This case takes place in Oklahoma and involves a fifty-nine-year-old female patient who presented to an ENT clinic with three week history of a clogged ear canal along with right sided tinnitus that persisted. The patient stated that her ear symptoms began when she developed an upper respiratory infection. Audiometric testing was performed and revealed mild conductive hearing loss involving the right ear. Tympanometry revealed decreased mobility on the right. A right myringotomy was performed, however the patient experienced no relief of symptoms. When the decreased hearing persisted following the procedure, the patient underwent a temporal bone CT on which revealed extensive soft tissue opacification involving the right mastoid and a small portion of the right middle ear. The physician recommended a tympanoplasty with mastoidectomy to address a cholesteatoma causing a possible obstruction. Intraoperatively, anencapsulated mass was uncovered that enveloped the ossicles and extending into the mastoid antrum. Initial frozen section of the mass obtained from the tissue located in the antrum suggested benign fibrous tissue inflammation with calcifications. A second frozen section obtained from the mass adjacent to the ossicles raised the question of a nerve sheath tumor. The mass appeared to encompass the facial nerve and removal of the mass appeared to have disrupted the facial nerve, severing the facial nerve in the tympanic segment. No attempt was made to repair the ossicular chain during the initial surgery as it was determined that the patient would likely require additional surgery to place a cable graft to repair the facial nerve injury. A nerve graft procedure was performed but the patient continued to experience facial paralysis and there were concerns that she may have developed visual disturbances. The patient was left with long term facial paralysis, tears when she drinks water, and has difficulty with swallowing. An expert witness in audiology and otolaryngology was retained for the matter.
Question(s) For Expert Witness
- 1. Did this surgeon do enough pre-op testing prior to attempting to excise this mass?
- 2. Should he have determined what he was removing before surgery?
- 3. Should imaging studies have been conducted before the procedure took place?
- 4. When he realized it was not a cholesteatoma, should he have stopped to reevaluate?
Expert Witness Response E-000324
I think this does reflect negligence. The presentation of someone with a cholesteatoma and someone with a facial neuroma are very different, both in history and exam. The presence of a mass behind an intact eardrum with no clear history of infection and no retraction pocket to indicate a source of retraction should have triggered further workup. There was therefore an error in diagnosis and subsequent treatment leading to the catastrophic complication of facial paralysis. A CT should have given him all the information that he would have needed. I would expect that a CT would have shown if the nerve was not in its canal. He should have protected the nerve and most likely used a facial nerve monitor during the case.