Forensic Science International Supplement Series 1 (2009) 66–68 Contents lists available at ScienceDirect Forensic Science International Supplement Series journal homepage: www.elsevier.com/locate/FSISUP From chronic rhinitis to death: Fatal outcome of nasal polyposis treatment D. Mayer a,* , A. Lukic b , V. Petrovecki a , M. Bakovic a , D. Strinovic a , J. Skavic a a Department of Forensic Medicine and Criminology, Medical School University of Zagreb, Salata 11, 10000 Zagreb, Croatia b Emergency Medicine Department, Health Center Varazdin, 42000 Varazdin, Croatia article info Article history: Received 21 July 2009 Accepted 25 September 2009 Keywords: Nasal polyposis Functional endoscopic sinus surgery Fatal outcome abstract Introduction: Nasal polyposis (NP) is considered to be the state of chronic inflammation of nasal mucosa and sinuses presenting with various nasal symptomatology. In most cases, it is treated conservatively. Recently, functional endoscopic sinus surgery (FESS) was developed as the valuable and advantageous surgical procedure to treat NP. Despite the inherited risks of this procedure, its complication rate is considered to be acceptable compared to potential benefits for the patient. Case: Fifty-five-year-old man was admitted to the hospital for surgical removal of the nasal polypus. After the usual pre-surgery procedures, the patient underwent FESS. Under general anesthesia, left sphenoid sinus was opened and cleaned from the imflammatory discharge, polypus was excised, and following the trepanation the left maxillary sinus was left to drain out. Polypus and pieces of sinonasal mucosa were sent to pathohistological analysis, which yielded in diagnosis of inverted sinonasal papilloma. The early postoperative recovery was regular, but 2 h upon the surgery, the patient started to lose consciousness gradually falling into the state of coma. CT scan and angiography of the head revealed pneumocranium, defect of the left ethmoidal sinus, hematoma in the left frontal cerebral lobe, as well as the hemorrhage in all four cerebral ventricles. A series of neurosurgical procedures followed in the next 8 days. Despite the attempts to resolve above complications, the patient remained comatous and died 16 days after the polypectomy. Autopsy revealed the extensive oval-shaped defect on the skull base in the left posterior part of cribrous plate of the left ethmoid bone. The brain appeared swollen and heavily congested, showing the zone of subarachnoidal hemorrhage in basal face of left frontal lobe. Frontal serial sections revealed large intracerebral haematoma in basal periventricular structures of left frontal lobe extending to the whole ventricular system. Apart from the above, most prominent finding was bilateral bronchopneumonia. The cause of death was attributed to bronchopneumonia following the brain trauma, manner of death ruled as violent. Conclusion: Although majority of the patients suffering from chronic rhinosinusitis or NP recover well after the endoscopic surgery, the possibility of undesirable outcome must not be ignored. This case calls for assessment of potential medical liability caused by malpractice. Having in mind rather high prevalence of chronic rhinosinusitis and NP, legal aspects of postoperative death should be carefully analyzed. © 2009 Elsevier Ireland Ltd. All rights reserved. 1. Introduction Nasal polyposis (NP) is considered to be state of chronic inflam- mation of nasal mucosa and sinuses [1–3]. It is defined by the appearance of round and soft structures originating from any part of the nasal of paranasal sinuses mucosa (most commonly in the eth- moid or middle meatus region) [3]. NP usually co-exists with many various states, and it is highly unlikely to find it alone [3]. Etiology of NP is still obscure [4], but it seems to be associated with asthma, aspirin intolerance, and cystic fibrosis [2,5]. Although incidence and prevalence of NP are rarely investigated, the incidences of symp- * Corresponding author. Tel.: +385 1 4590249; fax: +385 1 4590221. E-mail address: dmayer@mef.hr (D. Mayer). tomatic nasal polyps of 0.89 and 0.39 patients per thousand per year were suggested for men and women, respectively [6]. The reported prevalence of NP in Swedish population was 2.7%, being more fre- quent in men and in asthmatics [7], while French showed slightly lower prevalence of 2.1% [8]. Using the screening questionnaire [9], the last mentioned study also found higher prevalence of NP in elderly population and asthmatics [8]. At the same time, the asthma seemed to be the most relevant prognostic factor, along with the allergies [8]. Nasal symptomatology is present in more than half of the patients, and includes blocked nose, modification of the voice, loss of the sense of smell and/or taste, frequent nose blowing, feel- ing of discomfort or heaviness in the face, and nasal bleeding as the most frequently reported symptom [8]. As part of the diagnosis protocol, the patients usually undergo several common tests, such as blood or skin prick allergy testing, radiological examinations, 1875-1741/$ – see front matter © 2009 Elsevier Ireland Ltd. All rights reserved. doi:10.1016/j.fsisup.2009.09.007