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May 11, 2015

Tonsillectomy Lawsuit Due to Taste Loss

An ENT was sued for $1.5 million dollars for normal taste loss that occurred after tonsillectomy that was performed in 2009. The jury did not find the ENT negligent, but awarded the money due to failure to obtain "informed consent." Given the patient is a restaurant owner and cook, the loss of normal taste has impacted his life tremendously. [link]

Taste loss/alteration after tonsillectomy is an extremely rare complication... like very rare to the point where it is worth writing a case report in a medical journal to say publically to the world that this complication occurred. One can debate whether rare things should be part of the informed consent (for example, death is not something routinely included in informed consent given how rarely this occurs)... or one read more about informed consent and rare complications here.

But beyond informed consent... how/why can this complication occur?

It is hypothesized that this risk can be due to direct or indirect damage to the glossopharyngeal nerve or its lingual branch (LBGN), lack of dietary zinc, and habitual drug intake.

Regarding the nerve damage, depending on the literature data, this symptom may be reversible within two years after tonsillectomy, but it can also be irreversible.

Taste perception is contributed by three different cranial nerves (CN 7, 9, and 10).  Alterations in taste are classified into hypogeusia (reduced taste), ageusia (no taste), dysgeusia (distorted taste), aliageusia (altered taste), and phantogeusia (taste when no taste should be present).

The culprit nerve which is thought to be damaged in tonsillectomy cases is the lingual nerve (branch of CN 9). The lingual nerve carries nerve fibers that are responsible for providing taste sensation especially to the posterior aspect of the tongue. The are two ways this nerve can be injured during tonsillectomy.

The first way is through nerve compression through use of a mouth gag that is too large for the patient's mouth.

The second way is through nerve damage that occurs when the tonsil is removed, especially in the bottom area of the tonsil next to the tongue. In a cadaveric study, the lingual nerve was found to be adherent to the inferior tonsil capsule because of incomplete coverage of the tonsil fossa by the superior pharyngeal constrictor muscle.

As such, this complication can be avoided by using an appropriately sized mouth gag and perhaps by deliberately leaving the tonsil capsule intact inferiorly when removing the tonsil... although this means leaving tonsil tissue behind which can contribute to tonsil tissue regrowth in the future. Unfortunately, this location is a common spot where bleeding occurs after tonsillectomy requiring cauterization for control... and by cauterizing to stop the bleeding, may inadvertently damage the lingual nerve as well.

But, should this complication occur, there are a few steps that can be taken to optimize the chance for normal taste recovery including:

1) Prednisone
2) Zinc Gluconate 50mg 3x per day and Alpha lipoic acid 200mg 3x per day


Source:
Pittston man wins $1.5 million verdict for botched tonsil surgery. Citizensvoice.com 5/8/2015.

References:
Unusual complication of tonsillectomy: taste disturbance and the lingual branch of the glossopharyngeal nerve. J Laryngol Otol. 2003 Apr;117(4):314-7.

Posttonsillectomy taste distortion: a significant complication. Laryngoscope. 2004 Jul;114(7):1206-13.

Taste disorders after tonsillectomy: case report and literature review. Ann Otol Rhinol Laryngol. 2005 Mar;114(3):233-6.

Anatomy of the tonsillar bed: topographical relationship between the palatine tonsil and the lingual branch of the glossopharyngeal nerve. Acta Otolaryngol Suppl. 2002;(546):99-109.


Fauquier blog
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. Google+ Christopher Chang, MD Bio

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