Complications occur during and after endoscopic sinus surgery. Complications leading to temporary or most commonly permanent injury often are involved in litigation for malpractice. This article concentrates on areas of importance that are considered during medicolegal deliberations.
Key points
- •
Complications of endoscopic sinus surgery can and do result in medical malpractice suits.
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Complications that are treatable and prevent orbit or brain injury are rarely involved in a suit; surgeon communications and documentation are essential with any complication.
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Orbital and brain injuries are the most common litigated complications.
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Working closely with the defense lawyer is essential.
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Expert review using a time expert is very important.
Introduction
Every endoscopic sinus surgeon should consider preparing a check list of items to check off before, during, and after surgery. This check list, in the same vein as a pilot uses when flying, can ensure better patient care and decrease risk of litigation. This list can be mental or written (print or IT; Box 1 . See also the article by Eloy elsewhere in this issue, which provides an overview of complications in endoscopic sinus surgery [ESS]).
ESS Preoperative Check List
- 1.
Review all patient data for problem areas.
- 2.
Review CT scans, checking anatomy.
- 3.
Use endoscope to review anatomy at beginning of surgery.
- 4.
Control bleeding.
ESS Operative Check List
- 1.
Use landmarks as a guide for surgery.
- 2.
Know and observe areas of thin bone orbit and medial ethmoid skull base.
- 3.
Control bleeding during surgery.
- 4.
Use an instrument for measurement to know distances; make sure image guidance is properly calibrated.
- 5.
Observe eyes during surgery.
- 6.
Use bulb press test to test for lamina papyracea dehiscence.
- 7.
Use microdebrider carefully adjacent to orbit or skull base.
- 8.
Any sudden bleeding near skull base, suspect cerebrospinal fluid leak.
ESS Postoperative Check List
- 1.
Check patient mental status.
- 2.
Observe for any eye or orbital changes or vision loss.
- 3.
Observe for severe headache or clear fluid drainage, nausea, or vomiting.
- 4.
In clinic, ask about clear fluid leakage.
Abbreviation: ESS, endoscopic sinus surgery.
Introduction
Every endoscopic sinus surgeon should consider preparing a check list of items to check off before, during, and after surgery. This check list, in the same vein as a pilot uses when flying, can ensure better patient care and decrease risk of litigation. This list can be mental or written (print or IT; Box 1 . See also the article by Eloy elsewhere in this issue, which provides an overview of complications in endoscopic sinus surgery [ESS]).
ESS Preoperative Check List
- 1.
Review all patient data for problem areas.
- 2.
Review CT scans, checking anatomy.
- 3.
Use endoscope to review anatomy at beginning of surgery.
- 4.
Control bleeding.
ESS Operative Check List
- 1.
Use landmarks as a guide for surgery.
- 2.
Know and observe areas of thin bone orbit and medial ethmoid skull base.
- 3.
Control bleeding during surgery.
- 4.
Use an instrument for measurement to know distances; make sure image guidance is properly calibrated.
- 5.
Observe eyes during surgery.
- 6.
Use bulb press test to test for lamina papyracea dehiscence.
- 7.
Use microdebrider carefully adjacent to orbit or skull base.
- 8.
Any sudden bleeding near skull base, suspect cerebrospinal fluid leak.
ESS Postoperative Check List
- 1.
Check patient mental status.
- 2.
Observe for any eye or orbital changes or vision loss.
- 3.
Observe for severe headache or clear fluid drainage, nausea, or vomiting.
- 4.
In clinic, ask about clear fluid leakage.
Abbreviation: ESS, endoscopic sinus surgery.
Preoperative
The initial history and physical examination presents an excellent opportunity to prepare for a surgery, anticipate needs for the surgery, and plan the procedure recognizing possible increased risks. As part of the history, previous sinus surgery should be noted. Revision surgery is always more problematic given equal disease severity. Any previous complications should be noted. Medical therapy for chronic sinusitis and/or polyps should be noted and the success of treatment. Duration of treatment with oral and topical steroids and antibiotics by the surgeon or other treating physicians should be noted. Medical therapy should be noted in an attempt to make sure the patient has used “maximal” medical therapy before undergoing any planned surgery. Smell should be ascertained on a severity scale on and off prednisone or by using scratch and sniff smell testing. All of these assessments should be documented as part of the database necessary to make an informed decision regarding the patient’s need for surgery. Many of these historical points may be critical to the defense of malpractice suits, where indications for surgery or loss of smell are contested.
The physical examination, and especially the endoscopic examination, are important from a medicolegal standpoint. The extent of disease can be qualified and quantified, and changes in anatomy identified. Anatomy creating exposure problems needs to be identified. For example, a septal deviation that narrows the surgical field may direct the surgeon too lateral toward the orbit ( Fig. 1 ). This issue has been raised in medicolegal circumstance questioning proper visualization and exposure as a cause of a complication. A middle turbinate that is compromised by disease or associated with a low-lying skull base is hazardous. Anatomy totally distorted or obscured by severe polypoid disease is potentially problematic. Revision surgery with partially or totally missing landmarks is hazardous. This usually comes into play with frontal sinus surgery and altered middle turbinates with scarring or sphenoid sinus surgery.
Radiologic evaluation is not only important in noting the extent of disease, but it is more important from a medicolegal standpoint to identify anatomic pitfalls. Together with the preoperative endoscopic examination, the surgeon has a great picture of where danger lurks. The article by Zinreich elsewhere in this issue is dedicated to looking into CT changes and measurements important to any sinus surgeon hoping to avoid complications and should be reviewed. Every sinus surgeon should review the actual CT scan before any surgery and have that CT scan present in the operating room for quick reference. Every CT should be checked for skull base or orbital dehiscence, evidence of trauma jeopardizing the skull base or orbit, and ascertaining low-lying skull base involving the cribriform plate, fovea ethmoidalis, or both ( Figs. 2 and 3 ). Large vertical maxillary sinus and short vertical ethmoid distances are important to judge ethmoid height. Patients with orbital trauma to the lamina papyrcea with orbital tissue protruding into the ethmoid or the hypoplastic maxillary sinus with the uncinate process contacting the orbit are situations where actual medicolegal proceedings arose out of orbital injury ( Fig. 4 ). There have been several legal cases involving skill base injury where a low skull base was present and not noted by the surgeon radiographically. Even more troublesome is the actual circumstance where a CT that showed anatomic variations or abnormalities was not in the operating room during the surgery, and catastrophic brain complications occurred. Refer to the article by Zinreich elsewhere in this article.
