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EN2.9 | ENT Surgical Consent Counselling — SDL Guide (Part 2)

Interpreting Patient Questions and Concerns

Good consent counselling is not a monologue — it is a dialogue that anticipates and responds to the patient's fears and values. The following are the most common patient concerns in ENT consent consultations, with suggested responses that balance honesty with reassurance.

'Will I be permanently deaf after the operation?' (mastoidectomy/tympanoplasty):
Response: 'Permanent profound hearing loss is rare but not impossible — it occurs in fewer than 1 in 100 operations. In most cases the hearing either stays the same or improves. The surgeon will take every precaution to protect the cochlea and the hearing nerve. However, since you already have hearing loss from the cholesteatoma, not having surgery carries a higher long-term risk of greater hearing loss as the cholesteatoma erodes the ossicles.'

'Will my face be paralysed?' (mastoidectomy):
Response: 'The facial nerve does run through the area of the operation, and its injury is the most feared complication. In experienced hands, permanent facial weakness occurs in fewer than 1 in 100 cases. Temporary weakness (a feeling of heaviness around the eye or mouth) may occur in a small number of patients and usually recovers fully. The surgeon always uses a facial nerve monitor during the operation to help avoid this complication.'

'Can the operation be done under local anaesthesia?' (for operations requiring GA):
Response: 'This particular operation is performed under general anaesthesia because it requires complete immobility and precise microsurgical technique — any movement during the operation near the facial nerve or the inner ear would be unsafe. The anaesthetist will speak with you separately about the general anaesthesia.'

'What if I refuse the operation?' (non-emergency situation):
Response: 'You have every right to refuse the operation, and we will respect that decision. However, I must be honest with you about the consequences of not having surgery: the cholesteatoma will continue to grow, erode bone, and increase the risk of serious complications including facial paralysis and infection spreading to the brain. These complications can be life-threatening. I would encourage you to take some time to think about it, discuss it with your family, and come back with any further questions. The decision is entirely yours.'

Applied Practice: Consent Simulation Scenarios

These simulation scenarios are designed to be practised in pairs — one student as the clinician delivering consent, one as the patient or parent. The assessor evaluates: structure (all six framework elements present), accuracy of risk disclosure (specific risks for the named operation), language (patient-appropriate, not jargon-heavy), response to questions (honest, empathetic, non-coercive), and documentation (consent form completed).

Simulation 1 — Mastoidectomy consent for CSOM with cholesteatoma:
Patient: 38-year-old male schoolteacher. Family present.
Key elements to cover: indication (cholesteatoma — progressive and dangerous if untreated), GA, risks (facial nerve: 'rare but important — must be disclosed explicitly'; sensorineural hearing loss; CSF leak; meningitis; dizziness; recurrence), benefits (removal of disease, prevention of complications), alternatives (none safe — cholesteatoma must be removed), post-operative care (wound care, ear drops, follow-up for second look if required).
Assessor alert: If the candidate does not mention facial nerve injury specifically, score as FAIL for risk disclosure.

Simulation 2 — Adenotonsillectomy consent (parent for a 7-year-old child):
Parent scenario: Mother of a 7-year-old with recurrent tonsillitis.
Key elements: GA risks (anaesthetic risk in children — refer to anaesthetist), haemorrhage (primary <24h; secondary day 5–10 — most important, parent must know to return immediately), throat pain (significant, 2 weeks, adequate analgesia), diet (soft foods, no hard or sharp foods), return to school (usually 2 weeks), voice change (uncommon, usually temporary).
Assessor alert: Secondary haemorrhage timing (day 5–10) is the most commonly missed element.

Simulation 3 — Tracheostomy consent (emergency/urgent setting):
Patient: 55-year-old male with laryngeal carcinoma causing progressive airway obstruction.
Key elements: Indication (life-threatening airway — explain that this is an urgent operation to secure the airway and is prioritised above absolute completeness of consent), risks (haemorrhage, tube displacement, subcutaneous emphysema, long-term voice impact, need for tube care), the fact that the tracheostomy may be temporary (if laryngeal treatment succeeds) or permanent (if total laryngectomy is planned), carer training for tube management.

Self-Assessment: Consent Competency Check

For each question, state the answer and the justification before reading the explanation.

Q1: For which ENT operation is facial nerve injury the most feared specific risk? What is its approximate incidence in experienced hands?
Answer: Mastoidectomy. Permanent facial palsy: approximately <1% in experienced hands with facial nerve monitoring. Temporary facial weakness more common. This must be explicitly disclosed — saying only 'there may be complications' without naming facial nerve is legally inadequate disclosure.

Q2: What are the two types of post-adenotonsillectomy haemorrhage, their timing, and which is most clinically significant?
Answer: Primary (within 24 hours — usually intraoperative haemostasis failure) and secondary (days 5–10 — slough separation; most common type; can be life-threatening; patients must be warned to return to hospital immediately if any bleeding). Secondary haemorrhage is the more clinically significant type because it occurs after discharge.

Q3: A patient refuses mastoidectomy. What are your obligations?
Answer: Respect the refusal — a competent adult has the absolute right to refuse treatment. Ensure the refusal is informed (document that risks of non-treatment were explained). Document the discussion. Keep the option of surgery open for future re-consideration. Do not coerce. Arrange follow-up to monitor for disease progression.

Operation	Most feared specific risk	Key post-operative instruction
Mastoidectomy	Facial nerve injury	Ear drops, wound care, second-look if needed
Tympanoplasty	Graft failure; SNHL (rare)	Dry ear, no nose blowing for 6 weeks
FESS	Orbital injury; CSF leak	Saline rinses; no nose blowing
Adenotonsillectomy	Secondary haemorrhage (day 5–10)	Return immediately if bleeding; soft diet
Tracheostomy	Tube displacement; haemorrhage	Inner cannula cleaning; humidification
Myringotomy/grommet	Persistent perforation	Keep ear dry; report discharge