Case involves a delay in diagnosing & treating an aggressive squamous cell carcinoma of the parotid gland resulting in a right radical parotidectomy with facial nerve sacrifice, right auriculectomy, and a right neck dissection involving the removal of the right ear with hearing loss.
We have an expert dermatologist who has established a deviation in the SOC by the dermatologist in treating client's squamous cell carcinoma. The expert noted that there was a significant delay in surgical resection after cancer was identified so we require an expert on causation to determine whether the delay changed client's outcome.
TIMELINE:
On November 18, 2024, client presented to dermatologist's office with a right preauricular mass. A 4 mm punch biopsy was done.
On November 26, 2024, the punch biopsy results were reported: RIGHT PREAURICULAR - ACTINIC KERATOSIS ASSOCIATED WITH MILD DERMAL FIBROSIS, CHRONIC FOLLICULITIS and CHRONIC PERIFOLLICULITIS.
On 12/31, client returned with a bigger mass. The dermatologist didn't have time to biopsy it so he gave the client a steroid injection.
On January 20, 2025, client is admitted to TGH for HTN & a right preauricular mass. He states that the mass was biopsied by dermatologist & was negative for malignancy. Client states it’s difficult to eat because it’s pressing on his jaw. On 1/20, CT done & 2.2 x 1.4 x 1.8 cm mass found abutting the right EAC. On 1/23, biopsy confirmed squamous cell carcinoma with basaloid features.
Discharged on 1/26/25 with plan for right parotidectomy with free flap reconstruction at next availability. Need cardiology and nephrology clearance. Surgery wasn’t done until 2/17. With a squamous cell carcinoma at this site & prior melanoma & perineural invasion, our expert believes he should have been operated on immediately.
Files:
Q: 2024, client presented to dermatologist's office with a right preauricular mass. A 4 mm punch biopsy was done. On November 26, 2024, the punch biopsy results were reported: RIGHT PREAURICULAR - ACTINIC KERATOSIS ASSOCIATED WITH MILD DERMAL FIBROSIS,
A: —
Q: 2024, client presented to dermatologist's office with a right preauricular mass. A 4 mm punch biopsy was done. On November 26, 2024, the punch biopsy results were reported: RIGHT PREAURICULAR - ACTINIC KERATOSIS ASSOCIATED WITH MILD DERMAL FIBROSIS,
A: —
Q: 2024, client presented to dermatologist's office with a right preauricular mass. A 4 mm punch biopsy was done. On November 26, 2024, the punch biopsy results were reported: RIGHT PREAURICULAR - ACTINIC KERATOSIS ASSOCIATED WITH MILD DERMAL FIBROSIS,
A: —
Q: excuse text separate so question is whether this was a cutaneous finding exclusively meaning on the skin or is this a subcutaneous mass that was biopsied as described because that's a huge difference in the approach to the mass and it's pathology?
A: Subcutaneous nodule on the right superior preauricular cheek.
Q: where was the patient's melanoma that was described in his history, what was it stage, what was this metastatic status, how long ago was this?
A: Not sure. Dermatologist notes indicate hx significant for melanoma - unspecified, squamous cell skin CA
Q: how was the January 23 biopsy performed? Was this a open biopsy performed surgically or a CT guided radiologic needle aspirate biopsy?
A: USF OTOLARYNGOLOGY - HEAD & NECK SURGERY Procedure Note Procedure: Bedside 3 2mm Punch biopsies of right facial lesion
Q: it's reported that the patient was discharged with a need for cardiology and renal medicine surgical clearance. When were these obtained and was the patient cleared for surgery which appears to be the case?
A: Cleared by renal by 1/24/25. Cardiology also cleared him but I believe it was after d/c..
Do you believe there might have been medical error?
The preauricular mass first thing by the dermatologist was most likely an intraparotid node and would not have been properly biopsied with a punch biopsy. Hard to know for sure without seeing a picture but the subsequent CT scan showing a parotid mass in the same region points to that at the likely scenario. After that it is unlikely that a two week interval between being seen by the surgeon and having the operation had much material effect on the eventual outcome.
Do you believe there might have been causation (i.e. the medical error resulted in an injury)?
The initial biopsy being negative led to delay in treatment and disease progression.
What makes you a good expert for this case?
I'm a head and neck oncologic surgeon.
How often do you encounter cases similar to this one in your practice?
Several times a year. I deal with several cutaneous malignancies as well as metastatic lesions in the parotid as well as primary parotid malignancies.
Do you believe there might have been medical error?
Good afternoon. A complex, multispeciality case in a man with many co-morbidities. To respond fully would require more detailed medical data/fact/records. Causation and timeliness of complex care delivery, given information provided, strongly suggests lapses in SOC.
Do you believe there might have been causation (i.e. the medical error resulted in an injury)?
Best response is a given in my reply to the question above.
What makes you a good expert for this case?
45 years of Head and Neck Surgery Cancer experience and teaching.
How often do you encounter cases similar to this one in your practice?
Complex Head and Neck Cancer cases, particularly of major salivary gland, a regular part of practice. Have dealt with nearly similar case by the case presentation here.
Do you believe there might have been medical error?
Based on the information provided, there appears to be a likely deviation from the standard of care in the management of a progressively enlarging preauricular mass. The patient presented with a subcutaneous preauricular lesion that was biopsied on 11/18/24 with pathology reported as actinic keratosis. Actinic keratosis is a superficial epidermal lesion and does not typically present as a subcutaneous mass, which raises concern for sampling error or incomplete evaluation of the lesion. When the patient returned on 12/31/24 with a larger mass, the lesion was not re-biopsied and instead a steroid injection was administered. In the setting of an enlarging mass—particularly in a patient with a history of melanoma and immunosuppression from renal transplantation—the standard approach would typically involve repeat biopsy, imaging, or referral for further evaluation rather than steroid injection.
Do you believe there might have been causation (i.e. the medical error resulted in an injury)?
Based on the limited information available, causation is uncertain. The available summary does not include the operative report, final pathology report, extent of facial nerve involvement, or imaging details describing the tumor’s relationship to surrounding structures. Without these details it is difficult to determine whether an earlier diagnosis would likely have altered the surgical outcome, including the need for facial nerve sacrifice, auriculectomy, or neck dissection. Aggressive cutaneous squamous cell carcinoma in immunosuppressed patients can progress rapidly, and therefore additional records would be necessary to determine whether the delay materially changed the patient’s outcome.
What makes you a good expert for this case?
As a fellowship-trained neurotologist, I routinely treat benign and malignant conditions involving the ear, temporal bone, and surrounding structures. In my clinical practice I frequently collaborate with head and neck oncologic surgeons in the management of cutaneous and parotid malignancies involving the ear and temporal bone. These cases often involve complex surgical decision-making regarding facial nerve identification and preservation, auricular involvement, and temporal bone or ear canal resection. My experience managing tumors in this anatomic region provides relevant expertise in evaluating the diagnosis and management of lesions affecting the preauricular and parotid region.
How often do you encounter cases similar to this one in your practice?
I encounter malignant lesions affecting the ear, parotid region, and surrounding structures regularly in clinical practice. This includes cutaneous squamous cell carcinoma involving the auricle or preauricular region, parotid tumors, and metastatic cutaneous malignancies involving the parotid lymph nodes. I manage or participate in the surgical care of these types of cases multiple times per year.
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