September 06, 2013

Malpractice Lawsuit for Nerve Damage Sustained After Neck Cyst Excision

Earlier this month, a malpractice lawsuit resulted in a $4 million dollar award to the patient plaintiff who suffered permanent nerve damage after a family practice physician excised a cyst from the neck. [link]

Briefly, the patient visited the family physician in July 2009 for a lump in his left neck. The family physician recommended that the mass be surgically excised which was subsequently performed by the same family physician (not a surgeon) in the office. After the procedure, the patient experienced a weakened left arm and shoulder and had difficulty picking things up with that arm or moving the arm more than 90 degrees. Subsequent evaluation by an orthopedic surgeon and neurosurgeon determined that the spinal accessary nerve was cut at the time of the neck mass excision.

So what probably happened?

The spinal accessory nerve (also known as cranial nerve XI), is a major nerve that comes off the spinal cord and supplies motor function to the shoulder and arm (red arrow below pointing to the nerve which is yellow).

Image Modified from Wikipedia
I suspect that in this case, the mass was located in the same area denoted by the red arrow above. Now assuming that media and court documents were correct that it was truly a cyst that was excised, the cyst must have laid right below the skin, but on top of the nerve.

Careless excision of the cyst would have resulted in this nerve being cut especially during dissection on the mass's deepest aspect, especially if the physician did not hug the mass during dissection. Using an analogy, good surgical technique is like peeling an orange without puncturing the yummy orange underneath. Poor surgical technique would be peeling the rind and taking bits of the edible orange as well... or leaving some nasty rind on the fleshy orange itself.

Often, novice surgeons take large cuts around a mass with the tip of the scissor or scalpel extending beyond visualization. Also, thick layers of tissues are cut rather than thin transparent amounts. Furthermore, when a mass is grasped and pulled, anatomic structures like a nerve can get pulled out of its usual location along with the mass which can lead to unintentional damage. 

As such, experienced surgeons know when to cut big (no important structures are around) and when to cut in tiny microscopic degrees (important nerves and blood vessels are around).

The neck has a large number of important blood vessels and nerves in a highly compacted area making surgery in this part of the body potentially fraught with peril. However, there are certain "safe" areas where no significant important nerves or blood vessels are found. Such a "safe" zone from a nerve perspective is right under the chin extending down over the voicebox. Of course, there are other important structures located in this area that could get damaged even if nerves aren't a concern.

Montco jury awards Hatboro man $4M for nerve damage. Phillyburbs 8/27/13
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Fauquier ENT

Dr. Christopher Chang is a private practice otolaryngology, head & neck surgeon specializing in the treatment of problems related to the ear, nose, and throat. Located in Warrenton, VA about 45 minutes west of Washington DC, he also provides inhalant allergy testing/treatment, hearing tests, and dispenses hearing aids.

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