ORIGINALARTICLE - PDF document

ORIGINALARTICLE Malodorousconsequences: Whatcomprisesnegligenceinanosmialitigation? PeterF.Svider,MD 1 ,AndrewC.Mauro,BA 2 ,JeanAndersonEloy,MD,FACS 3,4,5 ,MichaelSetzen, MD,FACS 6 ,MichaelA.Carron,MD 1 andAdamJ.Folbe,MD 1 Background: Ourobjectivesweretoevaluatefactors raisedinmalpracticelitigationinwhichplaintisalleged thatphysiciannegligenceledtoolfactorydysfunction. Methods: Weanalyzedpublicallyavailablefederaland courtrecordsusingWestlaw,awidelyusedcomputerized legaldatabase.Pertinentjuryverdictsandselements werecomprehensivelyexaminedforallegedcausesofmal- practice(includingproceduresforiatrogeniccauses),de- fendantspecialty,patientdemographics,andotherfactors raisedinlegalproceedings. Results: Of25malpracticeproceedingsmeetinginclusion criteria,60.0%wereresolvedforthedefendant,12.0% wereseled,and28.0%hadjury-awardeddamages.Me- dianpaymentsweresigni“cant($300,000and$412,500for selementsandawards,respectively).Otolaryngologists werethemostfrequentlynameddefendants(68.0%),with themajorityofiatrogeniccases(55.0%)relatedtorhino- logicprocedures.Associatedmedicaleventsaccompanying anosmiaincludeddysgeusia,cerebrospinal”uidleaks,and meningitis.Otherallegedfactorsincludedrequiringaddi- tionalsurgery(80.0%),unnecessaryprocedures(47.4%of iatrogenicproceduralcases),untimelydiagnosisleadingto anosmia(44.0%),inadequateinformedconsent(35.0%), dysgeusia(56.0%),andpsychologicalsequelae(24.0%). Conclusion: Olfactorydysfunctioncanadverselyaect qualityoflifeandthusisapotentialareaformalpractice litigation.Thisisparticularlytrueforiatrogeniccausesof anosmia,especiallyfollowingrhinologicprocedures.Set- tlementsanddamagesawardedwereconsiderable,mak- inganunderstandingoffactorsdetailedinthisanalysisof paramountimportanceforthepracticingotolaryngologist. Thisanalysisreinforcestheimportanceofexplicitlyinclud- inganosmiainacomprehensiveinformedconsentprocess foranyrhinologicprocedure. C  2013ARS-AAOA,LLC. KeyWords: anosmia;hyposmia;malpractice;litigation;negligence;rhi- nology;rhinologic;informedconsent HowtoCitethisArticle : SviderPF,MauroAC,EloyJA,SetzenM,CarronMA, FolbeAJ.Malodorousconsequences:whatcomprisesneg- ligenceinanosmialitigation? IntForumAllergyRhinol . 2014;4:216–222. 1 DepartmentofOtolaryngology–HeadandNeckSurgery,WayneState UniversitySchoolofMedicine,Detroit,MI; 2 ,TheUniversityofMichigan LawSchool,AnnArbor,MI; 3 DepartmentofOtolaryngology–Headand NeckSurgery,RutgersNewJerseyMedicalSchool,Newark,NJ; 4 DepartmentofNeurologicalSurgery,RutgersNewJerseyMedical School,Newark,NJ; 5 CenterforSkullBaseandPituitarySurgery, NeurologicalInstituteofNewJersey,RutgersNewJerseyMedical School,Newark,NJ; 6 RhinologySection,NorthShoreUniversity Hospital,Manhasset,NY Correspondenceto:PeterF.Svider,MD,Departmentof Otolaryngology–HeadandNeckSurgery,WayneStateUniversitySchoolof Medicine,4201St.Antoine,5E-UHC,Detroit,MI48201;e-mail: psvider@gmail.com Potentialconictofinterest:M.S.isaspeakerforTEVAandMEDAontheir SpeakersBureau. Received:15August2013;Revised:10October2013;Accepted: 31October2013 DOI:10.1002/alr.21257 Viewthisarticleonlineatwileyonlinelibrary.com. R ecentinvestigationhasrevealedapotentialforolfac- toryepitheliumtoregenerateviaavarietyofmech- anismsinvolvingapopulationofmesenchymal-likestem cells,whichhavebeenshowntohaveasurprisinglybroad anatomicdistribution. 1 WhereasstemcellÐbasedtherapy andothercontemporaryadvancesinourunderstandingof olfactionofferpromisingfutureavenuesforanosmiaman- agement,ourcurrenttherapeuticrepertoireforrestoring smellinpatientsremainslimited.OlfactorydeÞcitsconsid- erablyaffectqualityoflifeandmayevenfacilitateadverse healthevents,rangingfrominabilitytosenseenvironmental cues(suchasleakingnaturalgas,spoiledfood)tounsafe lossesinweight. 2Ð4 Additionally,olfactoryfunctionisa criticalcomponentofbeingabletotaste,andtrueanosmia isthusfrequentlyaccompaniedbydysgeusia. 5 Theprofoundeffectsonbothhealthstatusandquality oflifepresentinpatientswitholfactorydeÞcitspredispose negativeoutcomestopotentialinvolvementinmedicolegal InternationalForumofAllergy&Rhinology,Vol.4,No.3,March2014 216 Anosmialitigation action.Giventheoutsizerolemalpracticelitigationandre- sultingdefensivemedicalpracticesplayinrisinghealthcare costs, 6Ð11 understandingpotentialsourcesofmedicalneg- ligenceandiatrogenicinjuryresultinginanosmiamaybe usefulforthepracticingphysician.Inadditiontodelineat- ingprocedurescausinganosmiaandresultinginlitigation, theobjectivesofthisanalysisweretodeterminealleged causesofnegligenceinpertinentlitigation,caseoutcomes andawards,andmedicalspecialtiesaffected.Ourhopeis thatphysicianswillusethisinformationtoenhancecom- municationwithpatientsand,ultimately,improvepatient safety. Materialsandmethods Acomputerizedlegaldatabase,Westlaw,wasusedtoob- taininformationregardingpertinentcasesforthepurposes ofthisanalysis.Westlawisavailablebysubscriptionand widelyusedbylegalprofessionalsintheUnitedStates,and hasbeeninvaluableinpreviouscomprehensiveexamina- tionsofawidevarietyofmedicolegaltopics. 11Ð38 This databaseÕsadvancedsearchfunctionwasusedtosearchfor juryverdictsandsettlementscontainingthefollowingcom- binationofterms:ÒmedicalmalpracticeÓANDÒanosmiaÓ ORÒhyposmiaÓORÒsmellÓORÒolfactionÓORÒolfac- tory.ÓOutof49initialresults,caseswereexcludedforthe followingreasons:incidentalmentionofanosmia(ie,anos- mianotanallegedinjuryinlitigation)(7),duplicatecases (2),casesthatdidnotinvolveanosmiaorolfactorydeÞcits (14),andcongenitalanosmia(1). The25pertinentjuryverdictandsettlementreportswith anosmiaasanallegedinjurywerecomprehensivelyeval- uatedfordetailsregardingoutcome,award,defendant specialty,patientdemographics,iatrogenicornoniatro- geniccause,proceduresinvolved,allegationsinvolvingin- completeinformedconsent,therequirementofreparative procedures,misdiagnosis/delayeddiagnosisleadingtoin- jury,dysgeusia,psychiatric/psychologicalsequelae,depres- sion/lossofenjoymentinlife,employment/incomeaffected, andotherallegedcausesofnegligence.Datacollectionwas completedinAugust2013. Statisticalanalysis Mann-WhitneyU-testswereusedforcomparisonofcon- tinuousdata,withthresholdforsigniÞcancesetat p 0.05. SPSSversion20(IBM,Chicago,IL)wasusedforstatistical analysis. Results The25juryverdictandsettlementreportscontaininganos- miaoccurredbetween1989and2011.Medianpatientage was54years,with52.2%maleplaintiffsand47.8%female plaintiffs.Themajorityofcasesincludedwereresolvedin thedefendantÕsfavor(60.0%),withremainingcasesre- solvedasout-of-courtsettlementsorwithplaintiffverdicts (Fig.1A).Althoughconsiderablylarge,themediandam- agesawardedbyjuriesdidnotsigniÞcantlydifferfromthe 2out-of-courtsettlementsreportingdollartotals(Fig.1A) ($300,000vs$412,500, p � 0.50).Otolaryngologistswere themostfrequentlynamedphysiciandefendants(68.0%of cases),followedbyoralsurgeons(Table1).Practitioners fromseveralotherspecialtieswerealsonamedasdefen- dants(Table1). Themostfrequentprocedureperformedleadingtoanos- mialitigationwasendoscopicsinussurgery(ESS)(7pro- cedures;Table2),followedbyavarietyofotherproce- duresperformedbyotolaryngologistsandoralsurgeons. Associatedmedicaladverseeventsallegedlyaccompany- inganosmiaincludeddysgeusia,cerebrospinalßuid(CSF) leaks,andmeningitis(Fig.1B).Otherallegedfactorsin- volvedinlitigationincludedanosmiabeingaresultofia- trogeniccauses(80.0%ofallcases),additionalsurgerybe- ingrequiredasaresultofanadverseoutcome(80.0%of allcases),andaprocedurebeingallegedlyunnecessaryor inappropriate(9/19iatrogenicproceduralcases);otheral- legedfactorsarealsoshowninFigure1C.Outofthe20 iatrogeniccases,19wererelatedtosurgicalproceduresand 1wasrelatedtomedicationadministration.SpeciÞcfac- torsinvolvedincasesresolvedwithpaymentareshownin Table3. Discussion Althoughtherehavebeennoformalanalysesofanosmia litigation,thepossibilityofmedicolegalactioninpatients experiencingthiscomplicationafterundergoingasurgi- calprocedurehasbeenanecdotallyreported.Inaletter toajournal,1otolaryngologistnotedhearingofseveral rhinologiccasesinwhichplaintiffsexploringlegalaction claimedtheyhadnotbeeninformedofanosmiaasapo- tentialcomplication. 39 Thisreportwasconsistentwitha surveyhehadconducted,inwhichfewerthan50%ofoto- laryngologistsincludedanosmiaintheinformedconsent processasapotentialcomplicationofnasalsurgery.Our presentanalysisreinforcespreviouslydescribedanecdotal ÞndingsfortheÞrsttime,asplaintiffsspeciÞcallybrought upinadequateinformedconsentinasigniÞcantproportion ofiatrogeniccases(35.0%)(Fig.1C).PerceiveddeÞcitsin informedconsenthavebeenrepeatedlycitedinasigniÞcant proportionofanalysesfocusingonvariousproceduresand complications. 14,16,24,33,34 Ratherthanphysiciansnotmen- tioningthepossibilityofolfactorydysfunction,asigniÞcant proportionofthesecasesmaysimplyrelatetopatientsnot comprehendingrisksexplainedtothem.Inadditiontodoc- umentingspeciÞcrisksinwriting,physiciansperforming proceduresthatmaypotentiallyresultinanosmiamaywish toconsiderprovidingpatienteducationmaterialswritten inacomprehendiblemanner. 40Ð51 Inadditiontoinformedconsent,severalotherpre- viouslydescribedconsiderationswerealsoidentiÞedas 217 InternationalForumofAllergy&Rhinology,Vol.4,No.3,March2014 Svideretal. FIGURE1. (A)OutcomeproÞleofcasesincludedinthisanalysis,withmedianandrangeofsettlementsandjuryawards(in$1000s).(B)Associatedalleged medicaladverseeventsincasesinvolvingallegedanosmia.(C)Allegedfactorspresentinlitigationincludedinthisanalysis.ResultsinBandCare illustrated asapercentageof pertinent cases;forexample,UPisoutofcasesinvolvingprocedures(19cases),Iatrisoutofallcases.AddtÕl = patientrequiredadditional surgeryasaresultofanadverseoutcomeexperience;Consort = lossofconsortium;CSF = cerebrospinalßuidleak;Def. = defendantdecision;Depress = depression/emotionaldistress;FtDx = failuretodiagnosiscancer;Iatr = iatrogenic;IC = allegeddeÞcitininformedconsent;Men = meningitis;Mis/Delay = failuretodiagnosisacomplicationinatimelymanner;NPS = nasopharyngealstenosis;Plaint. = plaintiffverdict;Psych = permanentpsychiatric/psychological effects;Settle = out-of-courtsettlement;Taste = dysgeusia;UP = allegedlyunnecessary/inappropriateprocedurechoice;Work = work/employmentallegedly affectedbyinjury. TABLE1. Defendantspecialtyincaseswithalleged anosmia Specialty Cases,n(%) Otolaryngology 17(68.0) Oralsurgery 3(12.0) Pathology 1(4.0) Neurosurgery 1(4.0) Primarycare 1(4.0) Plasticsurgery 1(4.0) Psychiatry 1(4.0) Radiology 1(4.0) recurrentfactorsinthepresentanalysis.Inapreviouseval- uationofmalpracticetrialswithallegediatrogeniccra- nialnerveinjuries,theauthorsfoundasuccessivedecrease indefendantverdictpercentageswiththepresenceofan increasingnumberofthefollowingfactors:(1)informed TABLE2. Procedures/conditionsinvolvedinlitigation Procedure/condition Cases(n) Endoscopicsinussurgery 7 Septorhinoplasty 3 Laryngectomy 2 Adenotonsillectomy 2 DelayedDxoftumor 2 Voiceprosthesisimplant 1 Medication-induced 1 Maxillectomy 1 Mandibular/maxillaryosteotomy 1 Failedsuicideattempt 1 CNVnervedecompression 1 Dentalprocedure 1 CN = cranialnerve;Dx = diagnosis. InternationalForumofAllergy&Rhinology,Vol.4,No.3,March2014 218 Anosmialitigation TABLE3. Characteristicsofcasesresolvedwithpayment A/SO Award Def Procedure AllegeddeÞcitinIC UP Taste Otherinjuries/comments 60MP 55 NS CNVdecomp. Y N Y PrimaryclaimthatICdid notincludeanosmia MP 102 OS Bridge N N Y Dentalpolymericmaterial retainedinsinus 30FP 200 Oto Septo/rhino N N N CribriformplateCSFleak, meningitis 42MP 300 Oto ESS N Y Y Olfactorynervesdirectly damaged,frontallobe injury,CSFleak, meningitis,cognitive impairment 63FP 925 PCP Medication Y N/A N MethadoneOD,cognitive impairment 33FP 1900 Oto ESS N Y Y Perforatedethmoidsinus, CSFleak,facial paralysis 72MP 2000 Oto Laryngectomy N Y N Foundnocanceron surgery(postradiation); surgeryunnecessary S 250 Oto T&A N N N Nasopharyngealstenosis 57MS 575 Oto ESS N N N CSFleak,meningitis, “mild”braindamage FS Conf. Psych FailedSA N/A N/A Y Failedattemptbyhanging; anosmia1ofseveral allegedinjuriesdueto ABI Awardsareshownin$1000s. ABI = anoxicbraininjury;A/SO = age/sexofplaintiffandoutcome;CSF = cerebrospinalßuid;CNV = cranialnerveV;CNVdecomp. = trigeminalnervedecompression; Conf = conÞdential;ESS = endoscopicsinussurgery;Def = defendantspecialty;FailedSA = failedsuicideattempt;IC = informedconsent;N/A = notapplicable;NS = neurosurgery;OD = overdose;OS = oralsurgery;Oto = otolaryngologist;P = plaintiffdecision;PCP = primarycareprovider;Psych = psychiatrist;S = settlement; Septo/rhino = septorhinoplasty;T&A = adenotonsillectomy;Taste = tasteaffected(dysgeusia);UP = allegedlyunnecessaryorinappropriateprocedure. consentallegations;(2)allegedlyunnecessaryprocedures; (3)additionalreparativesurgeryrequired;and(4)fail- uretodiagnoseacomplicationinatimelymanner. 16 As thesegeneralprinciplesappeartobeconsistentacrossnu- meroustopics,thishighlightstheimportanceofconsid- eringanout-of-courtsettlementincaseswhereseveralof thesefactorsarepresent.Althoughtherewasnostatisti- caldifferencebetweenthesizeofjury-awardeddamages andout-of-courtsettlementsinthecurrentanalysis,there areconsiderablygreatercostsassociatedwithcasesthat advanceallthewaytothecourtroomforbothsides.In fact,alargerproportionoflegalexpendituresarerelated totheseÒindirectÓcostsratherthanthecostsofdamages awarded. 52 Additionally,costsassociatedwithmalpractice litigationalsoinvolvethesigniÞcantproportionoftimea physicianmayexpendonproceedingsintheircareer,esti- matedby1analysistoencompassasmuchas5yearswith anopenclaimfortheaveragephysician. 7 Anotherindirect effectincludesaconcernabouttheimpactthatinvolve- mentinlitigationmayhaveononeÕsreputation,among bothpatientsandcolleagues. 10,53 Finally,thecurrentmedi- colegalenvironmentfacilitatesthepracticeofdefensive medicine.Allofthesefactors,alongwithsizeablemalprac- ticeinsurancepremiums,increasehealthcarecostsinthe UnitedStatesbyasmuchastensofbillionsofdollarseach year. 6,9,12,35,54Ð58 Itisimportanttorememberthatinorderfornegligence tobeproven,theoccurrenceofanadverseeventaloneis notgroundsforawardingdamages.Otherfactorsmustin- cludethepresenceofaduty,abreachofthisduty,and evidencethatthisbreachofdutywasdirectlyresponsible forcausingaharmfulevent. 12,19,59 Theseverityofinjuries otherthananosmiaalongwithanumberofoversightspo- tentiallyconstruedasnegligenceappearedtoplayarolein thesizeofdamagesawardedbyjuries(Table3).Severalin- terestinglessonscanbegatheredfromthesespeciÞccases. Forexample,therhinologiccasewiththehighestdamages awardresultedina$1.9Maward(Table3).Inthiscase, thedefendantotolaryngologistallegedlyfailedtodiagnose apostoperativeCSFleak,whichwaseventuallypickedup 219 InternationalForumofAllergy&Rhinology,Vol.4,No.3,March2014 Svideretal. bytheplaintiffÕsprimarycaredoctor.TheplaintiffÕsskull- basedefectwasdeemednottobeamenabletoendoscopic management,thusnecessitatingacraniotomytorepair theleak.Inadditiontoconvincingthejurythatanother otolaryngologistinasimilarscenariowouldhavebeen reasonablymorevigilantandwouldhaverecognizeda CSFleaksooner,theplaintiffallegedthatthedefendant otolaryngologistfailedtopursueconservativetreatment withantibioticsandothermedicationspriortosurgery, thusmakingtheESSnotindicated.Thesizeofthisjudg- mentwasfurthermoreinßuencedbypermanentdeÞcits fromboththeinitialandreparativeprocedures,includ- inganosmiaanddysgeusia,alongwithanallegedfacial paralysis. ThethreeESScaseswithanosmiainthisanalysisthat wereresolvedwithasettlementorjury-awardeddamages hadamedianpaymentof$575,000(range,$300,000- $1.9M)(Table3);thesecaseswereresolvedintheyears 1999to2002.TheauthorshaverecentlyexaminedESSlit- igationdatingfrom2003tothepresent, 30 andweretrieved oursourcedatafromthatanalysisandcomparedpayments iniatrogenicESScases(noneofwhichinvolvedanosmia), whichhadamedianof$905,000(range,$89,000-$3.9M). ThiscomparisonwasnotstatisticallysigniÞcant( p = 0.67), demonstratingthatthepresenceorabsenceofanosmia maynothaveanobviouseffectontheamountofdamages awarded,althoughthisisspeculativeduetothemultitude offactorsthatmaybepresentinallofthesecasesandwhich mayplayaroleincompensationtotals. Althoughplaintiffsinitiatedlitigationinseveralcases inwhichafailuretodiagnosecancerinatimelymanner playedaroleinthedevelopmentofanosmia(eitherthrough delayedtreatmentorthecanceritself)(Tables2and3),1of thesecasesisaneffectiveexampleoftheplaintifffailingto proveallofthefactorsrequiredforaÞndingofnegligence. Apatienthadseenhisdentistseveraltimesayearoversev- eralyearsforperiodontalcleaning,andon1visitasmall liplesionwasexcisedandfoundtobeadenoidcysticcarci- noma.Theplaintiffallegedthatadelayindiagnosisneces- sitatedradiationtherapy,whichsubsequentlyledtoaloss ofsmellandtaste.Thedefendantarguedthatperineural invasion,forwhichthisdiseaseprocessisknown, 60 likely startedthemomentthecancerstartedtogrow,andmost importantly,thatadelayintreatmentresultedinnodiffer- enceinthetreatmentreceived.Evenifthedentistshould havedetectedthelesionearlier,hislegalteamwasableto demonstratetothejurythatthiswouldnothavemadea differenceinthepatientÕsmanagement(andthusonra- diationsideeffectssuchasanosmia);thusthispotential ÒbreachofdutyÓwasnotdirectlyresponsibleforcausing anyadditionalharmtothepatient,anessentialcomponent ofattributingnegligence. 59 Onecaseofinterestresolvedwithanout-of-courtset- tlement(Table3)involvedcomplicationsstemmingfrom anadenotonsillectomyforchronichypertrophicadenoidi- tis,tonsillitis,andsleepapnea.Theadultplaintiffalleged thatthedefendantotolaryngologistremovedexcessivetis- sueduringsurgerythatresultedinÒexcessivescarringand obstructionofthenasalairway.ÓHeclaimedtheÒreduc- tionintheabilitytosmellÓcontributedtoaÒdiminished ability ...toenjoylife.ÓNoothermajorinjurieswereal- legedbytheplaintiffinthisparticularcase,anditappears thatanosmiaplayedaprimaryroleinthedefendantÕsdeci- siontopursueanout-of-courtsettlement. WehavepreviouslyevaluatedCSFleaksandtheirim- pactonmalpracticelitigation, 37 notingthatapproximately one-Þfthofcasesinthispreviousanalysisinvolvedanos- mia.Damagesawardedandout-of-courtsettlementswere foundtobeconsiderablyhigherinthatanalysis($1.1Mand $966,887,respectively)thanthosecalculatedinourcurrent analysis($300,000and$412,500,respectively),possiblya resultofthehighercoincidenceofintracranialcomplica- tionsassociatedwithpatientsexperiencingiatrogenicCSF leaks. Noneofthesecasesinwhichplaintiffsattributedanos- miaasaresultofmedicalnegligenceexplicitlymentioned theuseofobjectivetestinginanattempttoconÞrmthis complaint.Wewouldberemissnottoemphasizetheavail- abilityofavarietyoftoolsthatmaybeusefulinobjectively characterizingandconÞrmingthepresenceofanosmia,in- cludingtheSanDiegoOdorIdentiÞcationTestandthe UniversityofPennsylvaniaSmellIdentiÞcationTest. 61 For example,thelattertestisbasedona40-pointscaleand canlikelyidentifymanymalingerers, 62 whichmaybean importantpointinmalpracticelitigation. ThepresentanalysisistheÞrsttocomprehensivelysearch forandevaluatelitigationinwhichplaintiffsallegeanosmia asaresultofmedicalnegligence.Despiteitspotentialvalue ineducatingphysiciansaboutthetypesofcasesandout- comesresultingfromtheseproceedings,thereareseveral limitationsinherenttoananalysisofthisnature.Westlaw isahighlyusedresourceamonglegalprofessionalsand hasshownitsvalueinamultitudeofpreviousmedicolegal analyses, 11Ð35,37 butthisresourceisfocusedonjuryver- dictsandsettlementsthatadvancefarenoughinproceed- ingsforinclusionintopublicallyavailablecourtrecords. Anumberofout-of-courtsettlementsmaynotproceedfar enoughforinclusionintotheserecords,stressingthepoint thatthisresourceisfarmorevaluableforitsrichdetailand discussionofspeciÞcfactorsbroughtupinlitigationthan asatooltoestimatetheoverallprevalenceofaninjury leadingtolegalaction.Whilesomejuryverdictandset- tlementreportsfromsomejurisdictionsarecomposedof attorney-submittedcases, 15,17 manyjurisdictionsalsocon- taininvoluntarilysubmittedinformation;conÞdentialcases fromtheseplacesarelabeledasÒconÞdential,ÓÒJohn/Jane Doe,ÓorÒanonymous.Ó Anotherpotentiallimitationofthisanalysisisrelevant inthestudyofmalpracticeproceedingsfromanyresource: factorsaffectingthequalityoflegalrepresentationforde- fendantsandplaintiffsmaynotbeapparentthroughcourt recordsandmayplayaroleinthesuccessofmalprac- ticeproceedings.Forexample,qualitativedifferencesin medicalexpertwitnesstestimonyhavebeennotedamong InternationalForumofAllergy&Rhinology,Vol.4,No.3,March2014 220 Anosmialitigation neurologicalsurgeryandotolaryngologyproceedings,in whichdefendantwitnessestendtobemoreexperienced, havehigherscholarlyimpact,andaremorelikelytobe involvedinacademicpractice. 21,22,26 Ontheotherhand, theseanalysessuggestthosetestifyingfrequentlyorrepeat- edlytendtobetestifyingonbehalfofplaintiffs.Whileitis notentirelyclearwhateffectsthesephenomenaandother differencesinlegalrepresentationhaveonoutcomes,itis deÞnitelyanissuetokeepinmindwhentryingtodiscernthe differencesbetweencasesthatmayberesolvedwithpay- mentvsthoseresolvedinadefendantsfavor.Thisdiscus- sionregardingexpertwitnessqualiÞcationispurelyspecu- lativeinthecontextofthisanalysisbecausethesestatistics werenotexaminedandwouldhavebeenunlikelytopro- videanyreliableconclusions,astherewereonly25cases meetinginclusioncriteriainthecurrentanalysis. AÞnallimitationistheheterogeneousnatureofthese cases,speciÞcallyrelatingtothefactthatthepresenceof anosmiamayhavehadvaryingimportancedependingon otherassociatedinjuries.ItmayoftentimesbedifÞcultto teaseaparttheimportanceofspeciÞcinjurieswhennu- merousinjuriesarepresent,butwefeelwehaveaccom- plishedourobjectivesofrelayingthetypesofcasesinwhich anosmiamaybeafactor,andwhichproceduresnecessi- tateacomprehensiveinformedconsentprocessincluding anosmia. Conclusions AsolfactorydysfunctioncanhaveasigniÞcantimpacton qualityoflife,patientsexperiencingnew-onsetanosmiaas aresultofmedicalcarepursuemalpracticelitigation.Thisis particularlytrueforiatrogeniccases,includingthosestem- mingfromrhinologicprocedures.Casesresolvedwithpay- mentwereconsiderable,withthemediandamagesawarded byajurytotaling$300,000.Consequently,anunderstand- ingoffactorscriticalininitiatinglitigationisofparamount importanceforthepracticingotolaryngologist.Otherasso- ciatedinjuriesfrequentlyexperiencedinthesecases,such asdysgeusia,CSFleaksandmeningitis,andpsychologi- caleffects,shouldbetakenintoaccount.Requiringaddi- tionalsurgery,havingundergoneanallegedlyunnecessary procedure,missed/delaydiagnosisleadingtoanosmia,and perceiveddeÞcitsininformedconsentwerepresentina signiÞcantproportionofcases.Finally,thisanalysisrein- forcestheimportanceofexplicitlyincludinganosmiaina comprehensiveinformedconsentprocessforanyrhinologic procedure. References 1.GoldsteinBJ,HareJM,LiebermanS,CasianoR. Adulthumannasalmesenchymalstemcellshavean unexpectedbroadanatomicdistribution. IntForum AllergyRhinol .2013;3:550Ð555. 2.GainesA.Chapter13:olfactorydisorders. AmJRhi- nolAllergy .2013;27(Suppl1):S45-S47. 3.KatotomichelakisM,SimopoulosE,TripsianisG,et al.Improvementofolfactoryfunctionforqualityof liferecovery. Laryngoscope .2013;123:E10-E16. 4.GainesAD.Anosmiaandhyposmia. AllergyAsthma Proc .2010;31:185Ð189. 5.HummelT,LandisBN,H ¬ uttenbrinkKB.Smelland tastedisorders. GMSCurrTopOtorhinolaryngol HeadNeckSurg .2011;10:Doc04. 6.JenaAB,ChandraA,LakdawallaD,Seabury S.Outcomesofmedicalmalpracticelitigation againstUSphysicians. ArchInternMed .2012;172: 892Ð894. 7.SeaburySA,ChandraA,LakdawallaDN,JenaAB. Onaverage,physiciansspendnearly11percent oftheir40-yearcareerswithanopen,unresolved malpracticeclaim. HealthAff(Millwood) .2013;32: 111Ð119. 8.Medicalmalpracticelitigationraiseshealth-carecost, reducesaccess,andlowersqualityofcare. JMedPract Manage .2004;20:44Ð51. 9.AndersonGF,HusseyPS,FrognerBK,WatersHR. HealthspendingintheUnitedStatesandtherest oftheindustrializedworld. HealthAff(Millwood) . 2005;24:903Ð914. 10.AnnasGJ.Doctors,patients,andlawyersÑtwocen- turiesofhealthlaw. NEnglJMed .2012;367:445Ð 450. 11.SviderPF,BlakeDM,HusainQ,MauroAC,Turbin RE,EloyJA,LangerPD.IntheEyesoftheLaw:Mal- practiceLitigationinOculoplasticSurgery. Ophthal PlastReconstrSurg .[InPress,2013]. 12.SviderPF,KeeleyBR,ZumbaO,MauroAC,Setzen M,EloyJA.Fromtheoperatingroomtothecourt- room:acomprehensivecharacterizationoflitigation relatedtofacialplasticsurgeryprocedures. Laryngo- scope .2013;123:1849Ð1853. 13.LydiattDD.Medicalmalpracticeandfacialnerve paralysis. ArchOtolaryngolHeadNeckSurg . 2003;129:50Ð53. 14.SviderPF,KovalerchikO,MauroAC,BaredesS,Eloy JA.Legalliabilityiniatrogenicorbitalinjury. Laryn- goscope .2013;123:2099Ð2103. 15.NashJJ,NashAG,LeachME,PoetkerDM.Medical malpracticeandcorticosteroiduse. OtolaryngolHead NeckSurg .2011;144:10Ð15. 16.SviderPF,SunaryoPL,KeeleyBR,KovalerchikO, MauroAC,EloyJA.Characterizingliabilityforcra- nialnerveinjuries:adetailedanalysisof209malprac- ticetrials. Laryngoscope .2013;123:1156Ð1162. 17.ReillyBK,HornGM,SewellRK.Hearinglossresult- inginmalpracticelitigation:whatphysiciansneedto know. Laryngoscope .2013;123:112Ð117. 18.LekovicGP,HarringtonTR.Litigationofmissedcer- vicalspineinjuriesinpatientspresentingwithblunt traumaticinjury. Neurosurgery .2007;60:516Ð522; discussion522Ð513. 19.SviderPF,PashkovaAA,HusainQ,etal.Determina- tionoflegalresponsibilityiniatrogenictrachealand laryngealstenosis. Laryngoscope .2013;123:1754Ð 1758. 20.Frank-StromborgM,GanschowJR.Legalissuesin theearlydetectionandmonitoringofcancer. Semin OncolNurs .2002;18:128Ð134. 21.EloyJA,SviderPF,PatelD,SetzenM,BaredesS. Comparisonofplaintiffanddefendantexpertwitness qualiÞcationinmalpracticelitigationinotolaryngol- ogy. OtolaryngolHeadNeckSurg .2013;148:764Ð 769. 22.EloyJA,SviderPF,PatelD,SetzenM,BaredesS. InresponsetoÒcomparisonofplaintiffanddefen- dantexpertwitnessqualiÞcationinmalpracticeliti- gationinotolaryngologyÓ. OtolaryngolHeadNeck Surg .2013;149:649Ð650. 23.MorrisLG,ZiffDJ,DelacureMD.Malpracticelitiga- tionaftersurgicalinjuryofthespinalaccessorynerve: anevidence-basedanalysis. ArchOtolaryngolHead NeckSurg .2008;134:102Ð107. 24.BlakeDM,SviderPF,CarniolET,MauroAC,Eloy JA,JyungRW.Malpracticeinotology. Otolaryngol HeadNeckSurg .2013;149:554Ð561. 25.WegmanB,StannardJP,BalBS.Medicalliability ofthephysicianintraining. ClinOrthopRelatRes . 2012;470:1379Ð1385. 26.EloyJA,SviderPF,FolbeAJ,CouldwellWT,LiuJK. Comparisonofplaintiffanddefendantexpertwitness qualiÞcationinmalpracticelitigationinneurological surgery. JNeurosurg .2014;120:185Ð90. 27.BlaivasM,PawlR.AnalysisoflawsuitsÞledagainst emergencyphysiciansforpoint-of-careemergency ultrasoundexaminationperformanceandinterpre- tationovera20-yearperiod. AmJEmergMed . 2012;30:338Ð341. 28.LiuJK,EloyJA,SviderP,FolbeAJ,CouldwellWT. 199Comparisonofplaintiffanddefendantexpertwit- nessqualiÞcationinmalpracticelitigationinneurolog- icalsurgery. Neurosurgery .2013;60(Suppl1):186. 29.MitnickJS,VazquezMF,KronovetSZ,RosesDF. Malpracticelitigationinvolvingpatientswithcarci- nomaofthebreast. JAmCollSurg .1995;181:315Ð 321. 30.EloyJA,SviderPF,DÕAguilloCM,BaredesS,Stezen M,FolbeAJ.Image-guidanceinendoscopicsinus surgery:isitassociatedwithdecreasedmedicolegal liability? IntForumAllergyRhinol. 2013;3:980Ð985. 31.HongSS,YheulonCG,SniezekJC.Salivarygland surgeryandmedicalmalpractice. OtolaryngolHead NeckSurg .2013;148:589Ð594. 32.SviderPF,HusainQ,KovalerchikO,etal.Determin- inglegalresponsibilityinotolaryngology:areviewof 44trialssince2008. AmJOtolaryngol .2013;34:699Ð 705. 33.SviderPF,BlakeDM,SahniKP,etal.Meningitisand legalliability:anotolaryngologyperspective. AmJ Otolarygol .2013;34:699Ð705. 34.SviderPF,PashkovaAA,VidalGP,MauroAC,Eloy JA,ChokshiRJ.Esophagealperforationandrup- ture:acomprehensivemedicolegalexaminationof 59juryverdictsandsettlements. JGastrointestSurg . 2013;17:1732Ð1738. 35.ChoudhryAJ,AnandalwarSP,SviderPF,OliverJO, EloyJA,ChokshiRJ.Uncoveringmalpracticeinap- pendectomies:areviewof234cases. JGastrointest Surg .2013;17:1796Ð1803. 36.PaikAM,MadyLJ,SoodA,EloyJA,LeeES.Alook insidethecourtroom:ananalysisof292cosmetic breastsurgerymedicalmalpracticecases. AesthetSurg J .(inpress). 37.KovalerchikO,MadyLJ,SviderPF,etal.Physi- cianaccountabilityiniatrogeniccerebrospinalßuid leaklitigation. IntForumAllergyRhinol .2013;3:722Ð 725. 38.KhanMN,BlakeDM,VazquezA,SetzenM,Baredes S,EloyJA.Epistaxis:thefactorsinvolvedindetermin- ingmedicolegalliability. IntForumAllergyRhinol. 2014;4:76Ð81. 39.BiedlingmaierJF.Anosmiaafternasalsurgery:amal- practiceemergency. OtolaryngolHeadNeckSurg . 1999;121:510. 221 InternationalForumofAllergy&Rhinology,Vol.4,No.3,March2014 Svideretal. 40.SviderPF,AgarwalN,ChoudhryOJ,etal.Readabil- ityassessmentofonlinepatienteducationmaterials fromacademicotolaryngology-headandnecksurgery departments. AmJOtolaryngol .2013;34:31Ð35. 41.ColacoM,SviderPF,AgarwalN,EloyJA,Jack- sonIM.Readabilityassessmentofonlineurology patienteducationmaterials. JUrol .2013;189:1048Ð 1052. 42.MisraP,AgarwalN,KasabwalaK,HansberryDR, SetzenM,EloyJA.Readabilityanalysisofhealthcare- orientededucationresourcesfromtheAmerican AcademyofFacialPlasticandReconstructiveSurgery. Laryngoscope .2013;123:90Ð96. 43.HansberryDR,AgarwalN,ShahR,SchmittPJ, BaredesS,SetzenM,CarmelPW,Prestigiacomo CJ,LiuJK,EloyJA.Analysisofthereadability ofpatienteducationmaterialsfromsurgicalsubspe- cialties. TheLaryngoscope .2014;124:405Ð412.doi: 10.1002/lary.24261 44.MisraP,KasabwalaK,AgarwalN,EloyJA,LiuJK. Readabilityanalysisofinternet-basedpatientinfor- mationregardingskullbasetumors. JNeurooncol . 2012;109:573Ð580. 45.CherlaDV,SanghviS,ChoudhryOJ,JyungRW,Eloy JA,LiuJK.Readabilityassessmentofinternet-based patienteducationmaterialsrelatedtoacousticneuro- mas. OtolNeurotol. 2013;34:1349Ð1354. 46.CherlaDV,SanghviS,ChoudhryOJ,LiuJK,EloyJA. Readabilityassessmentofinternet-basedpatientedu- cationmaterialsrelatedtoendoscopicsinussurgery. Laryngoscope .2012;122:1649Ð1654. 47.SanghviS,CherlaDV,ShuklaPA,EloyJA.Read- abilityassessmentofinternet-basedpatienteducation materialsrelatedtofacialfractures. Laryngoscope . 2012;122:1943Ð1948. 48.PatelCR,CherlaDV,SanghviS,BaredesS,EloyJA. Readabilityassessmentofonlinethyroidsurgerypa- tienteducationmaterials. HeadNeck .2013;35:1421Ð 1425. 49.KasabwalaK,AgarwalN,HansberryDR,Baredes S,EloyJA.Readabilityassessmentofpatiented- ucationmaterialsfromtheAmericanAcademyof OtolaryngologyÐHeadandNeckSurgeryFoundation. OtolaryngolHeadNeckSurg .2012;147:466Ð471. 50.EloyJA,LiS,KasabwalaK,etal.Readabilityassess- mentofpatienteducationmaterialsonmajoroto- laryngologyassociationwebsites. OtolaryngolHead NeckSurg .2012;147:848Ð854. 51.KasabwalaK,MisraP,HansberryDR,etal.Read- abilityassessmentoftheAmericanRhinologicSociety patienteducationmaterials. IntForumAllergyRhi- nol .2013;3:325Ð333. 52.StuddertDM,MelloMM,GawandeAA,etal.Claims, errors,andcompensationpaymentsinmedicalmal- practicelitigation. NEnglJMed .2006;354:2024Ð 2033. 53.MehlmanMJ.Theshameofmedicalmalpractice. JLegMed .2006;27:17Ð32. 54.HermerLD,BrodyH.Defensivemedicine,cost containment,andreform. JGenInternMed . 2010;25:470Ð473. 55.BrennerRJ,SmithJJ.Themalpracticeliabilitycrisis. JAmCollRadiol .2004;1:18Ð22. 56.KilgoreML,MorriseyMA,NelsonLJ.Tortlaw andmedicalmalpracticeinsurancepremiums. Inquiry . 2006;43:255Ð270. 57.NahedBV,BabuMA,SmithTR,HearyRF.Malprac- ticeliabilityanddefensivemedicine:anationalsurvey ofneurosurgeons. PloSOne .2012;7:e39237. 58.ThomasEJ,StuddertDM,BurstinHR,etal.In- cidenceandtypesofadverseeventsandnegligent careinUtahandColorado. MedCare .2000;38: 261Ð271. 59.MoffettP,MooreG.Thestandardofcare:legalhis- toryanddeÞnitions:thebadandgoodnews. Western JEmergMed .2011;12:109Ð112. 60.HusainQ,KanumuriVV,SviderPF,etal.Sinonasal adenoidcysticcarcinoma:systematicreviewofsur- vivalandtreatmentstrategies. OtolaryngolHead NeckSurg .2013;148:29Ð39. 61.DaltonP,DotyRL,MurphyC,etal.Olfactory assessmentusingtheNIHToolbox. Neurology . 2013;80:S32-S36. 62.DotyRL,ShamanP,KimmelmanCP,DannMS.Uni- versityofPennsylvaniaSmellIdentiÞcationTest:a rapidquantitativeolfactoryfunctiontestfortheclinic. Laryngoscope .1984;94:176Ð178. InternationalForumofAllergy&Rhinology,Vol.4,No.3,March2014 222