56 year old male presents to ENT with a 3 week history of right sided sore throat and difficulty swallowing. On exam, right tonsil is 3+ and erythematous. Left tonsil is 2+. Neck exam reported as negative. Diagnosis of unilateral tonsillar hypertrophy made. Course of keflex and predisone prescribed with patient to provide an update. Patient has resolution of symptoms. However, patient returns for a follow-up appointment 9 months later when symptoms recur at which time tonsillectomy is recommended and performed which results in a Stage III HPV related squamous cell carcinoma of the right tonsil diagnosis. In providing history to subsequent treaters, i.e., oncology, patient references also having a right sided lump during initial evaluation.
Question: in the above scenario, does the standard of care require immediate tonsillectomy or is it reasonable for the practitioner to treat conservatively?
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Do you believe there might have been medical error?
Is the standard of care to perform an immediate tonsillectomy? No. A period a conservative therapy with antibiotics and follow-up after treatment is very reasonable. Based on the initial exam findings, the physician appeared concerned for an infectious process which is reasonable given the acuity of symptoms. The patient is also requested for an update - would need details on the follow-up plan as this is a potential breakdown point. There is also discrepancy between physician exam of a normal neck exam and the patient's report of the a neck lump, another potential breakdown point. I would be interested in the level of detail of discussion the physician had with the patient - was there concern for an underlying malignancy discussed and documented in the notes?
Do you believe there might have been causation (i.e. the medical error resulted in an injury)?
This patient initially present with throat pain and difficulty swallowing - antibiotic and steroid therapy helped with the symptoms and presumably the patient went on with his life (and without follow-up) until symptoms reoccured 9 months later, at which point an advanced staged cancer was diagnosed. Often patients lack symptoms until a tumor is large enough to bring on symptoms, hence delayed initial presentation. In this case, the opportunity to make an "early diagnosis" depends on the physician initial assessment and impression and patient compliance with follow-up instructions.
What makes you a good expert for this case?
fellowship trained head and neck surgical oncologist high volume academic cancer center practice
How often do you encounter cases similar to this one in your practice?
1-2 cases per month - either of my own or discussed in our tumor board.
Do you believe there might have been medical error?
The pt presented with a short history of throat symptoms. Exam as reported was consistent with inflammatory process. Treatment was appropriate at that time. The crucial issue is in this history provided: "unilateral tonsillar hypertrophy made. Course of keflex and predisone prescribed with patient to provide an update. Patient has resolution of symptoms." >how was update provided? >when was update provided? >what were followup recommendatons from MD? >how long did pt have recurrent symptoms before representing 9 months later? >what was his risk exposure in the intervening 9 months? >did the patinet self treat, self assess? The answers to these questions will determine the direction of this case.
Do you believe there might have been causation (i.e. the medical error resulted in an injury)?
As noted above, this case is dependent upon the update provided, the followup plans and the duration of symptoms pt had before returning to evaluation and care.
What makes you a good expert for this case?
38 years of experience and expertise in Otolaryngolgoy- Head and Neck Surgery in both academic and clinical settings in the USA and overseas, has given me a awareness of the Standard of Care,the reasonableness of clinical practice, and the patient -physician relationship. Years of case review for medical boards and medical liability entities.
How often do you encounter cases similar to this one in your practice?
Often enough to be fully versed and fully comfortable in an assessment of this clinical case.
Do you believe there might have been medical error?
While the index of suspicion should be raised in unilateral tonsillitis in the age group, immediate surgery is not the the standard of care. This is documented by the resolution of symptoms with the medication. The history of a neck mass at the initial presentation is difficult. If this is not documented by the physician at the initial presentation, then it maybe hard to say 9 months later it was there. This would also depend on the size of the neck mass and patient. If the patient is thin and there is a 5 cm neck mass, it was probably there 9 months prior at which point there would have been a medical error. If there is a 2-3 cm neck mass and the patient is obese, it would be difficult to examine this.
Do you believe there might have been causation (i.e. the medical error resulted in an injury)?
The only potential issue is the need for followup in this type of patient. Once again, unilateral tonsillitis in a 56 yo M is unusual. If this were an otolaryngologist, followup should be probably no later than 1 month to ensure the swelling has settled down after a presumed infection. If this were a PCP, then this is probably the standard of care. This all being said, there can be smaller, inferior pole tonsillar cancers which may be difficult to diagnose in the office, especially if the contralateral side is already 2+ at the time of presentation.
What makes you a good expert for this case?
I am an otolaryngologist/head and neck surgeon who participates in our system (Providence Health System/Oregon) head and neck cancer program and head and neck tumor board.
How often do you encounter cases similar to this one in your practice?
I operate and treat oropharyngeal cancer regularly with 3 patients requiring radical tonsillectomy and neck dissections over the past couple of months. Occasionally, I will see older patient with unilateral tonsillitis/peritonsillar abscess where we make sure there is followup 1 month afterwards to ensure there is not any concerning pathology.
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