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Lingual nerve damaged

01 August 2004

Mr G, a 50-year-old company director, had suffered with salivary-gland stones for some time. He’d had an excision of the right submandibular gland in 1991.

In 1999 his symptoms recurred, causing much pain, and he was referred privately to see Dr J, ENT consultant. Dr J found a palpable calculus in the left submandibular duct and a bulky left sublingual gland, both of which were excised. Histology confirmed sialolithiasis and mild sialoadenitis. Mr G developed a postoperative infection in the floor of the mouth, which settled on antibiotics.

From a few days after his surgery, Mr G noted some numbness and an inability to taste on the left side of his tongue. Dr J reassured him that this would settle. Six weeks after surgery the symptoms persisted, along with some troubling dysaesthesia.

Mr G’s speech was affected by his numb tongue. Dr J formally tested and documented this numbness, loss of taste sensation and speech difficulty, believing it to be a transient phenomenon due to stretching of the lingual nerve, which would settle.

When Dr J reviewed Mr G, six months after surgery, things hadn’t improved. Mr G had speech therapy, which vastly improved his speech intelligibility, but he was unable to maintain this for significant periods of time. He never recovered taste or sensation on the left side of his tongue.

Part of Mr G’s job was to give verbal presentations to an audience and participate at long board meetings. Mr G started legal proceedings against Dr J, alleging that he had failed to obtain informed consent for the procedure and negligently damaged the lingual nerve during surgery.

Expert opinion

Expert ENT advice remarked that lingual nerve damage was an accepted complication of this type of surgery, with an estimated incidence of permanent damage of about 3%. It was noted that the surgery was advisable, due to the risk of malignancy arising within the gland, plus the troublesome nature of Mr G’s symptoms.

On the basis of Dr J’s operative notes it was felt that he hadn’t exercised the care expected of a competent ENT surgeon because he had not used vasoconstrictor agents to allow careful delineation of structures in the operative field.

Regardless of the merits of Dr J’s technique, his failure to discuss and document permanent lingual nerve damage as a potential complication of the procedure hampered any defence. We settled the claim.

Learning points

Informed consent requires the imparting of information that your patient would expect to know before agreeing to undergo a procedure. Permanent impairment of everyday activities of living, such as speaking and tasting, would certainly fall into this category. It is important to document that such discussions took place as part of gaining consent.

Leaflets specific to a certain procedure are a useful way of outlining its major and significant risks, if it is documented in the notes that the relevant information was given and discussed in this form.

However, this cannot be the whole solution, as one mustn’t forget complications of a procedure that are specific to a particular patient’s medical condition or circumstances, such as their occupation, which may have a significant effect on a patient’s willingness to undergo a particular procedure.

The UK Department of Health has a range of approved consent forms which can be found on their website, www.gov.uk/government/organisations/department-of-health.

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