Can appearance be deceiving? A Strange Case of Nasal AVM.

Abstract: Article 5 of Law No. 24/2017 regulates good clinical-assistance practices and guidelines aimed at improving the quality of healthcare services and enhancing patient protection. The aim of this study is to highlight the importance of the pre-existing condition of an individual who suffers harm from an unlawful act in order to achieve an accurate damage assessment. Specifically, when a pre-existing impairment affects the organ or system injured by the unlawful act, the principle of differential damage can be legitimately applied. This principle allows for the distinction between the damage directly caused by the unlawful act and the pre-existing condition, enabling a more precise evaluation of the harm suffered. A 40-year-old woman with a high-flow vascular malformation of the nasal apex, classified as Schobinger stage III/IV, was referred to our medical team. She underwent an arteriographic examination and an initial embolization attempt, followed by a second attempt, both performed without further diagnostic investigations and without any benefit. Seeking treatment elsewhere, she underwent subtotal resection of the nose, with the histological examination revealing "ulcerated and infiltrating angiosarcoma of the nasal skin and striated muscle." She was then subjected to radiotherapy and chemotherapy. The failure to perform a biopsy necessitated a more destructive resection from both an anatomical and functional standpoint, as it was performed approximately one year later. The patient's prior condition played a crucial role in the assessment of damage: optimal medical-surgical treatment would still have resulted in significant permanent post-operative outcomes, including the loss of a large part of the nose (Class III). However, the greater biological damage resulting from the inadequate conduct of the medical staff caused significant aesthetic harm, culminating in the complete loss of the nose (Class IV). Therefore, she was recognized as having a permanent differential biological damage of 15%, representing greater damage starting from 20% (an outcome she would have experienced even with the best treatment) up to 35% of current biological damage, which is considered stabilized.