Discussion

Malpractice litigation is responsible for increased health care costs and is often viewed as adversarial by physicians.^{Reference Annas33–Reference Nahed, Babu, Smith and Heary36} Regardless of outcome, litigation can affect a practitioner's reputation among peers and patients.^{Reference Burkle, Martin and Keegan37} Given that dental and mucosal injuries are almost universally presented as possible complications of laryngoscopy during the consent process, some providers may find it perplexing that these complaints comprise more than one-third of all lawsuits in the field of anaesthesiology.^{Reference Owen and Waddell-Smith9,Reference Yasny12,Reference Cook, Scott and Mihai16} In many of these cases, poor documentation of existing problems with mucosa or dentition prior to laryngoscopy make such cases viable. In this report, allegations of medical malpractice that culminated in a lawsuit brought before a court of law were comprehensively analysed to reveal new insights into a key gap in the literature.

We report that dental and/or mucosal injury cases were unanimously ruled in favour of the defendant medical provider with none resulting in payment awards to a plaintiff. This outcome was consistently observed among both anaesthesiologist and certified registered nurse anaesthetist defendants. While laryngoscopy is commonly performed by otolaryngologists, there was no documented lawsuit brought before the court involving laryngoscopy-associated injury alleged against an otolaryngologist. This could be due to a lower volume of laryngoscopies performed among otolaryngologists. Although anaesthesia providers do perform the majority of these procedures in the peri-operative period, the fact that no allegation involved an otolaryngologist could suggest variability in technique and strain forces utilised between different specialties. Simulation-based exercises are one effective method to help minimise laryngoscope-associated injuries. Such educational resources may prove useful in training clinicians on best practices for laryngoscopy.^{Reference Batchelder, Steel, Mackenzie, Hormis, Daniels and Holding38–Reference Vanderbilt, Mayglothling, Pastis and Franzen40} Regardless of the specialty involved, a dental- or oral-surgery consultation should be sought upon recognition of any iatrogenic dental injury.

In addition to dental and mucosal injuries, it is also important to be mindful of delicate soft-tissue structures in contact with the laryngoscope. Indeed, the highest award ($1,225,000) was returned for a case in which a GlideScope® caused a tongue laceration, which lead to swelling of the tongue, airway obstruction, cardiopulmonary arrest, anoxic brain injury, aspiration pneumonia, septic shock and death.

Fortunately, severe complications directly attributable to laryngoscopy were rare. When such events did occur, they were commonly due to unforeseen anatomical circumstances. For instance, one case involved displacement of dentures causing transmural pharynx perforation, internal bleeding, aspiration, lung collapse, shock and death. Another case involved exsanguination due to disruption of a known congenital vascular malformation. As a result of the aforementioned cases, improper history and physical examination was the second most commonly cited allegation among all cases. This highlights the need for continued focus on peri-operative evaluation that adheres to previously established American Society of Anesthesiologists guidelines and consensus statements (https://www.asahq.org/standards-and-guidelines).

Although the field of anaesthesiology was implicated in the majority of laryngoscope-associated malpractice allegations, the authors think that the results of this report are of greatest relevance to otolaryngologists. In contrast to laryngoscopy performed by anaesthesia providers, laryngoscopy performed by otolaryngologists is often prolonged in duration and holds more potential for complications. Otolaryngologists routinely perform in-office flexible laryngoscopy, indirect mirror laryngoscopy, laryngeal stroboscopy, direct laryngoscopy and suspension laryngoscopy. When considering the high combined prevalence of these procedures, the fact that no laryngoscope injury malpractice case tried to date has implicated an otolaryngologist suggests that laryngoscopy procedures are highly safe and low-risk when performed by an otolaryngologist–head and neck surgeon. This represents an important counselling point that may provide a source of reassurance to patients who are averse to laryngoscopy. While the procedure may be uncomfortable and fear-inducing in some cases, patients may find it reassuring to know that no patient has ever taken their otolaryngologist to court over complications arising from a procedure to visualise the larynx.

Although claims of dental injury are very common, formal lawsuits brought before the courts are exceedingly rare. While prior reports have documented thousands of such dental injury claims,^{Reference Christensen, Baekgaard and Rasmussen41,Reference Kotani, Inoue and Kawaguchi42} these tend to culminate in out-of-court settlements, arbitration or a summary judgement motion without a trial. The present study is unique in that it is the first to analyse lawsuit outcomes as determined by objective review via trial by jury in a federal or state courtroom. A recent comprehensive review of a French legal database identified just 24 lawsuits involving peri-operative dental injuries.^{Reference Diakonoff, De Rocquigny, Tourtier and Guigon43} This relatively low case number highlights the rarity of these trials and reaffirms our assertation that the present review successfully captures all available court records on laryngoscope-mediated dental injuries. This report, therefore, may represent a valuable resource for predicting future litigation outcomes and may be referenced by expert witnesses under oath as precedent to justify verdicts.

There are several limitations to this study. Included cases were limited to those attributable to laryngoscopy, but not the process of intubation, which can be an independent source of litigation with a distinct set of injuries. Moreover, the Westlaw database only contains jury verdict reports from federal or state courts, thereby failing to capture cases that do not progress to this stage. Verdict and settlement summaries are also highly heterogeneous sources of information with variable degrees of information disclosed, as deemed necessary by attorneys privy to the case. Finally, most malpractice litigation does not go to trial, with up to 85 per cent of cases being dismissed in a summary judgment or resolved with an out-of-court settlement.^{Reference Jena, Seabury, Lakdawalla and Chandra44,Reference Jena, Chandra, Lakdawalla and Seabury45} Because the cost of defending cases in court can be vastly disproportionate to the cost of dental repairs, many dental claims may be settled informally.^{Reference Givol, Gershtansky, Halamish-Shani, Taicher, Perel and Segal11} Taken together, the cases presented herein likely represent a small subset of all allegations surrounding laryngoscopy-associated injuries. Despite these limitations, our analysis provides important insights that can be used to better understand laryngoscopy litigation, inform educational endeavours and improve patient care.