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Tunnel vision

01 May 2010

Mr P, a 45-year-old office manager, consulted Dr T, a consultant ENT surgeon, to discuss symptoms of chronic sinusitis. Mr P had previously consulted his GP, who had prescribed courses of antibiotics for these symptoms over a period of about two years. Despite repeated prescriptions, the symptoms of nasal congestion, infected rhinorrhoea and facial pain persisted.

Following consultation and examination (including nasal endoscopy with topical anaesthesia), Dr T arranged axial and coronal CT scan of the sinuses. The scan showed opacification of both antra and ethmoids, with air fluid levels in the antra. The radiologist also reported deviation of the nasal septum and hypertrophy of the inferior turbinates. The brain and orbits were reported as normal.

At a brief follow-up consultation, Dr T recommended endoscopic sinus surgery. No other treatment options were discussed. Dr T reassured Mr P that keyhole surgery was a simple procedure, and asked Mr P to sign a consent form for the operation during the consultation. No specific risks were documented.

During the operation, Dr T noted a CSF leak that was immediately repaired. Following the operation a few days later, Mr P complained of watery nasal discharge from both nostrils. Dr T arranged to see the patient the following day when he explained that the CSF leak had recurred. Dr T advised further surgery via an external approach to seal the leak. The second operation was performed later that week, with a satisfactory outcome and complete resolution of the leak.

Six weeks later, at his follow-up consultation, Mr P complained that when he blew his nose, air came through the corner of his left eye with a loud bubbling sensation. He became very upset, claiming he was not aware that so many things could go wrong. Soon after, Mr P instructed solicitors and started legal action against Dr T.

Expert opinion agreed the management of the surgical procedure was acceptable although, after the original operation, a second attempt at endoscopic closure of the CSF leak might have been appropriate before considering an external approach to close the leak. Expert opinion further agreed that both CSF leak and the ability to blow air through the naso-lacrimal system were common possible complications of this surgery, rarely causing significant symptoms or sequelae.

However, expert opinion was critical that when Dr T obtained consent from Mr P, he did not fully discuss, explain or record the possible risks and commonly occurring complications of the operation. It was also considered inappropriate that no discussion about alternative non-surgical management options was recorded in the notes.

While the surgical technique and management was not criticised, this case could not be defended because of deficiencies in the consent process. A modest settlement was negotiated.

Learning points

  • Complications can result from any surgery. Complications considered relatively common or non-serious by the surgeon might be very distressing and important to the patient. 
  • The importance of clear and comprehensive communication cannot be overstated. Document discussions, explanation and consent, including alternatives and commonly occurring and significant possible complications. 
  • Where possible, provide written information regarding possible complications for patients to take away, or direct patients to sources of such information. Patient information leaflets are invaluable, but it is important to document when these have been handed out. 
  • Links to information about endoscopic ENT procedures and their complications: