Found 21 Results Sorted by Case Date
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California – Otolaryngology – Public Letter Of Reprimand For Delayed Care And Failure To Inform Patient Of Potential Complication Of Epistaxis Treatment



An otolaryngologist failed to inform a patient of the potential for a septal perforation during treatment for epistaxis.

In another patient, there was a delay in care.  The otolaryngologist made an initial diagnosis of a nasopharyngeal mass.  However, there was a prolonged period of time between that initial diagnosis and when the biopsy was actually performed.

These actions were deemed to have constituted gross negligence and repeated negligent acts.

A Public Letter of Reprimand was issued against him.

State: California


Date: June 2017


Specialty: Otolaryngology


Symptom: Bleeding, Mass (Breast Mass, Lump, etc.)


Diagnosis: Hemorrhage, Post-operative/Operative Complication


Medical Error: Failure of communication with patient or patient relations, Delay in proper treatment


Significant Outcome: N/A


Case Rating: 1


Link to Original Case File: Download PDF



Virginia – Pathology – Excised Tissue Determined As “Changes Consistent With Tonsillitis”



On 8/1/2013, Pathologist A examined excised tissue from a 55-year-old male and diagnosed “changes consistent with tonsillitis.”

In September 2014, the patient discovered a palpable nodule in the right submandibular region of his throat, which was aspirated on 10/20/2014, and determined to be squamous cell carcinoma.

In December 2014, Pathologist B reexamined the original pathology tissue, determined that Pathologist A’s diagnosis had been incorrect, and found that the specimen showed “squamous cell carcinoma poorly differentiated.”

Histologic evidence showed that the poor differentiation of the malignant cells clearly distinguished them from the surrounding benign lymphocytes, and the tumor was present in approximately 80% of the excised tissue.

Pathologist A’s erroneous diagnosis resulted in a fourteen-month delay in the diagnosis and treatment of the patient’s cancer.

The Board issued a Reprimand.

State: Virginia


Date: February 2017


Specialty: Pathology, Otolaryngology


Symptom: Mass (Breast Mass, Lump, etc.)


Diagnosis: Cancer


Medical Error: False negative


Significant Outcome: N/A


Case Rating: 3


Link to Original Case File: Download PDF



Arizona – Otolaryngology – Acetaminophen With Codeine Elixir In A 2-Year-Old Post Tonsillectomy



The Board was notified of a malpractice settlement involving the care and treatment of a 2-year-old male.

On 06/18/2013, the otolaryngologist performed a tonsillectomy and adenoidectomy on the patient.  The patient had one desaturation recorded in the 70’s when he arrived from the operating room, but quickly recovered.  The patient was also noted to have had several episodes of desaturation while in the PACU and had oxygen saturations of 98-99% on room air at the time of discharge.  The patient was given acetaminophen with codeine elixir as an analgesic for home.

On 06/19/2013, the patient’s mother gave him the medication at 2:00 a.m. and again around 7:00 a.m.  By 9:30 a.m., the patient’s mother noted that he was listless and not really responsive.  She took him to his primary care provider.

The patient was evaluated by the primary care physician who noted that the patient was in respiratory arrest.  When EMS arrived, the patient was subsequently taken by ambulance to the emergency department where he died.

An autopsy identified bronchopneumonia as the cause of death.  The patient was found to have enlargement of the right atrium and ventricle, hypertrophy of the left ventricle with endocardiac thickening at the base of the aortic valve, and patent foramen ovale.

Labs found naloxone (administered by EMS), free codeine, and free morphine in the blood.  Codeine and morphine were in excess of therapeutic levels in the cardiac blood.

The Board judged otolaryngologist’s conduct to be below the minimum standard of competence given failure to admit the patient overnight for observation and failing to adhere to the FDA black box warning to avoid using acetaminophen with codeine elixir for treating pain in post tonsillectomy children.

The Board ordered  the otolaryngologist be reprimanded, be placed on 6 months probation, pay the costs of the proceeding, and take 5 hours of continuing medical education on perioperative management of pediatric patients.

State: Arizona


Date: January 2017


Specialty: Otolaryngology, Pediatrics


Symptom: N/A


Diagnosis: Drug Overdose, Side Effects, or Withdrawal


Medical Error: Procedural error, Improper medication management


Significant Outcome: Death


Case Rating: 3


Link to Original Case File: Download PDF



California – Otolaryngologist – Endoscopic Sinus Surgery For Right-sided Ear Pain, Hearing Loss, And Drainage



On 6/14/2011, a patient presented to an otolaryngologist on referral from another physician for evaluation of right-side ear pain, hearing loss, and drainage.  The otolaryngologist diagnosed a large right-sided tympanic membrane perforation, chronic sinusitis, and hearing loss secondary to chronic sinusitis and tympanic membrane perforation.

On 7/25/2011, the otolaryngologist ordered a CT scan and requested copies of the patient’s most recent hearing examination.  On 8/19/2011, the patient underwent a CT scan that did not show any significant sinus disease.  The otolaryngologist documented that the CT scan revealed chronic sinusitis and recommended endoscopic sinus surgery.  On 7/18/2012, the otolaryngologist performed endoscopic sinus surgery on the patient, which was complicated by right-sided CSF leak.  The otolaryngologist repaired the leak intra-operatively.

The Medical Board of California judged that the otolaryngologist committed gross negligence in his care and treatment of the patient given that he failed to appropriately diagnose chronic sinusitis and performed endoscopic sinus surgery on a patient without an appropriate medical indication.  The otolaryngologist also failed to order audiological testing for the patient, consider tympanoplasty surgery, and admit the patient to the hospital after she suffered a right-sided CSF leak during endoscopic surgery.

For allegations in this case and others, the Medical Board of California requested a hearing be held for the otolaryngologist and issue a decision on: permanent revocation or suspension of his license, revoking or denying approval of his authority to supervise physician assistants, placing him on probation, or taking other and further action as deemed necessary and proper.

State: California


Date: December 2016


Specialty: Otolaryngology


Symptom: Hearing Problems, Head/Neck Pain, Wound Drainage


Diagnosis: Ear, Nose, or Throat Disease, Post-operative/Operative Complication


Medical Error: Unnecessary or excessive treatment or surgery, Failure to order appropriate diagnostic test, False positive, Referral failure to hospital or specialist, Improper treatment


Significant Outcome: N/A


Case Rating: 1


Link to Original Case File: Download PDF



California – Otolaryngologist – Vertigo Diagnosed Secondary To Sinusitis Followed By Endoscopic Sinus Surgeries



On 9/8/2011, a patient presented to an otolaryngologist on referral from another physician for a vertigo evaluation.  The patient had a 2-year history of vertigo at the time the patient was seen by the otolaryngologist.  The otolaryngologist diagnosed the patient with chronic sinusitis and septal deviation, and that the patient’s vertigo was secondary to sinusitis.  The otolaryngologist did not order audiological testing, an MRI, or vestibular testing as well as not documenting an appropriate history to support a diagnosis of vertigo.

On 10/12/2011, the patient underwent a CT scan that did not show any significant sinus disease.  On 3/1/2012, the otolaryngologist performed an endoscopic sinus surgery on the patient.  After this surgery, the patient continued to suffer from vertigo.  On 7/24/2012, the patient underwent another CT scan, which now showed left-sided maxillary and frontal sinus disease consistent with findings expected in a patient who underwent sinus surgery in the absence of chronic sinusitis.  On 11/6/2012, the otolaryngologist performed a revision endoscopic sinus surgery on the patient.  This surgery was complicated by a left-sided CSF leak.  The otolaryngologist treated the CSF leak but did not admit the patient to the hospital.  After the surgery, the otolaryngologist documented that the patient continued to have chronic sinusitis.

On 8/14/2012, the patient underwent another postoperative CT scan that revealed findings consistent with previous endoscopic medial maxillectomy surgery, not endoscopic sinus surgery.  Despite the absence of CT findings consistent with chronic sinusitis, the otolaryngologist recommended that the patient undergo another sinus surgery, but that surgery was ultimately canceled.

The Medical Board of California judged that the otolaryngologist committed gross negligence in his care and treatment of the patient given that he failed to consider other etiologies or pursue further evaluation of the patient’s vertigo and performed endoscopic sinus surgery on the patient without an appropriate medical indication.  The otolaryngologist also failed to admit the patient to the hospital after she suffered a CSF leak during endoscopic surgery.

For allegations in this case and others, the Medical Board of California requested a hearing be held for the otolaryngologist and issue a decision on permanent revocation or suspension of his license, revoking or denying approval of his authority to supervise physician assistants, placing him on probation, or taking other and further action as deemed necessary and proper.

State: California


Date: December 2016


Specialty: Otolaryngology


Symptom: Dizziness


Diagnosis: Ear, Nose, or Throat Disease, Post-operative/Operative Complication


Medical Error: Unnecessary or excessive treatment or surgery, Failure to order appropriate diagnostic test, Referral failure to hospital or specialist, Lack of proper documentation


Significant Outcome: N/A


Case Rating: 2


Link to Original Case File: Download PDF



California – Otolaryngologist – Endoscopic Sinus Surgery For A Diagnosis Of Chronic Sinusitis That Had Caused Tinnitus



On 10/5/2012, a patient presented to an otolaryngologist on referral from another physician for evaluation of right-side ear tinnitus.  The otolaryngologist diagnosed chronic sinusitis with secondary eustachian tube dysfunction leading to tinnitus.  The otolaryngologist prescribed Augmentin for one week and hypertonic saline irrigation.  The otolaryngologist ordered a CT scan that revealed some maxillary sinus opacification bilaterally and a right-sided mucous retention cyst.  The otolaryngologist recommended endoscopic sinus surgery.

On 12/27/2010, the otolaryngologist performed an endoscopic sinus surgery on the patient.  Postoperatively, the otolaryngologist documented continued symptoms, diagnosed the patient with chronic sinusitis, and recommended revision endoscopic sinus surgery.  On 1/11/2012, the otolaryngologist performed a second endoscopic sinus surgery on the patient, which was complicated by a right-sided CSF leak.  The otolaryngologist attempted to repair the leak intra-operatively. On 1/12/2912, the otolaryngologist documented an active right-sided CSF leak.  The otolaryngologist prescribed Amoxicillin for 10 days and instructed the patient to contact him if his condition worsened.

On 1/18/2012, the otolaryngologist saw the patient postoperatively and noted that the right-sided CSF leak had stopped.  On 7/23/2012, the otolaryngologist saw the patient for anosmia and congestion and ordered another CT scan.  On 9/6/2012, the otolaryngologist saw the patient and diagnosed chronic sinusitis and recommended another revision endoscopic sinus surgery.

The Medical Board of California judged that the otolaryngologist committed gross negligence in his care and treatment of the patient given that he failed to appropriately diagnose chronic sinusitis, performed endoscopic sinus surgery on the patient without an appropriate medical indication, and failed to admit patient to the hospital after suffering a right-sided CSF leak during endoscopic sinus surgery.  The otolaryngologist also failed to properly diagnose and/or treat the patient’s tinnitus.

For allegations in this case and others, the Medical Board of California requested a hearing be held for the otolaryngologist and issue a decision on permanent revocation or suspension of his license, revoking or denying approval of his authority to supervise physician assistants, placing him on probation, or taking other and further action as deemed necessary and proper.

State: California


Date: December 2016


Specialty: Otolaryngology


Symptom: Hearing Problems


Diagnosis: Ear, Nose, or Throat Disease, Post-operative/Operative Complication


Medical Error: Unnecessary or excessive treatment or surgery, Diagnostic error, Failure to order appropriate diagnostic test, Referral failure to hospital or specialist, Improper treatment


Significant Outcome: N/A


Case Rating: 3


Link to Original Case File: Download PDF



California – Otolaryngologist – Hypertonic Saline Solution, Afrin, And Endoscopic Sinus Surgery For A Diagnosis Of Chronic Sinusitis



On 10/27/2011, a patient presented to an otolaryngologist on referral for a vertigo evaluation. The otolaryngologist noted additional symptoms of bilateral tinnitus, migraine headaches, post-nasal drip, and pus inside patient’s nose.  The otolaryngologist diagnosed the patient with chronic sinusitis and ordered hypertonic saline solution and Afrin spray to treat the patient’s diagnosis of chronic sinusitis.  The otolaryngologist did not order audiological testing, an MRI, or vestibular testing and did not document an appropriate history to support a diagnosis of vertigo.

On 12/6/2011, the patient underwent a CT scan that did not show any significant sinus disease.  Despite these negative findings, the otolaryngologist recommended endoscopic sinus surgery.  On 3/6/2012, the otolaryngologist performed an endoscopic sinus surgery on the patient, which was complicated by right-sided CSF leak.  The otolaryngologist attempted to repair the leak intra-operatively.  On 3/7/2012, the otolaryngologist saw the patient postoperatively and noted signs of an active right-sided CSF leak.  The otolaryngologist recommended saline irrigation and Afrin spray as needed.  The patient developed post-operative nasal polyps as a result of the otolaryngologist’s sinus surgery.

The Medical Board of California judged that the otolaryngologist committed gross negligence in his care and treatment of the patient given that he failed to consider other etiologies or pursue further evaluation of the patient’s vertigo, appropriately diagnose chronic sinusitis, and admit the patient to the hospital after suffering a CSF leak during endoscopic sinus surgery.

For allegations in this case and others, the Medical Board of California requested a hearing be held for the otolaryngologist and issue a decision on: permanent revocation or suspension of his license, revoking or denying approval of his authority to supervise physician assistants, placing him on probation, or taking other and further action as deemed necessary and proper.

State: California


Date: December 2016


Specialty: Otolaryngology


Symptom: Hearing Problems, Dizziness, Headache


Diagnosis: Ear, Nose, or Throat Disease, Post-operative/Operative Complication


Medical Error: Unnecessary or excessive treatment or surgery, Failure to order appropriate diagnostic test, Referral failure to hospital or specialist


Significant Outcome: N/A


Case Rating: 3


Link to Original Case File: Download PDF



California – Otolaryngologist – Flonase, Afrin Spray, and Endoscopic Sinus Surgery To Treat Chronic Sinusitis, Septal Deviation, and Allergic Rhinitis



On 9/19/2011, a patient presented to an otolaryngologist on referral from another physician for an evaluation of eye tearing for 8 months.  The otolaryngologist documented a history suggestive of sinus disease.  The otolaryngologist diagnosed chronic sinusitis, septal deviation, and allergic rhinitis.  The otolaryngologist ordered hypertonic saline solution and Claritin for treatment of the patient’s diagnosis of chronic sinusitis and allergic rhinitis.

On 2/23/2012, the patient presented to the otolaryngologist with continuing symptoms.  The otolaryngologist ordered a CT scan that showed some sinus disease in the left maxillary sinus and ordered the use of Flonase and Afrin spray every other day as well as recommended endoscopic sinus surgery.  On 8/1/2012, the otolaryngologist performed an endoscopic sinus surgery on the patient.  During the 6-month post-operative period, the otolaryngologist saw the patient several times.  Initially, the otolaryngologist noted “fairly heavy” polyps in the bilateral nasal cavities.  The otolaryngologist noted the polyps improved during the 6-month post-operative period.

The Medical Board of California judged that the otolaryngologist committed gross negligence in his care and treatment of the patient given that he performed endoscopic sinus surgery on the patient without an appropriate medical indication and recommended the chronic use of Afrin spray.  The otolaryngologist also failed to properly diagnose and/or treat the patient’s tearing complaints.

For allegations in this case and others, the Medical Board of California requested a hearing be held for the otolaryngologist and issue a decision on: permanent revocation or suspension of his license, revoking or denying approval of his authority to supervise physician assistants, placing him on probation, or taking other and further action as deemed necessary and proper.

State: California


Date: December 2016


Specialty: Otolaryngology


Symptom: N/A


Diagnosis: Ear, Nose, or Throat Disease, Post-operative/Operative Complication


Medical Error: Unnecessary or excessive treatment or surgery, Diagnostic error, Improper treatment, Improper medication management


Significant Outcome: N/A


Case Rating: 2


Link to Original Case File: Download PDF



California – Otolaryngologist – Complications During Submucous Resection Septoplasty And Endoscopic Sinus Surgery



On 1/30/2013, a patient saw Otolaryngologist A for an evaluation of decreased hearing in the right ear.  Otolaryngologist A diagnosed the patient with right-sided sensorineural “deafness” and chronic sinusitis and recommended a follow-up appointment in one month, hypertonic saline and Afrin spray for the sinusitis, and an MRI to rule out hearing loss caused by a schwannoma.  On 3/5/2013, the patient underwent a CT scan because the attending radiologist felt that the patient’s ventriculoperitoneal shunt from a previous intracranial aneurysm surgery was a contraindication for an MRI.  The CT indicated that the patient had normal sinuses and no deviation of the patient’s nasal septum.

On 3/7/2013, Otolaryngologist A saw the patient and documented that the cause of the patient’s right-sided deafness had not been delineated and that she continued to have nasal congestion and post-nasal drip.  Otolaryngologist A ordered an audiogram and recommended continued use of saline spray and a follow-up appointment in one month.  On 3/18/2012, the patient underwent diagnostic audiological testing that revealed the patient’s hearing was symmetrical and normal.

On 4/18/2012, Otolaryngologist A saw the patient and documented that all of the patient’s symptoms had resolved with nasal saline and Afrin sprays.  Otolaryngologist A diagnosed the patient with chronic sinusitis despite the fact that the patient’s previous CT scan was negative for sinusitis.  On 7/2/2013, the patient returned to Otolaryngologist A with sinus complaints and indicated the nasal saline and Afrin sprays were no longer helping.  Otolaryngologist A reviewed the previous CT scan and documented that the patient’s sinuses were normal, diagnosed chronic sinusitis, and scheduled the patient for endoscopic sinus surgery with possible submucous resection septoplasty.  On 7/7/2013, Otolaryngologist A performed a pre-operative history and physical on the patient that did not document a finding that the patient had a deviated septum.  On 8/21/2013, Otolaryngologist A documented a pre-operative history and physical on the patient that noted gross swelling of the turbinates, but he never offered any medical or surgical intervention for this condition other than nasal saline and Afrin sprays.

On 8/21/2013, Otolaryngologist A performed a submucous resection septoplasty surgery on the patient and then started endoscopic sinus surgery on the patient’s left-side sinuses by removing the uncinate process and the middle turbinates.  The otolaryngologist then resected the ethmoid sinuses and proceeded with the enlargement of the left maxillary sinus window.  At that point in the procedure, the patient suffered rapid bleeding and blood loss.  Otolaryngologist A decided to pack the patient’s left nose with numerous Codman pledgets to control the bleeding and then performed endoscopic sinus surgery on the ethmoid, maxillary, and sphenoid sinuses on the right side.  After completing the surgery on the right side, Otolaryngologist A decided not to remove the Codman pledgets and to leave the patient intubated for transfer to the hospital’s emergency department for evaluation and admission to the ICU and for possible blood transfusions.  Otolaryngologist A noted in his operative notes that he would determine the cause of the bleeding after the patient received blood transfusions.

On 8/22/2013, the patient was seen by another otolaryngologist.  Otolaryngologist B ordered an angiogram that revealed a pseudoaneurysm of the distal internal maxillary artery, which appeared to be the source of the patient’s bleeding.  On 8/24/2013, Otolaryngologist B performed surgery on the patient, removed the Codman pledgets from the patient’s right and left sinuses, and identified and treated two left maxillary sinusotomies that he believed to be the source of the patient’s bleeding.  On 8/25/2013, the patient was transferred out of the ICU. On 8/29/2013, the patient was discharged from the hospital.  On 9/16/2013, the patient saw Otolaryngologist A for a clinical visit.  Otolaryngologist A documented that the patient was not performing adequate post-operative care of her sinuses and recommended daily saline rinses and Afrin use every other day.  On 10/14/2013, the patient saw Otolaryngologist A. Otolaryngologist A recommended hypertonic saline rinses 6-8 times per day for the next 6 months.

The Medical Board of California judged that Otolaryngologist A committed gross negligence in his care and treatment of the patient given that he failed to formulate and/or implement a plan to address the patient’s intraoperative bleeding and obtain appropriate consultation to determine the source of the patient’s bleeding.  Otolaryngologist A also performed a septoplasty on the patient without medical indication, used an inappropriately large number of Codman pledgets during the patient’s surgery, left the Codman pledgets in place postoperatively, and recommended chronic use of Afrin spray.  Otolaryngologist A was also negligent when he removed the patient’s middle turbinates without medical indication, failed to appropriately treat the patient’s inferior turbinate hypertrophy, and failed to order a timely angiogram to assess the patient’s reported hearing loss.

For allegations in this case and others, the Medical Board of California requested a hearing be held for the otolaryngologist and issue a decision on permanent revocation or suspension of his license, revoking or denying approval of his authority to supervise physician assistants, placing him on probation, or taking other and further action as deemed necessary and proper.

State: California


Date: December 2016


Specialty: Otolaryngology


Symptom: Hearing Problems, Bleeding


Diagnosis: Ear, Nose, or Throat Disease, Post-operative/Operative Complication


Medical Error: Unnecessary or excessive treatment or surgery, Failure to order appropriate diagnostic test, False positive, Referral failure to hospital or specialist, Improper treatment, Improper medication management, Procedural error


Significant Outcome: N/A


Case Rating: 3


Link to Original Case File: Download PDF



North Carolina – Otolaryngology – Failure To Review Results Of Thyroid Biopsies Leads To Wrong Site Procedure



The Board was notified of a professional liability payment.on 03/17/2016.

A patient was referred to an otolaryngologist after a 07/12/2013 magnetic resonance angiography of the thyroid was positive for bilateral nodules.

On 08/16/2013, the patient also had a thyroid ultrasound that demonstrated normal thyroid lobe size bilaterally and three thyroid nodules: two nodules in the right lobe (middle and lower) and one larger nodule in the left thyroid lobe.

On 08/23/2013, the patient first presented to an otolaryngologist’s office, and his chief complaint was “thyroid nodule/US results.”  After examining the patient, the otolaryngologist noted “no lymphadenopathy, thyroid enlargement or masses.”  The otolaryngologist then recommended that the patient obtain an endocrinology consultation and a thyroid ultrasound guided fine needle aspirate biopsy (“FNA”).

On 09/12/2013, the patient was seen by an endocrinologist and the FNA was performed. Ultrasound measurements of each thyroid lobe were within normal limits.  FNA biopsies of three thyroid nodules were performed and reported as follows:

  1. Right middle nodule: This was larger than 1.0 cm, hypoechogenic, and had irregular borders with grade 3 vascularity.  These findings were suspicious for malignancy.
  2. Right lower nodule: This was solid, just less than 1.0 cm, and had smooth borders. These findings were consistent with less probability of malignancy.
  3. Lower left nodule: This was the largest of the three, measuring 3.63 cm x 1.79 cm x 1.17 cm, was complex with irregular borders, and had grade 3 vascularity. These findings could be consistent with possible malignancy.

On 09/18/2013, the FNA biopsy results were faxed to the otolaryngologist’s office.

Additionally, gene expression testing reported the patient’s right middle nodule to be suspicious for malignancy at a probability of 40%, the right lower nodule was classified as “non-diagnostic,” and the left lower nodule was classified as benign.  On 09/26/2013, the gene expression testing results were faxed to the otolaryngologist’s office.

On 10/02/2013, the patient returned to the otolaryngologist, and the otolaryngologist planned to perform a left thyroid lobectomy based on his physical examination of the patient and the patient’s self-report of a suspicious left thyroid nodule.  It does not appear that the otolaryngologist reviewed the FNA biopsy results or the gene expression testing results.  On 10/18/2013, the otolaryngologist thereafter performed a left thyroid lobectomy on the patient.

The Board obtained the patient’s records and sent them to a qualified independent medical expert for review.  The independent medical expert judged the otolaryngologist’s conduct to be below the minimum standard of competence given failure to review the results of the FNA biopsy and the results of gene expression testing.

The expert believed that it was inappropriate to perform a left thyroid lobectomy on the patient and that the otolaryngologist should have performed a right thyroid lobectomy or a total thyroidectomy on the patient.

The Board issued a public letter of concern, which was reported to the Federation of State Medical Boards.  It was not reported to the National Practitioner Data Bank.

State: North Carolina


Date: November 2016


Specialty: Otolaryngology


Symptom: Mass (Breast Mass, Lump, etc.)


Diagnosis: Cancer


Medical Error: Wrong site procedure, Failure to follow up


Significant Outcome: N/A


Case Rating: 3


Link to Original Case File: Download PDF



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