[From the expert's office. Atlanto-axial subluxation with spastic torticollis after adenoid-ectomy resp. tonsillectomy in rose position - malpractice of the surgeon or the anaesthesiologist?].

INTRODUCTION

An arbitration board had to decide whether or not there had been a causal connection between an adenoidectomy or resp. a tonsillectomy and an atlanto-axial dislocation and if so whether this was to be considered a case of malpractice.

CASE HISTORIES: In two young girls aged 6 and 11 a torticollis had developed 3 resp. 4 days after the operation. In both cases the proper diagnosis was made only after extensive diagnostic procedures including radiology, neurology, neurosurgery and orthopaedics. The findings are presented in detail. In both cases there was a rotary subluxation between cervical vertebrae C1 and C2 due to a retropharyngeal inflammation. Normal function could only be achieved by surgical reposition and the application of a fixateur externe for quite a long period.

DISCUSSION: A non-traumatic torticollis is a very rare complication of an adenoidectomy or tonsillectomy, two of the most common surgical interventions in oto-rhino-laryngology. It is known as Grisel's disease because Grisel in 1930 was the first to describe this sequel following nasopharyngitis and tonsillectomy. A detailed review of the literature and a discussion of the underlying pathology is presented. Predisposing factors might be additional local anaesthesia and electro-haemostatis.

CONCLUSIONS

: In both cases evidence for malpractice could not be found, neither concerning the intervention itself nor the handling in the postoperative period. The latency of several days between the operation and the manifestation of the torticollis is regarded as proof that intraoperatively there was no malpractice. In cases where the torticollis is present immediately after the intervention, as has been reported in the literature, a traumatic luxation during the operation or positioning of the patient may be taken into consideration. Because of the extreme rareness of the complication it does not seem compulsory to make it part of the preoperative informed consent.