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, M !"d, M A #$$% Con&ronted 'ith a patient 'ith pre(auricular mass, ) ha*e to +e &irst reminded o& the &ollo'ing, #. ) am to manage this patient-s health pro+lem. .. Managing a patient-s health pro+lem is essentially a pro+lem(sol*ing and decision(ma/ing acti*ity. 0. My goal in the management o& this patient is to resol*e the patient-s health pro+lem in such a 'ay ) don-t end up 'ith a dead or disa+led patient nor a dissatis&ied patient, and 1od, &or+id, a medicolegal suit. 2. My tas/s consist o& the &ollo'ing, 2.# "sta+lishing rapport initially and then maintaining it throughout the course o& patient management3 2.. 4ormulating a clinical diagnosis &ollo'ed +y an ad*ice to the patient on my &indings and diagnosis3 2.0 Deciding on 'hether ) need a paraclinical diagnostic procedure and i&, i& ) need one, selecting the most cost(e&&ecti*e procedure, to +e &ollo'ed +y an in&ormed consent on the part o& the patient3 i& paraclinical diagnostic procedures are done, ) need to interpret the results and correlate them 'ith the clinical &indings to come out 'ith a treatment diagnosis, again to +e &ollo'ed +y an ad*ice to the patient3 and lastly, 2.2 ) need to decide on the most cost(e&&ecti*e treatment procedure &or the patient. 2.5 My tas/s can +e summari6ed +y the &ollo'ing diagram,

5. 7he outcome o& my pro+lem(sol*ing and decision(ma/ing 'ill +e 8udged +y the &ollo'ing criteria, 5.# rational 5.. e&&ecti*e 5.0 e&&icient 5.2 humane RAPPORT "sta+lishing rapport 'ith the patient and his 9 her relati*es is my +est strategy &or o+taining satis&action &rom my patient and his9her relati*es. )t is also my strongest strategy in the pre*ention o& medicolegal suit in case ) commit errors o& commission and omission. ere are some 'ays in 'hich ) try to esta+lish rapport 'ith my patient and his9her relati*es, #. :eing courteous .. Sho'ing respect to person and +elie&s 0. 1i*ing honest and clear ad*ice on diagnosis, paraclinical diagnostic procedures, and treatment 2. Demonstrating humaneness and compassion 5. :eing gentle in 'ords and deeds (physical e;amination, procedure) <. Sho'ing the patient and relati*es that ) am trying my *ery +est =. :eing help&ul 'hen it comes to medical e;penses %. Ma/ing the patient and relati*es &eel that ) am approacha+le and easy to tal/ to

CLI ICAL DIA! O"I" )n &ormulating the clinical diagnosis, ) &irst *eri&y the e;pressed chie& complaint o& the patient. )n this particular patient, the e;pressed chie& complaint is the preauricular mass. 7o *eri&y, ) loo/ at and palpate the area pointed to +y the patient (let-s say, the le&t preauricular area). ) see and &eel a 5(cm mass in &ront o& the le&t ear. With this, ) conclude there is really a preauricular mass on the le&t side o& the &ace. )nitial impression o& the patient-s pro+lem, there&ore, is a le&t preauricular mass. ) need to +e more speci&ic than 8ust saying there is a mass. 7hus, the ne;t thing that ) should do is to determine the organ or tissue o& origin o& the preauricular mass. :y the location, the mass can come &rom any o& the &ollo'ing organs or tissues, #. .. 0. 2. 5. S/in o& the &ace So&t tissue !arotid gland >ymph node Mandi+le (ascending ramus)

) 'ill say the mass is originating &rom the s/in o& the &ace i& ) see a super&icial lesion on the s/in sur&ace. )n this patient, there is no +rea/ or lesion on the s/in. 7he mass is underneath the s/in. ) conclude, there&ore, that this mass in most li/ely ?O7 a s/in tumor. ) 'ill say the mass is originating &rom the mandi+le i& ) &eel the mass is a +ony tumor. )? this patient, the mass does not &eel +ony. ) conclude, there&ore, that this mass is most li/ely ?O7 a mandi+ular tumor. 7he le&t preauricular mass is +eneath the s/in and not a +ony tumor. 7he considerations on the tissue or organ o& origin are no' trimmed do'n to the &ollo'ing, #. So&t tissue .. !arotid 0. >ymph node At this point, a&ter &inishing inspection and palpation o& the le&t preauricular mass, ) ha*e gotten the &ollo'ing data, >e&t preauricular mass, +eneath the s/in, not a +ony tumor, 5 cm in si6e, not hard, mo*a+le, non(tender, +order 'ell(de&ined. ) /no' my priority at this point is still to &irst determine 'hether the mass is a so&t tissue tumor, parotid tumor, or a lymph node +e&ore ) decide on the /ind o& disease. ) &eel ) should in*estigate &irst the lymph node possi+ility +ecause o& the presence o& a clinical in*estigati*e path'ay &or lymph node. )& the mass is a lymph node, it is most li/ely secondary or metastatic. 7he primary lesion can +e &ound in the upper part o& the

head (scalp and &ace) or in the naso(oropharyn;. )& there is a lesion in any o& these areas, then the pre(auricular mass is most li/ely a metastatic lymph node. ) e;amine, there&ore, the upper part o& the head and nec/ and oropharyn;. 7here is no e*ident lesion in these areas. ) as/ &or any symptoms re&era+le to the nasopharyn; li/e nasal stu&&iness and +leeding. 7here is none. With these data, ) place lymph node in ?o. 0 in the line(up o& possi+ility o& sources o& tissue or organ o& origin. 7he consideration is no' centered on so&t tissue and parotid tumor. Since there are no clinical &eatures that 'ill di&&erentiate the t'o tumors, ) no' ha*e to rely on pre*alence data to choose 'hich one is more li/ely to +e the case. ) choose parotid tumor +ecause this is *ery much more common than so&t tissue tumor in the preauricular area. At this point, my impression is a le&t preauricular mass, most li/ely arising &rom the parotid gland. ) need to +e more speci&ic to include the possi+le disorder, 'hether in&lammatory, malignant or non(malignant. 7hus, the ne;t thing ) 'ill do is to loo/ &or signs &or in&lammation li/e pus, erythema, tenderness, and 'armth. )& there are signs o& in&lammation, then my diagnosis 'ill +e either a parotitis or parotid a+scess, depending on 'hether there is &luctuancy or not. )n this patient, there are no signs o& in&lammation. ) conclude that most li/ely the mass is ?O7 in&lammatory. 7he ne;t thing ) 'ill do is to loo/ &or signs o& malignancy 'hich include a hard non( osseous solid tumor, &i;ation, in*asion o& the s/in, &acial paresis or paralysis, ipsilateral nec/ nodes, and a distant mass suspicious &or metastasis. )& any o& these signs is present, then my diagnosis 'ill +e a parotid cancer. )n this patient, there are no signs o& malignancy. ) conclude, there&ore, that most li/ely the mass is ?O7 malignant. With no signs o& in&lammation and malignancy, ) am le&t 'ith a non(malignant tumor consideration. :e&ore ) settle &or this consideration, ) 'ill loo/ &or signs and other clues o& +enignity. As &or signs o& +enignity, a relia+le cue 'ill +e a cystic nature o& the mass. )& the mass is cystic, most li/ely the parotid mass is +enign, a parotid cyst. As &or other clues o& +enignity, the duration o& the mass may +e help&ul. )& the mass has +een present &or a long duration o& time 'ithout causing symptoms and there are no signs o& malignancy, most li/ely the parotid mass is +enign. )n this patient, the mass is not cystic and it 'as noted 0 years ago. 7hese data do not support the diagnosis o& +enignity +ut they also do not negate it. 7hus, in the a+sence o& in&lammation and malignancy and considering +enign parotid neoplasms are more common than malignant ones (%@A *s .@A), my clinical diagnosis, there&ore, is a +enign parotid tumor, le&t, most li/ely, pleomorphic adenoma. 7he +asis &or saying most li/ely pleomorphic adenoma is the pre*alence o& this disease. )t is the most common +enign parotid neoplasm.

As an added in*estigation to the parotid mass, +eside the onset, the other pertinent Buestions to as/ are 'hether there are associated symptoms and 'hether there is a history o& pre*ious medical consultation and treatment. 7o these Buestions, the ans'ers are all negati*e. )n &ormulating the clinical diagnosis o& a preauricular mass, the signs, symptoms, and personal data o& the patient are needed. )n this particular patient, the age is <5 and the se; is &emale. 7hese personal data as 'ell as other personal data li/e ci*il status, occupation, and menopausal status 'ill notma/e me change the diagnosis that ) arri*e at using pattern recognition (+ased on signs and symptoms) and pre*alence. 7he output e;pected in clinical diagnosis is a rational primary clinical diagnosis as 'ell as a secondary diagnosis. 7he primary clinical diagnosis is a parotid tumor, le&t, +enign pleomorphic adenoma. ) ha*e presented the +ases that ma/es my diagnosis rational. As to the secondary clinical diagnosis, ) 'ill consider a malignant parotid tumor. ) am con&ident o& the choice o& organ or tissue o& origin o& the preauricular mass, that is, the parotid gland. )& ) am not, then ) ha*e to ma/e so&t tissue as my secondary diagnosis, rather than a malignant parotid tumor. As ) ha*e said, ) am con&ident o& the parotid tumor. What ) am not *ery con&ident o& is 'hether the parotid tumor is +enign or malignant. 7he main +asis &or choosing +enign parotid tumor o*er malignancy is pre*alence, 'hich is a 'ea/er +asis compared to one that is +ased on +oth pattern recognition and pre*alence. PARACLI ICAL DIA! O"TIC PROC#DUR# Do ) need a paraclinical diagnostic procedureC My primary clinical diagnosis is parotid tumor, +enign. My secondary clinical diagnosis is parotid tumor, malignant. My +asis &or choosing +enign o*er malignant is pre*alence. 7hat ma/es my diagnosis not Buite certain. :eing uncertain, theoretically spea/ing, ) need a paraclinical diagnostic procedure. ) need to consider another &actor in deciding 'hether ) really need a diagnostic procedure. 7he treatment &or +oth primary and secondary diagnoses is operati*e e;tirpation. Whether the tumor +e +enign or malignant, my operati*e procedure 'ill +e e;tirpation o& all gross tumors. Since my treatment plan and procedure 'ill +e the same &or +oth my primary and secondary clinical diagnoses, then ) decide that ) don-t need a paraclinical diagnostic procedure. ?ote, ";tirpation o& all gross tumors may range &rom su+total parotidectomy to total parotidectomy. Su+total parotidectomy may range &rom partial super&icial parotidectomy, total super&icial parotidectomy, partial super&icial and total deep parotidectomy, and partial super&icial and partial deep parotidectomy. TR#ATM# T

My pretreatment diagnosis is parotid tumor, le&t, +enign. 7he goal and o+8ecti*e o& treatment is a resolution o& the tumor in such a 'ay that there 'ill +e no recurrence and no complications. 7he most cost(e&&ecti*e treatment is an operati*e e;tirpation. Drugs are ine&&ecti*e. 7he goal o& operati*e treatment is to completely e;tirpate all grossly e*ident tumor in such a 'ay that there 'ill no local recurrence and no complication, particularly, &acial ner*e paralysis. PR#OP PR#PARATIO !reoperati*ely, ) 'ill #. Secure an in&ormed consent a&ter ) ha*e e;plained to the patient and her relati*es the diagnosis and proposed treatment 'ith all possi+le complications, particularly, &acial ner*e paralysis. .. !ro*ide psychosocial support to allay &ear and an;iety. 0. )& there is a co(e;isting disorder, optimi6e the patient-s physical health so that she can 'ithstand the operati*e procedure. 2. Screen the patient &or any health condition that may inter&ere 'ith the outcome o& the treatment. 5. !repare the material needs &or the operation, i& these are not a*aila+le in the place o& treatment (hospital). I TRAOP#RATI$# MA A!#M# T Incision% O&'ecti(es% >ong enough to &acilitate accurate intraoperati*e e*aluation and complete e;tirpation o& the parotid tumor 'ithout complications. !lace it at an area that 'ill &acilitate achie*ement o& treatment goal. !lace it at an area that 'ill +e cosmetically accepta+le to the patient. !lanning and e;ecution o& incision 'ill +e +ased on the a+o*e o+8ecti*es. #)*osure% O&'ecti(es% 7o &acilitate accurate intraoperati*e e*aluation. 7o &acilitate complete e;tirpation o& the parotid tumor 'ithout complication. #)ecution% Create &laps to such an e;tent that 'ill &acilitate accurate intraoperati*e e*aluation and complete e;tirpation o& parotid tumor 'ithout e;tirpation. Create &laps not +eyond the anterior +order o& the parotid gland so as to a*oid in8ury to the +ranches o& the &acial ner*e. Create *ia+le &laps. Intrao*erati(e #(aluation% O&'ecti(es% 7o determine the e;act diagnosis. 7o determine the e;tent o& the tumor. 7o &acilitate decision on speci&ic operati*e procedure and maneu*ers.

#)ecution% )nspect and palpate 7o determine 'hether the mass is really parotid in origin. )& parotid in origin, determine 'hether +enign or malignant, e;tent o& tumor, super&icial or deep, in&erior pole, superior pole, 'hole gland, etc. Decide on e;tent o& parotidectomy D total parotidectomy3 su+total parotidectomy D total super&icial parotidectomy3 partial super&icial parotidectomy3 partial super&icial and partial deep parotidectomy. Decide on operati*e maneu*ers. O*erati(e Proce+ure Pro*er% O&'ecti(es% 7o completely e;tirpate all grossly e*ident tumor in such a 'ay that there 'ill +e no local recurrence and no complications, particularly, &acial ner*e paralysis. Maneu(ers% )denti&y &acial ner*e Main trun/ to +ranches :ranches ";tirpate all gross parotid tumor 'ith a rim o& normal parotid tissue (adeBuately) A*oid cutting or entering into the tumor (cleanly) A*oid in8ury to the &acial ner*e 'hile e;tirpating 'hich can occur either +y cutting, +urning ('ith cautery) or traction Attac/ tumor initially through areas o& lesser di&&iculty +e&ore entering through dense and di&&icult areas :e gentle. :e meticulous and precise. "*ery mo*e must ha*e a reasonE Hemostasis Chec,% O&'ecti(es% 7o a*oid +leeding and hematoma. 7o a*oid in8ury to &acial ner*e during hemostasis chec/. #)ecution% Choice o& suture(ligature and cauteri6ation. A*oid in8ury to the &acial ner*e during clamping, tying, and cauteri6ation +y right choice o& hemostatic method and +y +eing meticulous and precise. Drain% O+8ecti*es, 7o pre*ent un'anted accumulation o& &luid (serum and sali*a) in the 'ound space. 7o drain continuous sali*ary secretion into the 'ound site a&ter a su+total parotidectomy. #)ecution% Choice o& tu+e drain or ru++er drain. Remo*e 'hen drain is not needed anymore. Correct Count% O&'ecti(e% 7o a*oid lea*ing sponges, surgical instruments, and needles in the 'ound site. #)ecution% "nsure correct sponge, instrument, and needle count +e&ore 'ound closure.

-oun+ Closure% O&'ecti(es% 7o repair the s/in incision used to remo*e the parotid tumor. 7o repair the s/in incision in such a 'ay that ( a cosmetically accepta+le scar is e&&ected ( 'ill promote patient com&ort (e.g., pain o& s/in suture remo*al) #)ecution% Fse a+sor+a+le suture to a*oid pain on suture remo*al, i& non(a+sor+a+le sutures are used. Appose 'ound edges precisely to promote a cosmetically accepta+le scar. Posto* Care O&'ecti(es% Supply +asic needs o& patient Com&ort Analgesics 4luids and "lectrolytes ?utrition Wound care Monitoring &or complications and treat as indicated Ad*ice on home care o& 'ound Ad*ice on &ollo'(up plan .ollow-u* Plan% O&'ecti(es% "*aluate results o& treatment. !ro*ide psychosocial support. Monitoring guidelines !hysical e;amination Symptom(directed in*estigation .re/uency of .ollow-u* !ui+elines% Consider Fsual course o& disease (recurrence pro+a+ility and incidence) !ersonality o& patient !atient-s con*enience Outcome of Treatment% )& at the end o& the treatment, ) ha*e achie*ed all the &ollo'ing, Resolution o& the health pro+lem D parotid tumor e;tirpated 'ith no recurrence >i*e patient ?o &acial paralysis Satis&ied patient ?o medico(legal suit 7hen, ) can consider mysel& to +e success&ul in my pro+lem(sol*ing and decision(ma/ing in the management o& the patient.

Rey Joson #$$%