Case #4069 Negligent Surgery
On September 12, 2011, the Plaintiff, then 23 years old, presented to the Defendant Hospital for an ENT consultation. Previously, she had been evaluated on August 7, 2011 at the emergency department of a different hospital for a 2 week history of worsening headaches. An unenhanced CT of the head revealed a 1.8 cm clival mass. Additional head imaging studies performed at the Defendant Hospital confirmed the mass, without bony erosion. The Defendant ENT advised the Plaintiff that the mass was the likely cause of her headaches and should be removed.
On December 7, 2011, the ENT performed a transendoscopic sphenoidotomy and biopsy but failed to use an Insta Track guidance system or any other type of stereotactic surveillance. Upon entering the sphenoid sinus, he was unable to visualize the mucocele, which he characterized as “preclival”, and proceeded to unroof bone. Unfortunately, rather than enter the area where the mucocele actually resided, he entered the sella turcica and biopsied the Plaintiff’s pituitary gland. As a result, she suffered intractable, debilitating head pain, nightmares, forgetfulness and gait instability as well as clear drainage from her nose from a dural tear.
Despite several return visits to the Defendant Hospital, it was not until December 24, 2011 when she presented to the emergency department at another hospital that she was diagnosed with a cerebrospinal fluid leak. CT scan imaging revealed pneumocephalus, the existence of the posterior wall of the sphenoid sinus communicating with the sella, and the clival lesion which the Defendant ENT was supposed to have removed. Subsequent operative reports to repair the defect and to remove the mass confirmed the fact that the Defendant ENT completely missed the mucocele, entered the sella and damaged the pituitary, causing panhypopituitarism.
As a result of the negligence, the Plaintiff was left with severe polyuria/polydipsia, night sweats, hot flashes, insomnia, vaginal dryness, leg cramping, fatigue, decreased exercise tolerance, memory loss, headaches and depression. She takes a number of medications to regulate her thyroid and adrenal function, as well as oral contraceptives so that she is able to have a menstrual cycle. Inasmuch as the pituitary gland does not regenerate, the damage is permanent and the Plaintiff will suffer with the effects of panhypopituitarism, which also include infertility issues, for the rest of her life.
The Defendant denied all allegations of negligence, causation and harm.