Bechara Y. Ghorayeb, MD, PA
Otolaryngology-Head & Neck Surgery                                                    Phone: 713 464 2614
1140 Business Center Drive, Suite 560
Houston, TX 77055                                                                                                              www.ghorayeb.com


Intranasal Ethmoidectomy
Informed Consent
Intranasal ethmoidectomy is performed intra-nasally and is recommended only after it has been determined that medical management has been unsuccessful. Surgery, medical management, and failure to intervene all have risks, including as a group, postoperative bleeding, orbital complications (visual impairment), intracranial extension (brain damage or infection), leakage of cerebrospinal fluid, persistent or recurrent nasal obstruction due to failure to manage polyps and recurrent nasal or sinus infections.

Radiographs and endoscopic findings considered in conjunction with the patients clinical status - following medical evaluation and therapy - will identify the appropriate sinuses to treat.


I/We have been given an opportunity to ask questions about my condition, alternative forms of treatment, risks of nontreatment, the procedures to be used, and the risks and hazards involved, and I/we have sufficient information to give this informed consent. I/We certify this form has been fully explained to me/us, and I/we understand its contents. I/We understand every effort will be made to provide a positive outcome, but there are no guarantees.


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Patient / Legal Guardian
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Witness

Date:___________________________          Time:___________________________


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