Tumors of the Parotid Gland - How to Manage

Tumors of the Parotid GlandHow to Manage

Reynaldo O. Joson, MD, MSc Surg

April 18, 2014

Managing tumors of the parotid gland will always be a challenge!

Inexactness of medicine as a scienceNo two patients are the same

No two physicians are the same

toPrimary Health Care Physicians

General Surgeons – Head and Neck SurgeonsOther Head and Neck Surgeons and Specialists

PathologistsRadiologists

toPrimary Health Care Physicians

•Know how to recognize tumors and refer to Head and Neck Specialist•Know how to recognize mump-parotitis and manage with analgesics and watchful waiting

ToRadiologists

•Know how to detect tumors on imaging procedures and determine extent or boundary in the head and neck area•Know how to describe lesions with utmost clarity without making more unnecessary comments such as pathologic diagnosis and need for additional tests and follow-up

ToPathologists

•Know how to determine the pathology with utmost accuracy – malignant, nonmalignant, inflammatory disorders and specific type•Know how to describe the grading of malignant tumors with utmost accuracy

to General Surgeons – Head and Neck Surgeons

Other Head and Neck Surgeons and Specialists

Greatest Challenge Clinician – Diagnostician – Therapist - Adviser

Clinical Diagnosis

• Presence of an unusual bulge in the periauricular area - start of suspicion of a parotid tumor

• Determine whether the bulge is normal or abnormal (whether a swelling or mass). (see more notes)

• Determine the organ or tissue of origin of the swelling or mass – parotid or other. (see more notes)

• If parotid in origin, determine the disorder and disease and extent. (see more notes)

Clinical Diagnosis

• Presence of an unusual bulge in the periauricular area - start of suspicion of a parotid tumor

• Determine whether the bulge is normal or abnormal (whether a swelling or mass). • A more prominent ipsilateral part of the jaw,

muscle, or soft tissue in the periauricular area may be unusual but still considered as normal.

• If bulge is abnormal, is there a dominant mass that causes the bulge? If none, then consider swelling.

Clinical Diagnosis

• Presence of an unusual abnormal bulge in the periauricular area - start of suspicion of a parotid tumor

• Determine the organ or tissue of origin of the swelling or mass – parotid or other. • Assess for probability of other organ or tissue

before settling for parotid

Clinical Diagnosis• Determine the organ or tissue of origin of the swelling

or mass – parotid or other. • Assess for probability of other organ or tissue

before settling for parotid• Skin tumor – at skin level• Bony tumor – bony hard• Lymph node – presence of inciting source (naso-

oropharynx, mouth, face, scalp, others)• Soft tissue tumor – more superficial than

parotid with telltale pattern recognition for common tumors like epidermal cyst and lipoma

Clinical Diagnosis

• If parotid in origin, determine the disorder and disease and extent. • Use pattern recognition and prevalence processes

for diagnosis of disorder and disease• Use physical signs and symptoms for extent of

disease such as fixation and cervical lymph nodes

Clinical Diagnosis

• Use pattern recognition and prevalence processes for diagnosis of disorder and disease

PATTERN RECOGNITION-realization that the patient’s presentation conforms to a previously learned picture or pattern of disease

PREVALENCE- choice of a diagnosis is based on the frequency of occurrence of the disease in a certain locality, in a certain age and sex group, and in the affected organ and system

Clinical DiagnosisPattern Recognition

Parotitis, acuteParotitis, chronicParotid abscessParotid hemangioma / lymphangiomaParotid cystParotid mass, benign pleomorphic adenomaParotid mass, Warthins’ tumor, papillary cystadenoma

lymphomatosumParotid cancerParotid lymphomaothers

Clinical Diagnosis

for diagnosis of disorder and disease• Look for pattern for inflammatory tumors –

swelling with no dominant mass, pus, erythema, severe tenderness (parotitis, parotid abscess)

Clinical Diagnosis

for diagnosis of disorder and disease• If no pattern for inflammatory tumors, look for

pattern for malignant tumors – fixation, cervical lymph nodes, facial nerve paralysis, ill-defined border of parotid mass, extremely hard in consistency.

Clinical Diagnosis

for diagnosis of disorder and disease• If no pattern for malignant tumors, settle for

nonmalignant or benign tumors (especially so if the tumor feels cystic – parotid cyst)

Clinical Diagnosis• If parotid in origin, determine the disorder and disease

and extent. • Use pattern recognition and prevalence processes for

diagnosis of disorder and disease• After determining the most probable disorder,

determine the specific disease if possible.• Examples: • Parotitis, right• Parotid abscess, left• Parotid cyst, right• Parotid tumor, left, benign pleomorphic adenoma• Parotid tumor, left, malignant with neck mets

Clinical DiagnosisAfter using the clinical diagnostic process, come out with

primary and secondary clinical diagnoses.

Examples:Primary: Parotid tumor, right, parotid abscessSecondary: Parotid tumor, right, malignant

Primary: Parotid tumor, left, benign, pleomorphic adenomaSecondary: Parotid tumor, left, malignant

primary and secondary clinical diagnoses.

Examples:Primary: Parotid tumor, left, benign, pleomorphic adenomaSecondary: Soft tissue mass, preauricular, left, lipoma

Primary: Parotid tumor, left, benign, pleomorphic adenomaSecondary: Lymph node, preauricular, left, metastatic from

nasopharyngeal ca

primary and secondary clinical diagnoses and then quantitate certainty (certain: ≥ 90%; not certain < 90%)

Examples:Primary: Parotid tumor, left, benign, pleomorphic adenoma

(90%)Secondary: Soft tissue mass, preauricular, left, lipoma

primary and secondary clinical diagnoses and then quantitate certainty (certain: ≥ 90%; not certain < 90%)

Examples:Primary: Parotid tumor, left, benign, pleomorphic adenoma

(90%)Secondary: Parotid tumor, left, malignant (10%)

Clinical DiagnosisAfter using the clinical diagnostic process and coming with

primary and secondary clinical diagnoses with degree of certainty,

ADVISE patient and relative on the

clinical diagnoses with bases and degree of certainty.

Paraclinical Diagnosis

Diagnosis derived after the clinical diagnosis with the use of paraclinical diagnostic procedures.

Decision-making:• Indication• Selection• Interpretation

Paraclinical Diagnostic Process - Indication

PROCESSING OF DATA

CERTAINTY OF CLINICAL Dx 1O Dx 60% 99%

needed not needed

TREATMENT PLAN FOR 1O & 2O DxDifferent Sameneeded not needed

After analyzing on need or no need for paraclinical diagnostic procedure,

ADVISE patient and relative on recommendation and bases and

SECURE an informed consent.

Paraclinical Diagnostic Process - SelectionSELECTION PROCESS

Options Benefit Risk Cost Availability123

OBJECTIVES: Increase degree of certainty of diagnosis and extent

OUTPUT EXPECTEDMOST COST-EFFECTIVE DIAGNOSTIC PROCEDURE (with room

for “initial” testing and respect for patient’s concerns)

Paraclinical Diagnostic Process - Selection

SELECTION PROCESS

Options Benefit Risk Cost Availability1- Watchful monitoring2- Needle Evaluation + Biopsy3- Open Biopsy4- Frozen-section Biopsy5- Ultrasound6- X-ray7-Sialography8- CT Scan9- MRI

Objective: To increase the degree of certainty of diagnosis.Parotid Tumor, benign vs malignant

Benefit Risk Cost* Availability**

Type of exam

Potential Info Info Yield

Watchful monitoring

Indirect exam

Course and behavior of mass

99% Time lag (years) Consult feeP600

Needle evaluation + biopsy

Direct exam

Gross character and biopsy (benign vs malignant)

90% Pain, infection, seeding

Procedure Expense P6T

Type of exam

Needle evaluation + biopsy

Direct exam

90% Pain, infection, seeding

Procedure Expense P6T

Open biopsy(non-frozen)

Direct exam

98% Scar,pain, infection, seeding

P15T RA

Type of exam

Open biopsy(non-frozen)

Direct exam

P15T RA

Frozen biopsy

Direct exam

P30T(lab, anesthesia, operating room)

Benefit Risk Cost* Availability**Type of exam

X-ray Indirect exam-

Calcification- stone

1% Radiation P300 RA

Sialography Indirect exam

Stone; obstructed duct

1% Radiation, pain P9TNRA

Ultrasound Indirect exam

Cystic – benignIll-bordered solid - malignant

60% Necrosis P2T RA

CT Scan Indirect exam

Border and extent

70% Radiation, dye reaction, if usedclaustrophobia

P10T RA

CT Scan Indirect exam

Border and extent

70% Radiation, dye reaction, if usedclaustrophobia

P10T RA

MRI Indirect exam

Border and extent

80% Side effect of magnet Dye reaction

P15T RA

Paraclinical Diagnostic Process – Selection

Indication AdvisoryWatchful monitoring

•If suspicion for malignancy is low – below 10%•If there is patient’s informed refusal for other diagnostic procedures

Indication AdvisoryNeedle Evaluation + Biopsy

•If a parotid cyst is probable and can be treated with needle aspiration•If total parotidectomy has to be done if mass turns out to be malignant

Indication AdvisoryOpen Biopsy

•If there is a need for a definitive histologic diagnosis

Indication AdvisoryFrozen-section Biopsy

•If there is a need for a definitive intraop histologic diagnosis•If there is a patient’s informed refusal for a preop needle and open biopsy (non-frozen) – such as fear of pain of the procedure and willing to pay higher cost of frozen-biopsy

Indication AdvisoryX-ray

•If sialolithiasis is suspected•If there is a need to assess involvement of the adjacent bone structure by the parotid mass with a procedure of lesser expense compared to CT Scan and MRI

Indication AdvisorySialography

•If sialolithiasis is suspected•If there is a need to assess the ductal system of the parotid gland

Indication AdvisoryUltrasound

•If the organ or tissue of origin of the periauricular mass is uncertain•If there is a need to have an imaging evaluation of the parotid mass to increase degree of certainty of clinical diagnosis without having to do preop biopsy and also to have an idea of the depth and extent of the mass

Indication AdvisoryCT-Scan

•If there is a need for highly refined information compared to those that will be gotten from ultrasound to assist in assessment of resectability and extent of resection to be done•

Indication AdvisoryMRI

•If there is a need for highly refined information compared to those that will be gotten from ultrasound and CT Scan to assist in assessment of resectability and extent of resection to be done

Paraclinical Diagnostic Process - SelectionSELECTION PROCESS

OBJECTIVES: Increase degree of certainty of diagnosis and extent

OUTPUT EXPECTEDMOST COST-EFFECTIVE DIAGNOSTIC PROCEDURE (with room

for “initial” testing and respect for patient’s concerns)

After analyzing the BRCA for the options on paraclinical diagnostic procedure,

ADVISE patient and relative on recommendation and bases and

Paraclinical Diagnostic Process - Interpretation

DATA NEEDED

PRIMARY CLINICAL DIAGNOSISSECONDARY CLINICAL DIAGNOSIS

RESULT OF PARACLINICAL DIAGNOSTIC PROCEDURE

Paraclinical Diagnostic Process - Interpretation

INTERPRETATION PROCESS

CORRELATE RESULT OF PARACLINICAL DIAGNOSTIC PROCEDURE

WITH PRIMARY AND SECONDARY CLINICAL DIAGNOSIS

CONGRUENT - ACCEPTINCONGRUENT - MAKE A DECISION!

(Accept or Hold!)

Paraclinical Diagnostic Process - InterpretationINTERPRETATION PROCESS

INCONGRUENT - MAKE A DECISION!(Accept or Hold!)

HOLD Advisory:

•Paraclinical diagnosis is a clinical diagnosis least considered.•Paraclinical diagnosis does not jibe with the clinical picture or diagnosis.

Possible Actions: Discuss with physician-diagnostician; Discuss with patient; Repeat test; Go to higher-level test.

After interpreting the result of the paraclinical diagnostic procedure and correlating with clinical diagnoses,

ADVISE patient and relative on

PRETREATMENT DIAGNOSIS (if available already) or

recommendation for another paraclinical diagnostic procedure and bases and

Treatment Process - Selection

DATA NEEDED

PRETREATMENT DIAGNOSISSEVERITY OR STAGE

GOALS AND OBJECTIVESTREATMENT OPTIONS

SELECTION PROCESS

OBJECTIVE: To resolve the patient’s health problem

OUTPUT EXPECTEDMOST COST-EFFECTIVE TREATMENT PROCEDUREACHIEVEMENT OF GOALS OF PATIENT MANAGEMENT!

MANAGEMENT OF A PATIENTPROBLEM-SOLVING AND DECISION-MAKING

RESOLUTION OF HEALTH PROBLEM

LIVE PATIENT

NO COMPLICATION

NO DISABILITY

SATISFIED PATIENT

NO MEDICOLEGAL SUIT

SELECTION PROCESS

Treatment Benefit Risk Cost (PhP) AvailabilityOptions

1 most effective acceptable 2000 available2 effectivity <1 >3 acceptable 3000 available3 least effective acceptable 4000 available

Which is the most cost-effective treatment option?

Option 1

SELECTION PROCESS Treatment Benefit Risk Cost (PhP) AvailabilityOptions

1 as effective as 2 acceptable 8000 available2 as effective as 1 acceptable 4000 available

Which is the more cost-effective treatment option?

Option 2

SELECTION PROCESS Treatment Benefit Risk Cost (PhP) AvailabilityOptions

1 as effective as 2 more complication 8000 available2 as effective as 1 acceptable 4000 available

Which is the more cost-effective treatment option?

Option 2

TreatmentGuidelines

Parotitis, acuteParotitis, chronicParotid abscessParotid hemangioma / lymphangiomaParotid cystParotid mass, benign pleomorphic adenomaParotid mass, Warthins’ tumor, papillary cystadenoma

lymphomatosumParotid cancerParotid lymphomaothers

TreatmentGuidelines

Parotitis, acuteViral – mumps

NO antibiotics neededSymptomatic treatment

Non-pharmacologic – warm compress for pain; sponge bath for fever; etc.

Pharmacologic prn – analgesics; antipyreticsSoft diet if there is pain on chewing Rest and watchful waiting for spontaneous recovery from infection

TreatmentGuidelines

Parotitis, acuteBacterial

Antibiotics (BRCA) – Gram (+) and Gram (-) microbesInvestigate and remove cause (example: sialolithiasis)Symptomatic treatment

Pharmacologic prn – analgesics; antipyreticsSoft diet if there is pain on chewing Rest and watchful waiting for recovery from infection

TreatmentGuidelines

Parotitis, chronic, nonspecific Antibiotics (BRCA) – Gram (+) and Gram (-) microbes, if neededInvestigate and remove cause (example: sialolithiasis)Symptomatic treatment

TreatmentGuidelines

Parotid abscess, bacterial DrainAntibiotics (BRCA) – Gram (+) and Gram (-) microbes Investigate and remove cause (example: sialolithiasis)Symptomatic treatment

TreatmentGuidelines

Parotid tumor, benign Watchful waiting, if chosenExcision – subtotal parotidectomy; total parotidectomy if whole gland is involved

TreatmentGuidelines

Parotid tumor, malignant, resectableWide Excision – subtotal parotidectomy; total parotidectomy if whole gland is involved

Neck dissection if metastatic cervical lymph nodes present or strongly suspected – classical radical neck dissection for extensive nodes; otherwise modified radical neck dissection

TreatmentGuidelines

Parotid tumor, malignant, resectableWide Excision – subtotal parotidectomy; total parotidectomy if whole gland is involved

Neck dissection if metastatic cervical lymph nodes present or strongly suspected – classical radical neck dissection for extensive nodes; otherwise modified radical neck dissection

Postop adjuvant treatment – radiotherapy vs chemotherapy

TreatmentGuidelines

Parotid tumor, malignant, difficult or non-resectableRadiotherapy vs chemotherapySurgery if lesion becomes resectable

Parotid Cancer, Mucoepidermoid, Superficial Lobe, ResectableObjective: To resolve the cancer completely with small chance of local recurrence and with least complication

Benefit Risk Cost Availability

Resolve Survival Rate

Surgery 98% Longest LLLL

Operation AnesthesiaFacial nerve palsy

P100T RA

Radiotherapy 70% LLL Radiation P100T RA

Chemotherapy 30% LL Side effects drug

P120T RA

Alternative medicine

1% ShortestL

Side effects P120T RA

Parotid Cancer, Mucoepidermoid, Superficial Lobe, ResectableObjective: To extirpative the cancer completely with small chance of local recurrence and with least complication

Benefit Risk Cost Availability

Recurrence Rate (local)

Survival Rate

Subtotal parotidectomy (with good margin)

10% Same Facial nerve palsy (10%)

Less expensive by P10T

Total parotidectomy

5% Same Facial nerve palsy (90%)

More expensive

Treatment

After the options of the treatment have been analyzed,

Proposed treatment with bases and

Referral - When to Refer?

All physicians, both certified and not yet certified, must know their limitations.

Only they themselves can determine their own limitations.

They must realize their limitations so that they do not cause undue harm to their patients and so that they know when to refer to colleagues.

Referral - To Whom to Refer?

Referral must be made to somebody who may or can solve the patient’s health

problem rationally, effectively, efficiently, and

humanely, andwho has a good track record of handling the kind of problem on hand.

Referral

After the options of referral have been analyzed,

need of referral if needed and with bases and

Surgical Treatment

Assuming a surgical treatment will be done.How to manage it!

Surgical Treatment Process

PREOP PREPARATION

Surgical Treatment Process - Preop Preparation

INFORMED CONSENT PSYCHOSOCIAL SUPPORT OPTIMIZATION SCREENING OPERATIVE MATERIALS

See Preoperative and Preanesthetic Evaluation or Risk Assessment and Management

PCS Guidelines (Non-cardiac surgery)ASA Practice Advisory for Preanesthetic Evaluation (2011) – No routine!

Surgical Treatment Process - Preop Preparation

INFORMED CONSENT PSYCHOSOCIAL SUPPORT

Risk Information - parotidectomyFacial nerve palsy (temporary or permanent)Frey’s SyndromeNumbness of ear (great auricular nerve transection)BleedingInfectionAnesthestic

Risk Information – neck dissectionNumbness

Management of a Surgical Patient [Process]

INTRAOP MANAGEMENT

Surgical Treatment Process - Intraop MgtPHASES

INCISION EXPOSURE INTRAOP EVALUATION OPERATIVE PROCEDURE PROPER HEMOSTASIS CHECK CORRECT COUNT WOUND CLOSURE

Surgical Treatment Process - Intraop Mgt

Quality Standards:

GENTLE

METICULOUS and PRECISE

NO IATROGENIC INJURIES

NO UNNECESSARY MOVESEVERY MOVE HAS A REASON!

POSTOP CARE

Surgical Treatment Process - Postop Care

•SUPPLY BASIC NEEDS OF PATIENT COMFORT ANALGESICS FLUID AND ELECTROLYTES NUTRITION

SUPPORT ORGAN FUNCTION WOUND CAREMONITORING FOR COMPLICATIONSADVICE ON

HOME CARE FOLLOW-UP PLAN

POSTOP FOLLOW-UP PLAN

Surgical Treatment Process - Postop Follow-up Plan

OBJECTIVES:

EVALUATE TREATMENT OUTCOME PROVIDE PSYCHOSOCIAL SUPPORT

MONITORING GUIDELINE:

PHYSICAL EXAMINATIONSYMPTOM-DIRECTED

INVESTIGATION

Surgical Treatment Process - Postop Follow-up Plan

FF-UP FREQUENCY GUIDELINES: CONSIDER USUAL COURSE OF DISEASE PERSONALITY OF PATIENT PATIENT’S CONVENIENCE

Reynaldo O. Joson, MD, MSc Surg

0918-804-03-04

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