PC is a 63 yo M who reported to his primary care doctor for the first time in April of 2021 that he was having some discomfort and asymmetry in his left jaw. Also noted throughout his primary care records, PC complains of frequent migraines and generalized headaches. The primary care notated asymmetry and swelling and ordered a CT for May of 21.
For some reason an ultrasound was performed on May 25 instead (I don’t have any record of a change in order, etc), however it showed a 4.1 cm hypoechoic area of concern for a mass and further evaluation of a CT scan with contrast was recommended.
The CT scan that was scheduled for June 18th 2021 was ordered by APRN with his primary care office. The impression with this CT shows no mass in the neck and states asymmetry of the left-sided jaw muscle group.
PC had difficulty getting any further follow-up until October of 2021. There's nothing in this visit about his jaw swelling.
PC does not see his primary care again until June of 2022. It is noted in the chart about one year of jaw swelling which is getting worse. There is notation about a dental exam that was done in May, in which a X-rays (maybe CT?) were taken and was told that there was no bone involvement, ref back to PMD. I do not have any records of the radiology or these visits. Primary reports that the pain and asymmetry of the jaw have worsened. I do not see a specific jaw assessment made during this visit, however an MRI was scheduled. MRI was performed on July 29th. Impression of this MRI reports mild enlargement in edema in the left jaw muscle group and enlargement in edema of the left submandibular gland. States most likely inflammatory or odontogenic. no mass lesion or drainable collection. Also told to follow up with a CT scan with contrast.
PC has another follow-up appointment in September of 2022 in which he's given the MRI results however, still complaining of worsening edema, headaches and dizziness. Once again I see no specific jaw assessment done however is referred to an oral and maxillofacial surgeon. Pain is being controlled with PO Dilaudid.
12/6/22 PC has an appointment with ENT, head/neck surgeon who does a thorough exam stating that PC had quite large abnormal feeling tissue left mandible and nerve weakness. This provider is very concerned about the situation and sends him for an immediate CT scan WITH CONTRAST the same day. That reveals in asymmetric size, density and enhancement of the left paranoid gland and a mass that extends inferiorly and deep into the left mandibular angle which is concerning for neoplasm. There is also a rounded soft tissue mass in the left supraclavicular space measuring 2.6 cm. PC is sent for an immediate needle aspiration of the left parotid gland however unable to get definitive results due to low cellularity. However it stated that a neoplastic process could not be entirely excluded.
The biopsy of the supraclavicular mass was a vascular neoplasm with Epithelialoid Hemangioendothelioma.
In February of 2023, PC saw surgeon, in which he was told that he would need extensive surgery to remove cancer and reconstruct his jaw in late March of 2023, PC has a mandibularectomy and parotidectomy with lesion removal and resection of the left-sided neck and face. Also had reconstructing of the left mandible and facial nerve repair.
Radiation therapy, surgical sites infections since.
Attached you will see the radiology imaging in question. We'll be looking for a maxillofacial/oral surgeon who would treat a mass of this type, despite its rarity. I redacted the pieces name but you should be able to see the date of the exams.
What kind of different outcome would we have had if this was found much earlier?
Was this easily detectable and should have any provider acted with more urgency based on the symptoms and presentation?
Thank you in advance.
Files:
No questions yet!
Do you believe there might have been medical error?
1) Once the primary medical doctor saw an unexplained asymmetry and ultrasound saw a mass, patient should have been referred immediately to a head and neck, ENT or oral surgeon. The primary physician would not be qualified to diagnose and treat whatever the diagnosis. anyway. After the CT on 6/18 /21, a mass is definitely noted and again should have referred to a specialist. 2) The radiology report should have said further evaluation including biopsy was needed 3) This mass should have been palpable and if someone asked to look at photograph of the patient a year or 2 earlier, you could see the expansion. 4) On medical visit of 10/21 there is no mention of swelling but obviously still there. 5) The primary care physician now orders an MRI on 7/29/22 instead of again not referring to a specialist 6) Finally in 9/22 referred to an oral surgeon and then saw an ENT who biopsied both masses. Summary- The primary care physician failed to refer in timely manor on several occasions. The radiology reports did not adequately describe and raise some concern for further evaluation
Do you believe there might have been causation (i.e. the medical error resulted in an injury)?
The long delay in final treatment (1.5 years) probably caused a more extensive surgery . If was treated a year earlier, the mandibulectomy may have been spared. The parotidectomy would have been done anyway.
What makes you a good expert for this case?
Even though, I don't do surgery on head and neck cancer cases, I have been trained on diagnosis and have seen parotid tumors during training, practice and head and neck tumor conferences
How often do you encounter cases similar to this one in your practice?
once a year for parotid tumors but several oral cancers/year
Do you believe there might have been medical error?
The lesion was noticeable even on initial imaging. This would have warranted referral to a surgeon or interventional radiologist who would have been comfortable completing a biopsy of the region.
Do you believe there might have been causation (i.e. the medical error resulted in an injury)?
Delayed diagnosis likely allowed for disease progression.
What makes you a good expert for this case?
I am happy to provide my opinion but I have not performed this type of surgery since residency. My area of expertise is more with the hard tissue structures of the Maxillofacial skeleton.
How often do you encounter cases similar to this one in your practice?
This is a very rare tumor but I have treated many tumors of the maxillofacial region.
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