Consenting ENT Patients

Author: Mr Vik Veer MBBS(Lond) MRCS(Eng) DoHNS(Eng) — December 2007. Updated 2025.

Introduction

In this section we go through the information you need to give patients when consenting them for common ENT operations. The legal and ethical standard for surgical consent in the UK changed significantly following the Supreme Court judgment in Montgomery v Lanarkshire Health Board [2015]. This ruling replaced the historic Bolam standard for consent with a patient-centred test: doctors must now disclose any risk that a reasonable patient in the same position would consider material — not merely risks that a responsible body of medical opinion would think it necessary to disclose.

In practice this means you must discuss all complications that are either common (however minor) or serious (however rare), as well as reasonable alternative treatments. The GMC's updated consent guidance (2020) reinforces this approach.

Tonsillectomy

What the operation involves

Tonsillectomy is the surgical removal of both palatine tonsils under general anaesthesia. The tonsils are dissected from their fossae either by cold steel dissection, bipolar diathermy, coblation, or laser. The operation typically takes 8–15 minutes.

Indications

Recurrent acute tonsillitis (Paradise criteria: 7 or more episodes in one year, or 5 per year for two years, or 3 per year for three years), peritonsillar abscess (quinsy), obstructive sleep apnoea due to tonsillar hypertrophy, suspected tonsillar malignancy.

Consent discussion — complications to cover

Common complications:

• Pain: The wound left after tonsillectomy is like having two large ulcers in the throat and is significantly painful for 7–14 days. Some departments avoid NSAIDs post-operatively because of concerns about platelet function and secondary haemorrhage risk — regular paracetamol is usually prescribed.
• White slough and apparent infection: Patients will see a white membrane forming in the tonsillar fossae after surgery. This is normal — it is how the throat heals. Explain: "You will see a white fur collecting where the tonsils used to be. This is normal and is how the throat heals. However, if this becomes infected the pain can get much worse and you may need antibiotics."
• Secondary haemorrhage (approximately 1–3%): This is the most important complication to cover clearly. Bleeding typically occurs 5–10 days post-operatively as the slough separates. Instruct the patient: "If you cough up or spit out any blood — particularly 5 to 10 days after the operation — you must come directly to A&E. Do not wait for your GP or phone NHS 111 first. Even a small amount of blood can be an early warning of a more serious bleed, which may require an emergency operation. Call an ambulance if necessary." Haemorrhage occurs in approximately 1–3% of cases and can occasionally be life-threatening.
• Dental damage: The mouth is held open with a gag for 8–15 minutes. There is a risk of damaging teeth, particularly loose teeth in children, or caps and crowns in adults. Consent for this in all patients.
• Jaw ache and dislocation: Prolonged mouth opening causes jaw ache, which is common. Jaw dislocation is rare but does occur. Explain that if this happens it is reduced easily and causes no long-term harm in most cases.
• Diathermy burns: Burns to the lips, tongue, or teeth can occur from the diathermy device. These normally heal quickly.
• Neck injury: In young children, and especially those with Down syndrome, the neck extension required to view the tonsils can strain the atlanto-axial joint. This should be specifically mentioned in high-risk groups.

Dietary advice to share: "To help the wound heal and to reduce the risk of infection and bleeding, eat as much rough food as you can manage — toast, chicken, crackers. Ice cream and jelly sound appealing but they slip past without cleaning the wound. Rough food scrapes the white fur away and helps prevent infection. Eating well also helps the throat muscles stay mobile and reduces pain in the long run."

Recovery: Patients should take 2 weeks off work or school and minimise contact with other people to reduce the risk of acquiring an infection during the healing period.

Adenoidectomy

What the operation involves

The adenoids are a pad of lymphoid tissue in the post-nasal space (the space behind the nose and above the soft palate). They cannot be seen without a mirror or a camera. Under general anaesthesia, the adenoids are removed through the mouth, either by curettage (scraping) or by diathermy/coblation. A picture or diagram is very helpful to explain this to patients and parents because the anatomy is not intuitive. The operation takes approximately 10 minutes.

Indications

Persistent nasal obstruction due to adenoid hypertrophy, recurrent otitis media with effusion (glue ear) in children, chronic sinusitis in children, obstructive sleep apnoea.

Consent discussion — complications to cover

Common complications:

• Pain: Less severe than tonsillectomy but still significant. Again, NSAIDs may not be prescribed for the same reasons.
• Infection: Patients should take 2 weeks off school and avoid social contact to reduce infection risk.
• Haemorrhage: As with tonsillectomy, any post-operative bleeding requires direct attendance at A&E with ENT facilities. No waiting for GPs or helplines.

Specific complication — velopharyngeal incompetence (VPI) and hypernasal speech:

This is an important complication unique to adenoidectomy. The soft palate and posterior pharyngeal wall normally close together to separate the oral and nasal cavities during speech and swallowing. In some children — particularly those with a submucous cleft palate (not always clinically obvious) — the adenoids are actually compensating for this inadequate closure. Removing them can unmask the incompetence. Explain: "Sometimes when a large adenoid is removed, the tissue around it doesn't completely fill the space left behind. This can lead to food or water accidentally going up into the back of the nose, and some children find they speak with an excessively nasal quality. In most cases this resolves on its own, but occasionally it persists and requires further assessment."

All other complications are as for tonsillectomy (dental damage, jaw dislocation, diathermy burns, neck injury).

Myringotomy and Insertion of Grommets

What the operation involves

A grommet (also called a ventilation tube or tympanostomy tube) is a tiny flanged tube inserted into the tympanic membrane (eardrum) to ventilate the middle ear. A myringotomy (a small incision in the eardrum) is first made, the middle ear fluid is suctioned out, and the grommet is placed in the incision. The operation takes 2–5 minutes per ear under general anaesthesia in children, though it can be done under local anaesthesia in cooperative adults.

Indications

Persistent otitis media with effusion (glue ear) causing significant hearing loss and affecting speech, language, or educational development in children; recurrent acute otitis media; chronic middle ear effusion in adults.

Consent discussion — complications to cover

Use a diagram showing the external ear canal, tympanic membrane, and middle ear. Explain that the fluid in the middle ear prevents the eardrum from vibrating freely, which reduces hearing. The grommet keeps a small hole in the eardrum open, draining any further fluid as it accumulates. Grommets typically extrude spontaneously (fall out) in 9–12 months.

• Haemorrhage and pain: Minimal. Bleeding and discomfort after grommet insertion are usually self-limiting within a few hours.
• Infection (otorrhoea): This is perhaps the most important complication to explain to parents. "We are creating an artificial opening between the outside world and the normally sterile middle ear. This means your child is more likely to get ear infections — you may see fluid draining from the ear. To minimise this, no water should enter the ear at all. Every shower and bath, plug the ear with cotton wool mixed with Vaseline. Swimming requires a head band or ear putty. The infections that do occur will often not be as painful as before, because the pus can drain through the tube rather than building up pressure."
• Non-extrusion (retained grommet): Rarely, the grommet does not fall out naturally. If it is still present after 2–3 years it may need to be removed under a brief general anaesthetic.
• Persistent perforation: Very occasionally the hole in the eardrum does not heal after the grommet falls out, leaving a permanent perforation. This may require a myringoplasty operation to repair it.
• Scarring (tympanosclerosis): Repeated instrumentation of the eardrum causes calcium deposits to form within the drum. This can make it slightly stiffer but rarely affects hearing significantly.
• Hearing loss: Any operation on the ear carries a small risk of hearing deterioration. This risk is very small for grommet insertion but cannot be entirely excluded.

Why accept the infection risk? "We accept the increased infection risk because children's hearing is critical during their early years of language acquisition. A year of poor hearing at age 3 or 4 can set a child behind their peers at school, and it can be difficult to catch up. That is why we believe the benefits of improved hearing outweigh the relatively manageable risk of ear infections."

Ear Operations (Mastoidectomy, Tympanoplasty, Myringoplasty, Ossiculoplasty)

General consent points for all ear operations

The following complications apply to all major ear operations and should be discussed:

• Haemorrhage
• Infection
• Pain
• Scarring (post-auricular scar for mastoid approaches)
• Hearing loss — sensorineural or conductive — any ear operation carries a risk of worsening hearing
• Ear packing — the ear will be packed post-operatively and this will temporarily reduce hearing in the operated ear
• Recurrence — particularly relevant for cholesteatoma, which has a significant recurrence rate
• Vertigo and dizziness — inner ear structures may be disturbed during surgery
• Tinnitus — may worsen or arise after surgery
• Facial nerve injury — the facial nerve runs through the middle ear and mastoid. Damage can cause weakness or paralysis of the face on the same side. This is a rare but serious complication that must always be mentioned.
• Chorda tympani injury — the chorda tympani nerve runs through the middle ear and carries taste sensation from the front two-thirds of the tongue. Damage causes a metallic or altered taste on one side. It often recovers but can be permanent.

For tympanoplasty or myringoplasty, additionally advise: no flying for at least 2 months post-operatively; avoid nose-blowing; avoid submerging the head underwater.

Functional Endoscopic Sinus Surgery (FESS) ± Polypectomy

What the operation involves

FESS uses small endoscopes and instruments passed through the nostrils (no external cuts) to open the natural drainage pathways of the sinuses. Where nasal polyps are present, these are removed. The operation typically takes 30–45 minutes. It is performed under general anaesthesia and is often combined with septoplasty when the nasal septum is obstructing access.

Indications

Chronic rhinosinusitis not controlled by medical treatment, nasal polyposis, fungal sinusitis, orbital and intracranial complications of sinusitis, mucocoele drainage.

Consent discussion — complications to cover

• Haemorrhage: Some bleeding after FESS is universal. "There will always be a little bleeding from the nose after this operation. Sometimes there is more than we can manage before waking you up, and we will place a small tampon in your nose to stem the flow. This will be removed a few hours later before you go home."
• Infection: "The chance of infection is quite low, especially if you use the salt water nasal douches provided after the operation. If there are any problems we can prescribe antibiotics."
• Recurrence of polyps (approximately 50%): A very important consent point. "This operation is not designed to cure your polyps. It is designed to open the drainage channels so that your nasal steroid spray can reach the areas where polyps form and prevent them returning. You will still need nasal sprays after this operation indefinitely. If you stop using them, polyps will very likely come back."
• Orbital haematoma and visual loss: A serious but rare complication. The sinuses sit between the eyes and adjacent to the orbit. "In rare cases we can damage a thin bone near your eye that can lead to a black eye (orbital haematoma). On its own this is not usually a permanent problem, but there are rare cases in the world literature of permanent visual damage after FESS. This is extremely uncommon but I am obliged to tell you about it."
• CSF leak and meningitis: "We are working very close to the base of the brain. There is a small risk of damaging the thin bone separating the sinuses from the brain, allowing the fluid surrounding the brain to drip through the nose. In itself this is not catastrophic, but it does create a route for infection to reach the brain, potentially causing meningitis. Again, this is very rare but I cannot guarantee it will not happen."

Septoplasty / Rhinoplasty

What the operation involves

Septoplasty corrects a deviated nasal septum (the central cartilaginous and bony partition dividing the two sides of the nose) to improve nasal airflow. All work is done through the nostrils with no external cuts. Rhinoplasty modifies the external shape of the nose and may be combined with septoplasty (septorhinoplasty). The operation takes 20–45 minutes.

Consent discussion — complications to cover

• Haemorrhage: As for FESS — some bleeding is universal and a nasal pack may be required post-operatively.
• Infection: Managed with salt water douches and antibiotics if needed.
• Recurrence / less than perfect result: For rhinoplasty — "We cannot guarantee a perfect cosmetic result. The nose changes slightly as swelling resolves over 12–18 months, and the final outcome is not always exactly as planned. Revision surgery is sometimes needed."
• Septal perforation: A hole in the nasal septum can occur if both sides of the mucosa are damaged in the same area. This can cause a whistling sound during breathing, crusting, and nosebleeds. "We are removing cartilage and bone from the middle part of your nose. If a small hole forms in the partition between the two sides of the nose, this can occasionally cause crusting and a whistling noise. Most are small and cause no major symptoms, but larger perforations can sometimes require a further operation to repair."
• Nasal tip or supratip depression: Removing too much cartilaginous support can cause the tip or the area above the tip to dip over time. This is rare after a primary septoplasty but is more likely after revision procedures.
• Saddle nose deformity: Extreme loss of septal support — classically seen in boxers after repeated trauma — causes collapse of the nasal bridge. This is very unlikely after a primary septoplasty.

Panendoscopy ± Biopsy

What the operation involves

Panendoscopy involves examining the entire upper aerodigestive tract under general anaesthesia using rigid telescopes and endoscopes — typically including nasendoscopy (nose and post-nasal space), pharyngoscopy (throat and base of tongue), direct laryngoscopy (voice box), oesophagoscopy (gullet), and sometimes bronchoscopy (airways). Biopsies are taken from suspicious areas. The procedure usually takes 5–30 minutes depending on what is found.

Indications

Staging and biopsy of known head and neck tumours; exclusion of a synchronous primary tumour; identification of an unknown primary in a patient with cervical lymphadenopathy; removal of oesophageal foreign bodies.

Consent discussion — complications to cover

• Haemorrhage: "There is a risk of scratching the lining of the throat causing some bleeding, usually just a few specks. If we take a biopsy there is more chance of some bleeding from that site."
• Infection: "With any scratching or biopsy there is a small risk of infection — like a sore throat — which can be treated with antibiotics."
• Dental damage: "There is a chance of damaging your teeth — especially caps or crowns — as we use a rigid scope and a mouth guard. If we damage them we will arrange for them to be fixed."
• Jaw pain and dislocation: The mouth must be held open during the procedure. Jaw ache is common; dislocation is rare.
• Perforation of the aerodigestive tract: This is the most serious specific complication. "Very rarely there is a chance that we could puncture any part of the throat, gullet, or airways during this procedure. If this were to happen it would require immediate surgical repair. In the worst case scenario this could mean an exploration of the chest to repair a perforation of the oesophagus."