Management of a Patient with a Pre-auricular Mass
How I Usually Do It
(Whole Case Management including Surgical Aspect)
Reynaldo O. Joson, MD, MSc Surg, MHPEd, MHA
Confronted with a patient with pre-auricular mass, I have to be first reminded of the following:
- I am to manage this patient’s health problem.
- Managing a patient’s health problem is essentially a problem-solving and decision-making activity.
- My goal in the management of this patient is to resolve the patient’s health problem in such a way I don’t end up with a dead or disabled patient nor a dissatisfied patient, and God, forbid, a medicolegal suit.
- My tasks consist of the following:
4.1 Establishing rapport initially and then maintaining it throughout the course of patient management;
4.2 Formulating a clinical diagnosis followed by an advice to the patient on my findings and diagnosis;
4.3 Deciding on whether I need a paraclinical diagnostic procedure and if, if I need one, selecting the most cost-effective procedure, to be followed by an informed consent on the part of the patient; if paraclinical diagnostic procedures are done, I need to interpret the results and correlate them with the clinical findings to come out with a treatment diagnosis, again to be followed by an advice to the patient; and lastly,
4.4 I need to decide on the most cost-effective treatment procedure for the patient.
4.5 My tasks can be summarized by the following diagram:
5. The outcome of my problem-solving and decision-making will be judged by the following criteria:
Establishing rapport with the patient and his / her relatives is my best strategy for obtaining satisfaction from my patient and his/her relatives. It is also my strongest strategy in the prevention of medicolegal suit in case I commit errors of commission and omission.
Here are some ways in which I try to establish rapport with my patient and his/her relatives:
1. Being courteous
2. Showing respect to person and beliefs
3. Giving honest and clear advice on diagnosis, paraclinical diagnostic procedures, and treatment
4. Demonstrating humaneness and compassion
5. Being gentle in words and deeds (physical examination, procedure)
6. Showing the patient and relatives that I am trying my very best
7. Being helpful when it comes to medical expenses
8. Making the patient and relatives feel that I am approachable and easy to talk to
In formulating the clinical diagnosis, I first verify the expressed chief complaint of the patient.
In this particular patient, the expressed chief complaint is the preauricular mass. To verify, I look at and palpate the area pointed to by the patient (let’s say, the left preauricular area). I see and feel a 5-cm mass in front of the left ear. With this, I conclude there is really a preauricular mass on the left side of the face. Initial impression of the patient’s problem, therefore, is a left preauricular mass. I need to be more specific than just saying there is a mass.
Thus, the next thing that I should do is to determine the organ or tissue of origin of the preauricular mass.
By the location, the mass can come from any of the following organs or tissues:
1. Skin of the face
2. Soft tissue
3. Parotid gland
4. Lymph node
5. Mandible (ascending ramus)
I will say the mass is originating from the skin of the face if I see a superficial lesion on the skin surface. In this patient, there is no break or lesion on the skin. The mass is underneath the skin. I conclude, therefore, that this mass in most likely NOT a skin tumor.
I will say the mass is originating from the mandible if I feel the mass is a bony tumor. IN this patient, the mass does not feel bony. I conclude, therefore, that this mass is most likely NOT a mandibular tumor.
The left preauricular mass is beneath the skin and not a bony tumor. The considerations on the tissue or organ of origin are now trimmed down to the following:
1. Soft tissue
3. Lymph node
At this point, after finishing inspection and palpation of the left preauricular mass, I have gotten the following data:
Left preauricular mass, beneath the skin, not a bony tumor, 5 cm in size, not hard, movable, non-tender, border well-defined.
I know my priority at this point is still to first determine whether the mass is a soft tissue tumor, parotid tumor, or a lymph node before I decide on the kind of disease.
I feel I should investigate first the lymph node possibility because of the presence of a clinical investigative pathway for lymph node. If the mass is a lymph node, it is most likely secondary or metastatic. The primary lesion can be found in the upper part of the head (scalp and face) or in the naso-oropharynx. If there is a lesion in any of these areas, then the pre-auricular mass is most likely a metastatic lymph node.
I examine, therefore, the upper part of the head and neck and oropharynx. There is no evident lesion in these areas. I ask for any symptoms referable to the nasopharynx like nasal stuffiness and bleeding. There is none.
With these data, I place lymph node in No. 3 in the line-up of possibility of sources of tissue or organ of origin.
The consideration is now centered on soft tissue and parotid tumor. Since there are no clinical features that will differentiate the two tumors, I now have to rely on prevalence data to choose which one is more likely to be the case. I choose parotid tumor because this is very much more common than soft tissue tumor in the preauricular area.
At this point, my impression is a left preauricular mass, most likely arising from the parotid gland. I need to be more specific to include the possible disorder, whether inflammatory, malignant or non-malignant.
Thus, the next thing I will do is to look for signs for inflammation like pus, erythema, tenderness, and warmth. If there are signs of inflammation, then my diagnosis will be either a parotitis or parotid abscess, depending on whether there is fluctuancy or not.
In this patient, there are no signs of inflammation. I conclude that most likely the mass is NOT inflammatory.
The next thing I will do is to look for signs of malignancy which include a hard non-osseous solid tumor, fixation, invasion of the skin, facial paresis or paralysis, ipsilateral neck nodes, and a distant mass suspicious for metastasis. If any of these signs is present, then my diagnosis will be a parotid cancer.
In this patient, there are no signs of malignancy. I conclude, therefore, that most likely the mass is NOT malignant.
With no signs of inflammation and malignancy, I am left with a non-malignant tumor consideration. Before I settle for this consideration, I will look for signs and other clues of benignity. As for signs of benignity, a reliable cue will be a cystic nature of the mass. If the mass is cystic, most likely the parotid mass is benign, a parotid cyst. As for other clues of benignity, the duration of the mass may be helpful. If the mass has been present for a long duration of time without causing symptoms and there are no signs of malignancy, most likely the parotid mass is benign.
In this patient, the mass is not cystic and it was noted 3 years ago. These data do not support the diagnosis of benignity but they also do not negate it.
Thus, in the absence of inflammation and malignancy and considering benign parotid neoplasms are more common than malignant ones (80% vs 20%), my clinical diagnosis, therefore, is a benign parotid tumor, left, most likely, pleomorphic adenoma. The basis for saying most likely pleomorphic adenoma is the prevalence of this disease. It is the most common benign parotid neoplasm.
As an added investigation to the parotid mass, beside the onset, the other pertinent questions to ask are whether there are associated symptoms and whether there is a history of previous medical consultation and treatment. To these questions, the answers are all negative.
In formulating the clinical diagnosis of a preauricular mass, the signs, symptoms, and personal data of the patient are needed. In this particular patient, the age is 65 and the sex is female. These personal data as well as other personal data like civil status, occupation, and menopausal status will notmake me change the diagnosis that I arrive at using pattern recognition (based on signs and symptoms) and prevalence.
The output expected in clinical diagnosis is a rational primary clinical diagnosis as well as a secondary diagnosis.
The primary clinical diagnosis is a parotid tumor, left, benign pleomorphic adenoma. I have presented the bases that makes my diagnosis rational.
As to the secondary clinical diagnosis, I will consider a malignant parotid tumor.
I am confident of the choice of organ or tissue of origin of the preauricular mass, that is, the parotid gland. If I am not, then I have to make soft tissue as my secondary diagnosis, rather than a malignant parotid tumor.
As I have said, I am confident of the parotid tumor. What I am not very confident of is whether the parotid tumor is benign or malignant. The main basis for choosing benign parotid tumor over malignancy is prevalence, which is a weaker basis compared to one that is based on both pattern recognition and prevalence.
PARACLINICAL DIAGNOSTIC PROCEDURE
Do I need a paraclinical diagnostic procedure?
My primary clinical diagnosis is parotid tumor, benign. My secondary clinical diagnosis is parotid tumor, malignant. My basis for choosing benign over malignant is prevalence. That makes my diagnosis not quite certain. Being uncertain, theoretically speaking, I need a paraclinical diagnostic procedure. I need to consider another factor in deciding whether I really need a diagnostic procedure.
The treatment for both primary and secondary diagnoses is operative extirpation. Whether the tumor be benign or malignant, my operative procedure will be extirpation of all gross tumors. Since my treatment plan and procedure will be the same for both my primary and secondary clinical diagnoses, then I decide that I don’t need a paraclinical diagnostic procedure.
Note: Extirpation of all gross tumors may range from subtotal parotidectomy to total parotidectomy. Subtotal parotidectomy may range from partial superficial parotidectomy, total superficial parotidectomy, partial superficial and total deep parotidectomy, and partial superficial and partial deep parotidectomy.
My pretreatment diagnosis is parotid tumor, left, benign.
The goal and objective of treatment is a resolution of the tumor in such a way that there will be no recurrence and no complications.
The most cost-effective treatment is an operative extirpation. Drugs are ineffective. The goal of operative treatment is to completely extirpate all grossly evident tumor in such a way that there will no local recurrence and no complication, particularly, facial nerve paralysis.
Preoperatively, I will
1. Secure an informed consent after I have explained to the patient and her relatives the diagnosis and proposed treatment with all possible complications, particularly, facial nerve paralysis.
2. Provide psychosocial support to allay fear and anxiety.
3. If there is a co-existing disorder, optimize the patient’s physical health so that she can withstand the operative procedure.
4. Screen the patient for any health condition that may interfere with the outcome of the treatment.
5. Prepare the material needs for the operation, if these are not available in the place of treatment (hospital).
Long enough to facilitate accurate intraoperative evaluation and complete extirpation of the parotid tumor without complications.
Place it at an area that will facilitate achievement of treatment goal.
Place it at an area that will be cosmetically acceptable to the patient.
Planning and execution of incision will be based on the above objectives.
To facilitate accurate intraoperative evaluation.
To facilitate complete extirpation of the parotid tumor without complication.
Create flaps to such an extent that will facilitate accurate intraoperative evaluation and complete extirpation of parotid tumor without extirpation.
Create flaps not beyond the anterior border of the parotid gland so as to avoid injury to the branches of the facial nerve.
Create viable flaps.
To determine the exact diagnosis.
To determine the extent of the tumor.
To facilitate decision on specific operative procedure and maneuvers.
Inspect and palpate
To determine whether the mass is really parotid in origin.
If parotid in origin, determine whether benign or malignant, extent of tumor, superficial or deep, inferior pole, superior pole, whole gland, etc.
Decide on extent of parotidectomy – total parotidectomy; subtotal parotidectomy – total superficial parotidectomy; partial superficial parotidectomy; partial superficial and partial deep parotidectomy.
Decide on operative maneuvers.
Operative Procedure Proper:
To completely extirpate all grossly evident tumor in such a way that there will be no local recurrence and no complications, particularly, facial nerve paralysis.
Identify facial nerve
Main trunk to branches
Extirpate all gross parotid tumor with a rim of normal parotid tissue (adequately)
Avoid cutting or entering into the tumor (cleanly)
Avoid injury to the facial nerve while extirpating which can occur either by cutting, burning (with cautery) or traction
Attack tumor initially through areas of lesser difficulty before entering through dense and difficult areas
Be meticulous and precise.
Every move must have a reason!
To avoid bleeding and hematoma.
To avoid injury to facial nerve during hemostasis check.
Choice of suture-ligature and cauterization.
Avoid injury to the facial nerve during clamping, tying, and cauterization by right choice of hemostatic method and by being meticulous and precise.
To prevent unwanted accumulation of fluid (serum and saliva) in the wound space.
To drain continuous salivary secretion into the wound site after a subtotal parotidectomy.
Choice of tube drain or rubber drain.
Remove when drain is not needed anymore.
To avoid leaving sponges, surgical instruments, and needles in the wound site.
Ensure correct sponge, instrument, and needle count before wound closure.
To repair the skin incision used to remove the parotid tumor.
To repair the skin incision in such a way that
– a cosmetically acceptable scar is effected
– will promote patient comfort (e.g., pain of skin suture removal)
Use absorbable suture to avoid pain on suture removal, if non-absorbable sutures are used.
Appose wound edges precisely to promote a cosmetically acceptable scar.
Supply basic needs of patient
Fluids and Electrolytes
Monitoring for complications and treat as indicated
Advice on home care of wound
Advice on follow-up plan
Evaluate results of treatment.
Provide psychosocial support.
Frequency of Follow-up Guidelines:
Usual course of disease (recurrence probability and incidence)
Personality of patient
Outcome of Treatment:
If at the end of the treatment, I have achieved all the following:
Resolution of the health problem – parotid tumor extirpated with no recurrence
No facial paralysis
No medico-legal suit
I can consider myself to be successful in my problem-solving and decision-making in the management of the patient.