Otolaryngologists may encounter claims of medical malpractice during the course of their careers. A sample of 15 cases involving patient claims of medical malpractice relating to care delivered for problems of the nose and paranasal sinus is presented. A short summary of each case is provided, which may be useful to practicing otolaryngologists.
Rhinology is a highly litigated area of otolaryngology. This article presents a sample of 15 malpractice claims involving surgery on the nose and paranasal sinuses provided by member companies of the Physician Insurers Association of America (PIAA). Cases are arranged in chronologic order and are summarized to include facts that might be useful to practicing otolaryngologists. These examples were selected from hundreds of cases, and are representative of several similar cases reviewed. Outcomes of malpractice claims were not available in all cases.
Cases
Case 1
An adult male patient with chronic sinusitis with polyps, and septal deviation underwent septorhinoplasty and bilateral endoscopic sinus surgery in 1991. The patient’s post-operative course was notable for persistent epiphora from lacrimal duct injury, and he was referred to an ophthalmologist who performed a dacrycystorhinostomy. It was noted during the course of the malpractice claim that although lacrimal duct injury may be a known and accepted complication of sinus surgery, it was not adequately listed in the consent forms used by the surgeon.
Case 2
A pediatric male patient with nasal obstruction and chronic sinusitis underwent septoplasty, bilateral inferior turbinate reduction, adenoidectomy, and bilateral endoscopic sinus surgery in 1995. The patient developed a sinus infection 4 months postoperation. Repeat computed tomography (CT) scan revealed radiopaque material consistent with a retained sponge that required a return visit to the operating room for removal and debridement.
Case 3
A pediatric female patient with a history of chronic sinusitis that persisted through multiple episodes of intravenous (IV) antibiotics underwent bilateral endoscopic maxillary antrostomies and total ethmoidectomies in 1995. Five weeks after surgery, she began to have purulent nasal drainage and fevers. She was taken back to the operating room (OR) where a 4-cm foreign body covered in purulent debris and granulation tissue was removed from the left middle meatus. Pathology report confirmed the presence of a large piece of cotton with acute inflammatory exudate.
Case 4
An adult male Chinese American patient, former smoker, with several months of epistaxis, was referred to an otolaryngologist in 1996 for further evaluation. The otolaryngologist’s examination was negative, although the evaluation did not include nasal endoscopy. One year later, the patient saw another otolaryngologist and was diagnosed with invasive squamous cell carcinoma arising from the sphenoid sinus.
Case 5
An adult patient who underwent sinus surgery in 1997 complained of bilateral eye pain post-operatively and was diagnosed with bilateral corneal abrasions.
Case 6
An adult female patient underwent right sinus surgery in 1999 for a persistent lesion/cyst in the right frontal sinus. Post-operatively it was found that the radiologist had mislabeled the coronal scans and that the lesion was, in fact, in the left frontal sinus.
Case 7
An adult male patient underwent bilateral endoscopic sinus surgery in 1999. The patient had been on multiple prior courses of antibiotics, and so the treating surgeon did not prescribe an additional course of antibiotics prior to surgical intervention. The patient was noted to have a cerebrospinal fluid (CSF) leak during surgery. The leak was repaired by the surgeon intra-operatively with middle turbinate graft. The patient had a unilateral loss of vision and proptosis in the recovery room. Lateral canthotomy was performed. Orbital CT was performed on the day of surgery and there was significant intraorbital air but no obvious violation of the lamina. The patient was discharged and seen the following day in the office. The plaintiff’s attorney alleged deviation from the standard of care by failure to treat the patient with a trial of appropriate antibiotics before performing surgery. Plaintiff’s attorney also alleged deviation from the standard of care while performing surgery, as well as failure to immediately admit the patient to the hospital for observation of sequelae from CSF leak.
Case 8
An adult female patient underwent bilateral endoscopic total ethmoidectomy and maxillary antrostomies in 2002 for chronic sinusitis with polyposis. The surgeon noted violation/dehiscence of the lamina papyracea intra-operatively and was able to see orbital fat. This area was left undisturbed and the surgery was completed. No iatrogenic injury was noted by the surgeon during surgery. The patient was seen for her initial post-operative visit 2 days after surgery. She complained of diplopia and was noted to have an ecchymotic right eye. The surgeon stated that he would continue to follow the patient closely. The patient sought a second opinion from an ophthalmologist who ordered a CT scan. Defect of the right lamina papyracea with displacement of the right medial rectus muscle was noted. The plaintiff’s attorney alleged deviation from the standard of care during surgery, with inappropriate informed consent.
Case 9
An adult male patient underwent bilateral endoscopic total ethmoidectomy, sphenoidotomies, maxillary antrostomies, and frontal recess exploration in 2002 for chronic sinusitis with polyposis. During surgery, while opening what was felt to be the frontal recess, increased bleeding and what appeared to be fat were encountered. An intraoperative biopsy of this area showed muscle fibers. Intra-operative consultation was obtained from an ophthalmologist. The patient was noted to have post-operative diplopia with disruption of the medial rectus, and subsequently underwent several ophthalmologic procedures for attempted correction of this defect. The plaintiff’s attorney alleged the surgeon’s performance was a deviation from the standard of care, with violation of the lamina papyracea and damage to the orbital contents.
Case 10
An adult male patient with rhinosinusitis with polyps underwent bilateral endoscopic total ethmoidectomies and maxillary antrostomies in 2002. There was no complication noted during surgery and the procedure was concluded uneventfully. On post-operative day 2, the patient was difficult to arouse. He was transferred to the emergency room and was obtunded on arrival. CT scan showed intracranial free air. The patient was taken to the OR for evacuation of the air by a neurosurgeon; however, he experienced brain herniation and significant brain damage.
Case 11
An adult female patient underwent right endoscopic sphenoidotomy in 2002 for persistent symptomatic sinusitis despite treatment with antibiotics and oral steroids. CT scan was notable for persistent opacification of the right sphenoid sinus. During surgery, the uncinate process was removed and an anterior and posterior ethmoidectomy was performed. The sphenoid sinus was entered with a straight Blakesley forceps. A culture swab was placed into the sinus and thick yellow discharge was removed, which was followed by a copious amount of arterial bleeding filling the nasal and oral cavities. Gauze was packed into the nasal cavity, nasopharynx, oral cavity, and oropharynx followed by placement of large-bore IV catheters and a Foley catheter. The patient was emergently taken for a CT scan that revealed subarachnoid hemorrhage and hydrocephalus. Angiography was also performed, which revealed a possible aneurysm. The patient was transferred to the surgical intensive care unit and prepared for clipping of the supraclivoid portion of the carotid artery. On post-operative day 1, a craniotomy was performed and 2 clips were placed on the internal carotid artery along the site of the apparent defect. On post-operative day 16, the patient had a massive stroke to the right brain and was declared dead. Postmortem analysis revealed no aneurysm, but a defect in the lateral sphenoid wall and a laceration of the internal carotid artery.
Case 12
An adult male patient underwent bilateral endoscopic sinus surgery in 2003 for chronic rhinosinusitis. During surgery, the fovea ethmoidalis was breached and a CSF leak occurred that was repaired intra-operatively with a turbinate graft. Post-operatively the patient was informed of this complication, admitted for observation, and placed on antibiotics to prevent meningitis. The pathology report confirmed the presence of glial cells. The patient was discharged on post-operative day 2. On post-operative day 6, the patient returned for follow-up and complained of fatigue and headaches. He had no further rhinorrhea, but a complete blood count revealed an elevated white blood cell count. The patient presented to the emergency room (ER) on post-operative day 7. Lumbar puncture revealed CSF with elevated levels of white blood cells. CT scan revealed a 2-cm lesion; intracranial abscess versus cerebritis with focal edema. The patient was placed on IV antibiotics and made a good recovery. He was released to return to work 2 months after surgery.
Case 13
An adult female patient underwent septoplasty in 2003. Post-operatively she fell to the floor from the operating room table and suffered bruising on the face and head.
Case 14
An adult male patient with a history of chronic sinusitis sought treatment by an otolaryngologist in 2005. The patient was treated with Augmentin (amoxicillin and clavulanate), although his chart noted allergies to penicillin, cephalosporins, and sulfa drugs. He later presented to the ER with swelling of the lips and tongue, pruritic rash, and difficulty in breathing and swallowing. The symptoms improved with epinephrine and IV diphenhydramine (Benadryl).
Case 15
An adult male patient underwent revision right Caldwell-Luc maxillary sinus surgery in 2006. Intra-operatively, the surgeon noted that the anterior entrance into the maxillary sinus was likely too superior because of the presence of orbital fat. The surgeon did not remove this fatty tissue and proceeded to perform a second canine fossa trephination in a more inferior location; however, this opening was also found to be too superior. The surgeon then performed a traditional endonasal maxillary antrostomy using blunt and powered instrumentation. When the patient awoke in the recovery room, he had no light perception in his right eye. An ophthalmologist was immediately consulted, and a lateral canthotomy and cantholysis was performed and high-dose IV steroids given. However, the patient’s vision was not restored. The pathology report noted the presence of fibro-fatty and muscle tissue. Post-operative CT scan revealed violation of the inferior orbital floor, anterior orbital hemorrhage, damage to the inferior rectus muscle, and possible contusion of the optic nerve. Ophthalmologic examination on post-operative day 3 revealed severe motility restriction, hypoglobus and enophthalmos, and ischemic retina. The patient continued to have problems with right maxillary sinusitis, and underwent additional revision maxillary sinus surgery approximately 1 year later.
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