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Kinetics of gentamicin uptake
LETTERS TO THE EDITOR Kinetics of gentamicin uptake To the Editor: The article by Balough et al (1998; 119:427-31) attempted to quantify the uptake of gentamicin by the ear during intratympanic administration. They reported that the clearance follows first-order kinetics during the final phase with a high correlation. They hope that this information will be useful to clinicians administering gentamicin to patients. As a clinician, I have several questions: I. It appears that there are only 3 data points in the final phase of elimination. Considering that 2 points define a line with perfect correlation, it would seem that the conclusion of kinetics and quantification of the elimination of gentamicin is determined by a single data point. Is this adequate? 2. Figures 1 and 2 appear to illustrate mean values for gentamicin concentration with no indication of variability of the data (SD or SEM). Variability data probably contain more meaningful information to the clinician than the simple mean. For example, if the average concentration is just below the threshold of auditory damage, but there is great variability, wouldn't many adverse outcomes be expected? 3. Would it be better to actually label the axes on the graph so that the reader could know the times and concentrations involved? 4. The gentamicin concentration in the control ear is about half the concentration in the treated ear at 168 hours in Fig 2. How is this possible?
Brian W. Blakley, MD, PhD, FRCSC Professor and Chairman Department of Otolaryngology University of Manitoba GB421-820 Sherbrook St Winnipeg, Manitoba, Canada R3A 1R9 23/8/101570 The authors were given an opportunity to respond.
Anosmia after nasal surgery: A malpractice emergency To the Editor: Within the past 3 years I have been contacted by attorneys who were defending physicians in lawsuits brought by patients suing because they developed anosmia after septal and sinus surgery. Since 1996, I have published 4 articles indirectly dealing with the alteration of smell as it relates to sinus
510 Otolaryngology-Head and Neck Surgery
surgery. I suspect, therefore, that these articles brought me to the attorneys' attention. In the cases about which I was contacted, 2 patients had undergone septal surgery only, and 1 patient had had septal and sinus surgeries. All patients had complete anosmia after surgery. All patients shared another complaint. None of the patients had been told about anosmia as a potential complication. I am sure that to many of you this complaint is not surprising because a formal survey of Academy members done by my residents Dr Wolf and Dr Berry (to be submitted for publication) showed that less than one half of the otolaryngologists who completed the survey informed patients about anosmia as a complication of any nasal surgery. Another common thread to these 3 cases is that none of the surgeons had previously had a patient develop anosmia after nasal surgery. They argued that because it had never happened to any of their patients, they did not consider the patient at risk. As you can guess, because none of the patients had been informed, not one case was successfully defended. These cases illustrate several points. First, even if a complication has never occurred to any of your patients, it does not mean that it cannot. I am certain that few of.you have had the horrible experience of ocular injury to a patient after sinus surgery. However, I am certain that a high percentage of you inform the patient of this complication. Second, informing the patient of a risk in no way prevents you from getting sued. You can bet that if a patient goes blind after a sinus operation, you will be getting a letter from the patient's attorney regardless of informed consent. However, having informed consent at least allows your attorney to mount a defense because the patient was aware of the risk. Finally, hearing the patient elaborate on how his or her life was ruined and all pleasant memories of smell were taken away seems to have a great impact on the judges and juries. It is my strong recommendation that you add anosmia to the list of potential complications on your informed consent form before doing a septoplasty or sinus surgery. At least you have the basis of a reasonable defense should a patient develop anosmia.
John E Biedlingmaier, MD, FACS Clinical Associate Professor University of Maryland Medical Systems Director Head and Neck Services Maryland General Hospital 827 Linden Ave Baltimore, MD 21201 23/8/98755
October 1999
Brian W. Blakley, MD, PhD, FRCSC Professor and Chairman Department of Otolaryngology University of Manitoba GB421-820 Sherbrook St Winnipeg, Manitoba, Canada R3A 1R9 23/8/101570 The authors were given an opportunity to respond.
Anosmia after nasal surgery: A malpractice emergency To the Editor: Within the past 3 years I have been contacted by attorneys who were defending physicians in lawsuits brought by patients suing because they developed anosmia after septal and sinus surgery. Since 1996, I have published 4 articles indirectly dealing with the alteration of smell as it relates to sinus
510 Otolaryngology-Head and Neck Surgery
surgery. I suspect, therefore, that these articles brought me to the attorneys' attention. In the cases about which I was contacted, 2 patients had undergone septal surgery only, and 1 patient had had septal and sinus surgeries. All patients had complete anosmia after surgery. All patients shared another complaint. None of the patients had been told about anosmia as a potential complication. I am sure that to many of you this complaint is not surprising because a formal survey of Academy members done by my residents Dr Wolf and Dr Berry (to be submitted for publication) showed that less than one half of the otolaryngologists who completed the survey informed patients about anosmia as a complication of any nasal surgery. Another common thread to these 3 cases is that none of the surgeons had previously had a patient develop anosmia after nasal surgery. They argued that because it had never happened to any of their patients, they did not consider the patient at risk. As you can guess, because none of the patients had been informed, not one case was successfully defended. These cases illustrate several points. First, even if a complication has never occurred to any of your patients, it does not mean that it cannot. I am certain that few of.you have had the horrible experience of ocular injury to a patient after sinus surgery. However, I am certain that a high percentage of you inform the patient of this complication. Second, informing the patient of a risk in no way prevents you from getting sued. You can bet that if a patient goes blind after a sinus operation, you will be getting a letter from the patient's attorney regardless of informed consent. However, having informed consent at least allows your attorney to mount a defense because the patient was aware of the risk. Finally, hearing the patient elaborate on how his or her life was ruined and all pleasant memories of smell were taken away seems to have a great impact on the judges and juries. It is my strong recommendation that you add anosmia to the list of potential complications on your informed consent form before doing a septoplasty or sinus surgery. At least you have the basis of a reasonable defense should a patient develop anosmia.
John E Biedlingmaier, MD, FACS Clinical Associate Professor University of Maryland Medical Systems Director Head and Neck Services Maryland General Hospital 827 Linden Ave Baltimore, MD 21201 23/8/98755
October 1999