Man Sues ENT for Wrongful Tracheostomy

Image from ParaMedicine101

In December 2012, a West Virginia man suffered angioedema causing tongue swelling due to a not uncommon reaction from lisinopril. Presumably due to airway concern from the tongue swelling, an urgent tracheostomy (cutting a hole in the throat) was performed.

The patient later filed suit against the ENT who performed the tracheostomy stating that it was unnecessary as the tongue swelling was getting better. [link]

Although a tracheostomy is not always performed for tongue swelling due to angioedema, it also is not unusual to do so, mainly because the alternative outcome is airway loss and death. It is a judgement call on the physicians who are caring for a patient with angioedema whether close monitoring alone is sufficient versus performing a tracheostomy. If the tongue swelling is large enough to cause some airway obstruction, no physician or ENT would ever question the need for a tracheostomy, regardless of whether the swelling "might" be getting better or not.

If one waited until the airway became critical before performing a tracheostomy, the risk of death and complications become MUCH larger. As such, a tracheostomy is performed well before there's any chance of airway loss. (Intubation is not recommended or at times even possible as the act of trying to intubate may trigger airway loss.)

Indeed, the patient who is suing the ENT may not be alive today to sue the ENT if it weren't for the tracheostomy. Instead, it would be the family who would be suing the ENT for wrongful death for NOT doing a tracheostomy.

Check out this lawsuit where an ENT did NOT perform a tracheostomy for airway swelling resulting in death. Here's another lawsuit for similar though under more convoluted circumstances.

Source:
Clay Co. man says doctors performed unnecessary tracheostomy. West Virginia Record. 1/29/14

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ENT Sued for Wrongful Death from Airway Closure

Media reported on a malpractice case whereby in October 2010, a woman presented to the emergency room at Ochsner Medical Center (Louisiana) with symptoms of sore throat, neck pain, and painful swallowing.

A CT neck performed at that time revealed "swelling in her neck and a narrowing at the top of the throat" [link]. Patient was given a strong pain medication to help with her discomfort (presumably a narcotic), admitted into the hospital, and ENT consulted for further evaluation and management. Unfortunately, the patient's airway completely closed early the next morning resulting in a massive brain injury due to oxygen deprivation with eventual withdrawal of life support four days later.

Lawsuit against the hospital and ENT among others pending.

What could have happened?

Based on the limited information provided, it seems that the airway swelling noted on the CT scan could have been due to a large peritonsillar abscess, throat tumor, or epiglottitis.

A peritonsillar abscess is basically a tonsillitis gone real bad with pus collecting under the tonsil causing it to swell. This condition could have been treated quickly with an incision and drainage.

Epiglottitis is when the "throat flap" becomes infected resulting in massive swelling which can lead to airway closure. Typical management would include IV antibiotics, IV steroids, and close observation. If airway truly becomes critical, an awake tracheostomy should be pursued. However, medical management is most always tried first if airway is still patent (albeit narrowed).

Throat tumor (ie, cancer) is pretty much a large growth in the throat causing airway narrowing. Treatment is an emergent awake tracheostomy followed by biopsies to determine what type of cancer is present so that treatment can be pursued as quickly as possible.

It is unclear from media reports exactly what was causing the airway narrowing and whether ENT had even seen the patient until the airway closed off. Also unclear was whether the ENT was made aware just how critical the airway was.

A tragedy...

Source:
Daughter of woman who died from brain damage after airway swollen shut sues hospital. The Louisiana Record 4/15/13

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With A Deviated Septum, Why Does Nasal Obstruction Come and Go?

A deviated septum is a well known factor causing nasal obstruction in people. However, many patients with a deviated septum will also state that there are times when they can breath just fine from their nose. As such, can a deviated septum truly be the cause of their nasal obstructive symptoms? Shouldn't the obstruction be constant?

The blunt answer is ABSOLUTELY nasal obstruction can be intermittent OR constant with a deviated septum!!! It's more a question of degree.

To begin with, a deviated septum is when the wall that separates the right and left nasal cavities is bent one way (green arrow) instead of being perfectly straight.

If there is no mucosal swelling, a person with a deviated septum is able to breath from both sides just fine. However, if there is the slightest bit of mucosal swelling from turbinate hypertrophy, allergies, upper respiratory infection, or any other environmental irritation, the side that is more narrow will obstruct much more readily with less swelling given there is just "less room" for swelling to occur before obstruction occurs.

Below is the same exact nose and septum as above, but with mucosal swelling present.

As you can see, with the same exact amount of swelling present, the deviated septum significantly influences how much space is present for air to pass through compared with a straight septum.

As such, even though a deviated septum may not technically be obstructive, given there is less room for any swelling to be accomodated, a patient will complain of nasal congestion and obstruction much more readily compared to someone with a straight septum due to the slightest changes in mucosal swelling.

How is a deviated septum fixed? Click here to read more.

Of course, one can try and control the mucosal swelling to avoid any surgical intervention, typically with steroid or anti-histamine nasal sprays. The downside is that such medications need to be used daily to prevent swelling from occurring in the first place.

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