Risks and medico-legal aspects of endoscopic sinus surgery: a review

Abstract

The aim of this study was to perform a systematic literature review of risks and medico-legal aspects of endoscopic sinus surgery. The development of sophisticated technologies and instruments for endoscopic sinus surgery (ESS) has caused a dramatic increase in the number of otolaryngologists performing sinus surgery and the number of cases performed. This expansion was accompanied by an increase in malpractice lawsuits. Over the past 20 years, rhinology claims represented 70 % of the total indemnity compensation for otolaryngology claims and ESS was the surgical procedure most often involved. Only then will a careful analysis and assessment of the possible and potential risk factors of ESS, which may mislead the surgeon, allow a correct clinical risk management, with activities and procedures aimed at reducing the possibility of complications that may expose the physician to a malpractice suit.

Preventing and Managing Complications in Frontal Sinus Surgery

“…Illustrative of this principle, complaints of inadequate informed consent are among the most consistently cited allegations in litigation related to rhinologic procedures. [2][3][4][5][6][7][8] Preoperative Review of Imaging…”

A proposal for limited criminal liability in high-accuracy endoscopic sinus surgery

“…The risk of error depends largely on the patient's characteristics, i.e. on the "specific bio-individual reactions" or the so-called 'endogenous risks' (anatomical variations, type of disease, individual reactions, co-morbidities and medications), rather than on 'exogenous risks' (including type of method chosen, type of instruments, type of anaesthesia administered, positioning of the patient, skill and experience of the surgeon) 7 . The risk of error during a medical (surgical) procedure can be reduced (or minimised) with a thorough preoperative evaluation of individual anatomical variations using CT scan in axial, coronal and parasagittal planes 1 7 8 , the use of image guidance (IG) surgery 7 9 and limiting the possibility of excessive intraoperative bleeding (using reverse Trendelenburg body positioning, maintaining low arterial blood pressure etc.)…”

“…in revision surgery with potential scarring, syndromes including Kartagener syndrome, cystic fibrosis, connective tissue disorders, diffuse polyposis with connective tissue growth etc. 7 . The common causes of an obscure operative field include polyposis or intraoperative bleeding, especially during revision surgery 3 11 , which predisposes intervention to major complications, although this has been disputed recently 12 .…”

“…In 3-42% of patients 7 , a so-called (sphenoethmoid) "Onodi cell" is found; this is a posterior ethmoid cell pneumatising into the superolateral aspect of the SS 1 7 . It represents a risk for the ESS surgeon, since it is very close to the optic nerve, internal carotid artery and sellar floor, and associated with dehiscence of the optic nerve and internal carotid artery 30.…”

“…The 76% of ESS-related malpractice litigation refers to negligence 4 . Common serious injuries caused by FESS include: CSF leak and diplopia (24% and 17%, respectively, according to one study), blindness, intracranial brain injury, life-threatening haemorrhage and nerve injuries 4 7 .…”