Wrong-site sinus surgery in otolaryngology

Objective: To determine the scope of wrong-site sinus surgery. Study Design: Electronic mail survey. Setting: E-mailed via the American Academy of Otolaryngology–Head and Neck Surgery's weekly newsletter. Subjects and Methods: Members were asked about wrong-site sinus surgery in an 11-item survey. Results: A total of 455 members responded (response rate 19.8%). Forty-two (9.3%) have heard of a case of wrong-site sinus surgery occurring. Twenty-one cases were analyzed; of these, 10 (48%) implicated radiographic error, and the Universal Protocol was followed in one third. In seventeen reports (81%), there was disclosure to the family, one case with delayed disclosure; there was no disclosure in three cases. Sixty-one percent (n = 266) are concerned about operating on the wrong sinus or side. Forty-nine percent (n = 216) routinely use a checklist preoperatively. There is large variation in site marking for sinus surgery. Sixty-five percent (n = 282) routinely review the computed tomography scan prior to surgery. Conclusion: Approximately 10 percent of survey respondents know of a case of wrong-site sinus surgery occurring; the majority of respondents are concerned about a wrong-sinus or wrong-sided surgery occurring in their practice. Otolaryngologists should be vigilant regarding the potential for inverted computed tomography images; there should be national efforts to address this latent systems defect. Surgeons should be trained in understanding the role of and engaging in disclosure and in other techniques that are of greatest support to the patient. Consideration of sinus-specific checklists should be led by the societies representing sinus surgeons.