She is happy that she no longer has to carry tissues with her at all times, and can finally get some sleep.

Although there is no specific information regarding the nature of any injuries sustained in the accident, there are codes for:

G96.0                    Cerebrospinal fluid leak

S09.90XS              Unspecified injury of head, sequela

V49.9XXS             Car occupant (driver) (passenger) injured in unspecified traffic accident, sequela

In the words of Charles Comiskey, also known as “The Old Roman,” an American Major League Baseball player, manager and team owner:

It is the small things in life which count; it is the inconsequential leak which empties the biggest reservoir.