A 56-year-old male patient with gradually worsening, left mixed hearing loss was referred for left stapedectomy. A stapedectomy was attempted but aborted partway through because of an overhanging left facial nerve near the oval window.
The operative report reads in pertinent part:
"Upon entering the middle ear space, the chorda tympani was identified and noted to be in the normal location. It was gently mobilized and displaced anteriorly. Visualization of the stapes superstructure was made. There was a prominent midportion soft tissue hump that was identified. The concern was for facial nerve prolapse. However, given his inability to benefit from a hearing aid, the decision was made to proceed with attempted stapedectomy.
"Via the ear canal, the IS joint was gently mobilized and noted to be fixed. The stapes superstructure was partially impinging and fixed. The IS joint was carefully incised. The stapes superstructure was lasered on the inferior aspect. It was gently mobilized and then downfractured. The stapes footplate was identified and noted to be mobile. Using CO2 laser, a stapedotomy was performed. Unfortunately, the prolapsed facial nerve continued to impinge onto the surgical site. Multiple attempted fenestrations were unsuccessful because of the significant overhanging facial nerve. The temporalis fascia was combined to reinforce the surgical fenestration site. After multiple attempts, the decision was made to abort the procedure...."
Since the aborted procedure, the patient's hearing in the left ear is markedly, measurably worse. Should the surgeon have aborted the procedure in the very beginning when concerns about an overhanging facial nerve were first evident?
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Do you believe there might have been medical error?
The surgeon made a decision to proceed with the surgery with the idea he could fenestrate the footplate. In many patients the facial nerve can be retracted or worked around. In this instance the surgeon made his best attempt but ultimately was unsuccessful exercising reasonable clinical judgement. https://journals.sagepub.com/doi/abs/10.1016/j.otohns.2004.01.011 https://medicine.uiowa.edu/iowaprotocols/stapedotomy https://pubmed.ncbi.nlm.nih.gov/15323174/ https://pubmed.ncbi.nlm.nih.gov/25711736/ 50% British otologists make management of facial nerve a judgement call
Do you believe there might have been causation (i.e. the medical error resulted in an injury)?
Likely adequate discussion of risks benefits. Known risk of procedure would be to abort procedure. If patient developed facial paralysis may have case, but simply worsening hearing is not.
What makes you a good expert for this case?
Otolaryngologist with 20 years of clinical practice
How often do you encounter cases similar to this one in your practice?
No not otologist better someone who does regular stapes surgery
Do you believe there might have been medical error?
I think this is dependent upon the preoperative discussion with the patient. An overlying facial nerve is a known potential encounter, and its not a binary its there or its not type thing. It may be partially overhanging and still enough room to do the procedure. So you need to have a discussion about this potentiality ahead of time, and would the patient want an attempt or not.
Do you believe there might have been causation (i.e. the medical error resulted in an injury)?
Worsening hearing is a known complication of this procedure. This discussion very likely occurred in clinic and preoperatively.
What makes you a good expert for this case?
I am an otolaryngologist and I see patients with hearing loss and I do otology cases.
How often do you encounter cases similar to this one in your practice?
Not very often, as I care for a majority pediatric population. That said, this is a known ENT situation surgically as well as regarding thorough preoperative discussions.
Do you believe there might have been medical error?
This is a known potential intra-operative finding and the expert opinion is to abort procedure so as not to cause a facial nerve paralysis. What is not clear is if the stapes fenestration encountered any fluid which would indicate a potential perilymph release and potential for hearing loss if not sealed. This is unclear. Regardless a facial nerve injury is a potential in this case and likely a worse outcome if the surgeon had proceeded. Also what is not clear is if the worsening was sensorineural or conductive. Some extremely experienced surgeons are able to navigate around a facial nerve but again this is not standard for those routinely doing these procedures and again the teaching is to abort procedure if facial nerve is at risk.
Do you believe there might have been causation (i.e. the medical error resulted in an injury)?
Again need to know if a PLF was created and whether the worsening hearing loss is conductive or sensorineural.
What makes you a good expert for this case?
I am an otolaryngologist and have done these procedures in the past. Admittedly I no longer do these cases but I am able to at least opine based on the surgical knoweldge.
How often do you encounter cases similar to this one in your practice?
This is well described and discussed at national meetings. I do not do these cases any longer.
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