Perforation of sinus

Presentation

On March 6, a 78-year-old woman came to Hospital A’s emergency department (ED) after coughing excessive amounts of blood overnight. The patient had a history of hearing loss, rhinitis, deviated nasal septum, dementia, depression, anxiety, hypertension, atrial fibrillation (AFib), hypercholesterolemia, tachycardia, COPD, and heavy, daily use of nicotine and alcohol. 

An exam and CT revealed bronchial thickening with no masses and some pulmonary nodules inconsistent with cancer. The emergency medicine (EM) physician documented that the patient likely had irritation in the back of her nasopharynx that caused the bleeding. 

The EM physician instructed the patient to follow up with her primary care physician and a pulmonologist for possible bronchoscopy. The patient did not follow these instructions. Instead, she went to see her otolaryngologist (ENT) whom she regularly saw for treatment of chronic ear infections.
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Physician action

On March 11, the patient came to the ENT reporting a cough with hemoptysis and to inform the physician of her visit to the ED. The patient stated that the bleeding had improved, but that her throat was “itchy.” 

The ENT examined the patient and ordered X-rays of the sinuses. The films showed bilateral maxillary sinusitis, more pronounced on the right. The ENT noted that the bleeding was probably from the nose. The patient had a severe left septum deformity with an apparent nodule/polyp. The ENT recommended septoplasty with biopsy. 

The next day, the patient was taken by ambulance to the ED for coughing large amounts of blood and phlegm. The patient informed the ED staff that she had seen her ENT, who told her that he believed there was a blood vessel bleeding on the right side of her nose and a biopsy was scheduled for the back of her throat in two days. 

The EM physician examined the patient and noted that the right nasal passage had minimal bleeding, and the bilateral nasal mucosa was inflamed, but there was no active bleeding. The EM physician prescribed azithromycin for sinusitis and called the ENT to confirm that the patient was scheduled for the septoplasty with biopsy. The patient was instructed to follow-up with the ENT.

During a pre-operative visit with the ENT on March 18, the patient was diagnosed with bilateral inferior turbinate hypertrophy and chronic maxillary sinusitis. An outpatient surgery at Hospital A was scheduled for March 20.

On March 20, the ENT performed a septoplasty, nasopharynx biopsy, partial reduction of the inferior turbinates, and right and left antral irrigation with temporary antrostomies. In his operative report, the ENT stated “the bony cartilaginous junction divided. A portion of bone was removed posteriorly. The remainder was infracted at the midline. There was significant sphenoid deviation which was fractured in the midline as well as possible.” The patient was discharged home. 

At 8:17 p.m. that night, the patient experienced a grand mal seizure at home and was taken by ambulance back to Hospital A’s ED. The patient experienced another seizure in the ED, became hypoxic and unresponsive, and her eyes were rolling laterally from left to right. The patient was obtunded and intubated with a Glasgow Coma Scale (GCS) of 3. 

The patient was given levetiracetam for persistent rolling eye movements, which indicated she was likely still having seizures. A CT found a “large volume of free air within the head apparently from previous sinus surgery.” The EM physician called the ENT. The patient was transferred to Hospital B for neurosurgical evaluation. 

At Hospital B, the patient was seen by Neurosurgeon A, who found her to be unresponsive with no tracking of the eyes. A head CT showed suspected acute left-sided hematoma along the tentorium and significant pneumocephalus, with tension pneumocephalus “likely related to osseous defects along the cribriform plate.” The left sinus also “appeared violated as the inner table was not present.” 

The patient was taken to the OR for evacuation of the pneumocephalus, as well as a repair of the left sinus. Neurosurgeon A performed an emergency bifrontal craniotomy for decompression of tension pneumocephalus, exploration of the anterior cranial fossa floor, and placement of dural graft over the cribriform plate. 

On March 21, the patient’s family requested that she be transferred to Hospital C. The patient underwent a second craniotomy by Neurosurgeon B at Hospital C for repair of the floor of the anterior fossa surgery. The same day, the ENT called Hospital C to check on the patient. The ENT did not have privileges at Hospital C and did not have access to any additional information after the patient’s transfer. 

On March 24, the ENT made an entry in the patient record that he called “Problem Story.” He noted that, based on the evaluation of the CT, the patient developed pneumocephalus in the ED because of unexplained continued lethargy. “The patient has some dementia and kept trying to blow her nose in the recovery room which was discouraged probably to no avail. The fracture should be along with sphenoid probably on the left side. If a CSF leak develops/persists they could consider a transsphenoidal pituitary approach fat graft obliteration.” 

On March 25, the ENT called Hospital C and was informed that the patient was on a respirator and had been taken to surgery for a total ethmoid with fascia lata graft. The ENT made an entry in the patient’s record: “Probably some delirium tremens (DTs) from alcohol abuse. I think it probably would have been better to watch her expectantly to see if she had a persistent CSF leak and do intervention later if needed. She tends to not heal well and again has some dementia.” 

During her stay at Hospital C, the patient experienced intermittent AFib, sinus rhythm, and sinus tachycardia. A cardiology consult noted that “the patient was found to have pulmonary emboli and was not started on anticoagulation. Then, the patient had occipital hematoma and bifrontal hematoma.” 

The patient was kept on a ventilator and a percutaneous endoscopic gastrostomy (PEG) tube was placed. A neurologist noted that the patient appeared to have a severe brain injury, was nonverbal, and did not follow commands. 

On May 6, she was transferred to a hospice facility. The family agreed to the removal of life support. The patient died on May 28. The death certificate stated the cause of death to be pneumonia, postoperative tension pneumocephalus with cerebral spinal fluid leak, and chronic sinusitis.

Allegations

The patient’s family filed a lawsuit against the ENT, alleging injury to the dura, cribriform plate, and anterior cranial fossa during the septoplasty procedure.  The plaintiffs further alleged that these injuries caused tension pneumocephalus within the cranial air cavity and a cerebral spinal fluid leak. This — along with complications from pneumonia —caused her death. 

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Legal implications

During his deposition, the ENT stated that his procedure caused the perforation in the patient’s sinus that allowed air to enter the brain. However, he believed that if he had been notified by the ED upon the patient’s arrival, he could have taken steps to prevent elevated air pressure in the patient’s sinuses to keep air from being forced into the brain. 

The ENT explained that when the cribriform plate and dura are perforated, cerebrospinal fluid would escape, since it is under some pressure and is contained within the dura. If the patient was not being subjected to procedures that would increase air pressure within the sinus (bagging, pressure masks, etc.), the area of the leak can typically be repaired before any significant air enters the skull. He said that once the perforated area is closed, the patient can recover when the air is absorbed by the body, and cerebrospinal fluid is replaced.

Instead, the ENT firmly stated that the patient’s condition was mismanaged (“overly aggressive”) by the neurosurgeon and ventilation assistants at Hospital B.

Expert consultants for the plaintiff were critical of the ENT for not attempting more conservative care before recommending surgery. One consultant stated that the technique of fracturing the bones of the septum, especially higher in the nose, is below the standard of care. This consultant concluded that the infracture of the bony septum to the midline and the fracturing of the sphenoid deviation to the midline, with damage to the base of the skull, led to the tension pneumocephalus, the need for multiple craniotomies, and the cascade of events that led to the patient’s death.

Two expert consultants for the defense were also critical of the ENT. While both conceded that inadvertent injury to the cribriform plate is a known complication of the procedure, they said they did not know of any colleague who had encountered this complication. 

The defense of this case presented several challenges. Septoplasty is a common treatment for a deviated septum and pneumocephalus is a rare complication. Tension pneumocephalus is even more rare. Unfortunately, the patient had to be bagged in the ED, which forced additional air into her brain through an opening created during the ENT’s procedure. Several experts stated that fracturing the patient’s bones higher in the septum was below the standard of care.

The ENT’s documentation was detrimental to the defense. He documented several criticisms and subjective opinions about the patient. He referred to her as a “problem,” due to her alcohol use and dementia.

In accordance with good risk management practices, entries in the medical record should clearly state the patient’s condition and the care provided, avoiding speculation. Using subjective, unsubstantiated language in the medical record could stigmatize the patient and negatively affect their health care. 

This type of language could also be interpreted as stereotyping and could paint the provider as having implicit bias. Discriminatory or defaming language used to describe a patient’s condition, lifestyle, race, ethnicity, sexuality, sexual orientation, religion, or living conditions would be difficult to explain to a jury or medical board. 

A better way to document that a patient does not reliably fill prescriptions or take medication, is that the patient is “noncompliant in taking medication,” instead of describing them as “unreliable,” “irresponsible,” or “erratic.” Also, avoid referring to a patient in non-medical terms such as a “drug addict.” If conditions are confirmed and diagnosed, use of medical terms such as alcohol or substance “use disorder” or “dependence” is preferred. Symptoms and observations may also be reported, such as that the patient “exhibited drug-seeking behavior,” “had slurred speech,” or reported “heavy drinking almost every night.”

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Disposition

This case was settled on behalf of the ENT.

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