On April 21, 2021, 63 y/o male patient reports recent history of left sided jaw swelling to his family practice ARNP. ARNP notes left lower mandible swelling on physical examination. ARNP orders US of head and neck which is completed on May 28, 2021.
The image was interpreted as showing a hypoechoic area measuring at least 4.1 cm at the area of concern at the left jaw; concerning for mass. The ARNP orders a CT Neck with and without IV contrast which is completed on 6/8/21.
The CT images (which are uploaded) were interpreted by the radiologist as showing asymmetry of masticator muscles, left larger than right; no mass in left mandible/submandibular region. However, I have had these images reviewed and have been informed that the images demonstrate an abnormal appearance to the left parotid gland possibly infiltrating the left masseter muscle.
Patient was next seen by ARNP on October 12, 2021 for a six month checkup. No mention made in the ARNP notes regarding the CT results. Patient did report frequent or severe headaches. Patient told to return to office as needed.
Patient returns on June 21, 2022 for complaints of neck pain. It is noted that the patient has left sided jaw swelling that has been occurring for approximately one year. The CT of June 2021 is referenced as showing no mass in neck or jaw. Patient reports the swelling has gotten worse. ARNP orders an MRI of the orbital, face and neck without contrast. Patient is further instructed to return to the office on September 8, 2022.
The MRI (pics uploaded) is completed on July 29, 2022. The radiologist interpreted the imaging as reflecting “mild enlargement/edema in the left masseter and lateral pterygoid muscles, not seen on the right side; no mass in the neck soft tissue; mild enlargement of the left submandibular gland; most likely inflammatory/odontogenic; no mass lesion; consider contrast enhanced maxillofacial CT”.
Patient was seen by ARNP on September 8, 2022. He reported that his swelling had gotten worse and was causing worsening asymmetry of his jaw, headaches and dizziness. ARNP assesses patient as having hypertrophy of left masseter muscle. Patient was instructed to return as needed. It is also noted that the patient was referred to an oral maxillofacial surgeon. However, there was no specific provider info given.
Patient, on his own, schedules an appointment with ENT on October 27, 2022. ENT examines patient and notes “mild asymmetry with increased soft tissue overlying the left parotid area; the skin over the left parotid area is firm with thickening of the dermis; submandibular glands-normal size, nontender to palpation”. His note does refer to the radiologist’s findings on the MRI completed in July. ENT’s assessment was “dermal fibrosis”. He recommended a dermatology evaluation.
Patient sees a dermatologist on November 7, 2022. Dermatologist notes a 4 cm “hard fixed tumor- patient has solid mass on left mandible extending to neck”. Dermatologist recommends patient be seen by general surgery or ENT.
On December 5, 2022, patient is seen by oral maxillofacial surgeon. The surgeon notes that patient has left sided facial pain and swelling “gradually over the last two years and now it is to the side of his neck and in the back of his neck”. Patient was unable to turn his neck without pain. He also was reporting trismus. He refers to the MRI of July as showing possible involvement of the parotid gland. He refers patient to another ENT.
Patient sees new ENT on December 6, 2022. He reports to the ENT that the lesion has grown and there is swelling in the mandibular region that had not been there before. ENT describes there to be at least 4 cm of rock hard abnormal tissue in the mandible on exam. He ordered a CT that day and it revealed there to be an abnormal process in the left parotid gland invading the masseter muscle and highly suspicious of malignancy. Left parotid fine-needle aspiration that day revealed a “hypocellular specimen with a few scattered single atypical epithelial cells, a neoplastic process could not be entirely excluded”.
A subsequent biopsy of the left parotid mass was completed on February 28, 2023 and demonstrated “high grade poorly differentiated carcinoma”. A CT of the neck completed on March 20, 2023 was interpreted as showing a “large infiltrative mass involving the left parotid gland and masticator space, extending into the submandibular space inferiorly, compatible with a poorly differentiated neoplasm; the inferior portion of the mass has mildly enlarged since the prior CT (12/6/22).
On March 31, 2023, patient underwent surgical resection. The procedure performed was described as follows:
1. Infratemporal preauricular approach to the parapharyngeal space/infratemporal fossa with mandibulotomy and parotidectomy
2. Excision of neoplastic lesion of the parapharyngeal space.
3. Radical resection of tumor of soft tissue neck/face, greater than 8 cm.
4. Left modified radical neck dissection, levels Ib through IV.
5. Transosteal reconstructive plating of the left mandibulotomy.
6. Repair of facial nerve, suing NeuraGen nerve tubule, from the main trunk of the facial nerve to the superior division.
7. Placement of maxillomandibular fixation for restoration of occlusion following mandibulotomy.
8. Excision of bone of the mandible for margin clearance around the left mandibular angle.
The mass was found to be extensively involving the mandible like a horseshoe wrapping around the ascending ramus and extensively involving the parapharyngeal space. The mass also involved the main trunk of the facial nerve.
Surgical pathology revealed “salivary duct carcinoma with rhabdoid features forms a parotid mass measuring 6.5 cm extending in the masseter muscle, sternocleidomastoid muscle and submandibular gland. One of six incorporated lymph nodes positive for metastatic carcinoma.” Tumor cells to be strongly positive for CK7, E-Cadherin, Cytokeratin AE1/3, GCDFP15.
My Questions based on the foregoing:
1. What would biopsy of area in 2021 have revealed (malignancy or precancerous)? Was surgical excision warranted at that time?
2. Would excision in 2021 be less extensive than what occurred in March 2023? If so, to what degree?
3. What would biopsy in July 2022 (when MRI was completed) have revealed?
4. Was surgical excision indicated in July 2022? If it had been done, would it have likely been the same surgery performed in March 2023? If not, how would it be different?
Files:
Q: I would be happy to opine on this case, as I deal with parotid masses almost daily. Kalivar will not let me respond since I am not yet 5 years training. I would be happy to consult with you independent of Kalivar if you wish: anthony.ferrara@bassett.org
A: —
Do you believe there might have been medical error?
Pt presented with L perimandible findings. Exam noted does not indicate angle of mandible? UTZ noted mass/abnormal. CT 6/2021 image quality poor but abnormality noted. Radiology report as given in error. 4 MOS pass and return exam not included, CT 6/21 not discussed. The next events illustrate missed dx by several providers. Dermotologist Nov, 2023 is hero iin this case. From this point onward, timing of care by quality physicians accelerates.
Do you believe there might have been causation (i.e. the medical error resulted in an injury)?
For the reasons noted above, the delayed/missed diagnosis went on for quite some time with enlargement of mass into adjacent structures resulting in increase magnitude of surgical resection. There is no mentioin of pre-surgery VII FACIAL nerve function.
What makes you a good expert for this case?
44 years of experience in diagnosis and management of many head and neck masses, both benign and malignant, in both academic and clinical settings. Faculty, past Head and Neck Service Mass Eye Ear
How often do you encounter cases similar to this one in your practice?
was regular occurence to diagnosis parotid and skull masses
Do you believe there might have been medical error?
This case seems to be very concerning for a significant delay in diagnosis in my opinion. I was surprised by the one month delay in the beginning (from 4/21 to 5/28) in getting the ultrasound done, little lone the more than 1 1/2 years more it would take for a repeat CT and FNA getting done by the 2nd ENT doctor to finally arrive at some diagnosis. There seem to be missed opportunities and perhaps failures to meet the standard of care at several steps - two month delay in getting first CT scan (preferred over ultrasound) and then no follow-up of results; MRI on 7/29/24 read as "no mass lesion"; ARNP recommending follow-up as needed on 9/8/22; ENT concluding "dermal fibrosis" on 10/27/22. The Dermatologist and ENT after this point seemed to act appropriately and more timely and the ultimate surgical treatment sounds appropriate for the situation at that time. 1. What would biopsy of area in 2021 have revealed (malignancy or precancerous)? Was surgical excision warranted at that time? - This is hard to know, but I believe that it is likely that an FNA or tissue biopsy at that time would have been concerning for malignancy. It's possible it may have been better differentiated at that time and perhaps a less aggressive lesion. There are some parotid lesions that can start out benign with potential for malignant transformation such as pleomorphic adenoma - a head & neck pathologist would be able to assess the likelihood of this scenario. 2. Would excision in 2021 be less extensive than what occurred in March 2023? If so, to what degree? It does seem likely, but again hard to know for sure. - If caught sooner, perhaps the mandibular resection might not have been needed and the facial nerve spared. 3. What would biopsy in July 2022 (when MRI was completed) have revealed? - Difficult situation as the MRI indicated "no mass". However, I think it's very likely that a biopsy would have revealed the concern for malignancy. 4. Was surgical excision indicated in July 2022? If it had been done, would it have likely been the same surgery performed in March 2023? If not, how would it be different? - As mentioned before it seems likely that, if caught sooner, perhaps the mandibular resection might not have been needed and the facial nerve spared. Also, long term outcome / disease-free survival would likely have been higher.
Do you believe there might have been causation (i.e. the medical error resulted in an injury)?
This case seems to be very concerning for a significant delay in diagnosis in my opinion. I was surprised by the one month delay in the beginning (from 4/21 to 5/28) in getting the ultrasound done, little lone the more than 1 1/2 years more it would take for a repeat CT and FNA getting done by the 2nd ENT doctor to finally arrive at some diagnosis. There seem to be missed opportunities and perhaps failures to meet the standard of care at several steps - two month delay in getting first CT scan (preferred over ultrasound) and then no follow-up of results; MRI on 7/29/24 read as "no mass lesion"; ARNP recommending follow-up as needed on 9/8/22; ENT concluding "dermal fibrosis" on 10/27/22. The Dermatologist and ENT after this point seemed to act appropriately and more timely and the ultimate surgical treatment sounds appropriate for the situation at that time.
What makes you a good expert for this case?
I am a board certified Otolaryngologist-Head & Neck Surgeon with 21+ years of experience. I started my career in Academic medicine, but am now in general private practice while still maintaining my University affiliation as a Professor. I have a lot of experience in diagnosis, work-up, and management of similar issues including parotid tumors. I have provided case reviewed in over 25 cases, primarily for plaintiffs, and participated in sworn deposition testimony in 2.
How often do you encounter cases similar to this one in your practice?
I am involved in evaluating, working-up, and diagnosing lesions of this type, including parotid tumors several times a week and have been doing so for around 21 years since completing my fellowship and Johns Hopkins Hospital in Baltimore, MD. Please let me know if I can provide further information or be of any help in a more detailed review of this case.
Do you believe there might have been medical error?
The CT and MRI were both ordered without contrast. Despite this (should have been with contrast), there are lesions visible on these studies that were missed. Nearly all providers refer to the reports of these imaging studies - did they actually view them? Most likely not. The patient made multiple repeat visits to physicians with increasing complaints. This all has resulted in a delayed diagnosis, which has likely led to disease progression requiring a more extensive surgical resection. This diagnosis appears to have been significantly delayed while disease progressed. 1. What would biopsy of area in 2021 have revealed (malignancy or precancerous)? Was surgical excision warranted at that time? Hard to say with certainty, but likely yes. 2. Would excision in 2021 be less extensive than what occurred in March 2023? If so, to what degree? Based on the imaging available, it is likely that surgery would not have been as extensive. I cannot say to what degree less extensive. 3. What would biopsy in July 2022 (when MRI was completed) have revealed? Again not possible to say with certainty, but given that there was a mass visible, it is likely that it could have been diagnosed by biopsy at that time. 4. Was surgical excision indicated in July 2022? If it had been done, would it have likely been the same surgery performed in March 2023? If not, how would it be different? Had a biopsy been done July 2022 and been positive for malignancy, then yes a surgical excision would have been indicated. While not possible to say with certainty, it is likely that it would have been less extensive.
Do you believe there might have been causation (i.e. the medical error resulted in an injury)?
The delay likely led to growing neoplasm and the need for more extensive resection and surgery. The diagnosis was delayed by improper imaging, incorrect interpretation of that imaging, and subsequent delays in correct imaging, biopsy, diagnosis and management.
What makes you a good expert for this case?
I am a head and neck surgeon, which means I have completed a residency in Otolaryngology - Head and Neck Surgery.
How often do you encounter cases similar to this one in your practice?
Infrequently, as I take care of pediatric age patients more often than the elderly. For greater expertise surrounding the actual surgical management, you may want to find a fellowship trained head and neck cancer surgeon.
Do you believe there might have been medical error?
Fairly obvious radiographic evidence of a mass despite the interpretation from the radiologist on the CT from 2021 as well as the MRI from July, 2022. If this was the same radiologist or radiology group employing some group think, this would be problematic. Difficult for the primary care provider to provide additional recommendations if the radiologist is not describing a mass or recommendations for further investigation, despite more advanced imaging.
Do you believe there might have been causation (i.e. the medical error resulted in an injury)?
Medical error may have provided a delay in diagnosis which resulted in a more extensive surgery with probable increase in morbidity with probable cosmetic deformity given the extent of the surgery as well as sacrifice of the facial nerve. However, at the initial time of the patient's complaint with initial imaging of the ultrasound in 2021, this most likely represented malignancy where there was not necessarily a change from a benign/premalignant condition to a malignant condition. At a 4 cm tumor as seen by the ultrasound, the facial nerve very possibly would have been involved. However, given the pathology, the nerve very possibly would have needed to be sacrificed for oncologic reasons in 2021 if surgery had proceeded at that time. It is possible that the mandible would not have needed to be involved. However, this is some conjecture given the lack of complete records to review.
What makes you a good expert for this case?
I am an otolaryngology/ head and neck surgeon who performs 5 to 10 parotid surgeries a month. I'm on the teaching /Clinical faculty for the local academic medical Center for the surgery residency. In addition, I serve as a medico/legal consultant in otolaryngology for the state medical board.
How often do you encounter cases similar to this one in your practice?
Several times a year. I am referred patient from around the state for similar issues.
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