Tumors of the Parotid Gland
How to Manage
Reynaldo O. Joson, MD, MSc Surg
April 18, 2014
Tumors of the Parotid Gland
How to Manage
Managing tumors of the parotid gland
will always be a challenge!
Inexactness of ...
Tumors of the Parotid Gland
How to Manage
Managing tumors of the parotid gland
will always be a challenge!
to
Primary Heal...
Tumors of the Parotid Gland
How to Manage
Managing tumors of the parotid gland
will always be a challenge!
to
Primary Heal...
Tumors of the Parotid Gland
How to Manage
Managing tumors of the parotid gland
will always be a challenge!
To
Radiologists...
Tumors of the Parotid Gland
How to Manage
Managing tumors of the parotid gland
will always be a challenge!
To
Pathologists...
Tumors of the Parotid Gland
How to Manage
Managing tumors of the parotid gland
will always be a challenge!
to
General Surg...
Tumors of the Parotid Gland
How to Manage
Clinical Diagnosis
• Presence of an unusual bulge in the periauricular area
- st...
Tumors of the Parotid Gland
How to Manage
Clinical Diagnosis
• Presence of an unusual bulge in the periauricular area
- st...
Tumors of the Parotid Gland
How to Manage
Clinical Diagnosis
• Presence of an unusual abnormal bulge in the
periauricular ...
Tumors of the Parotid Gland
How to Manage
Clinical Diagnosis
• Determine the organ or tissue of origin of the swelling
or ...
Tumors of the Parotid Gland
How to Manage
Clinical Diagnosis
• If parotid in origin, determine the disorder and
disease an...
Tumors of the Parotid Gland
How to Manage
Clinical Diagnosis
• Use pattern recognition and prevalence processes
for diagno...
Tumors of the Parotid Gland
How to Manage
Clinical Diagnosis
Pattern Recognition
Parotitis, acute
Parotitis, chronic
Parot...
Tumors of the Parotid Gland
How to Manage
Clinical Diagnosis
• If parotid in origin, determine the disorder and
disease an...
Tumors of the Parotid Gland
How to Manage
Clinical Diagnosis
• If parotid in origin, determine the disorder and
disease an...
Tumors of the Parotid Gland
How to Manage
Clinical Diagnosis
• If parotid in origin, determine the disorder and
disease an...
Tumors of the Parotid Gland
How to Manage
Clinical Diagnosis
• If parotid in origin, determine the disorder and disease
an...
Tumors of the Parotid Gland
How to Manage
Clinical Diagnosis
After using the clinical diagnostic process, come out with
pr...
Tumors of the Parotid Gland
How to Manage
Clinical Diagnosis
After using the clinical diagnostic process, come out with
pr...
Tumors of the Parotid Gland
How to Manage
Clinical Diagnosis
After using the clinical diagnostic process, come out with
pr...
Tumors of the Parotid Gland
How to Manage
Clinical Diagnosis
After using the clinical diagnostic process, come out with
pr...
Tumors of the Parotid Gland
How to Manage
Clinical Diagnosis
After using the clinical diagnostic process and coming with
p...
Tumors of the Parotid Gland
How to Manage
Paraclinical Diagnosis
Diagnosis derived after the clinical diagnosis with the u...
Paraclinical Diagnostic Process - Indication
PROCESSING OF DATA
CERTAINTY OF CLINICAL Dx
1O
Dx 60% 99%
needed not needed
T...
Tumors of the Parotid Gland
How to Manage
Paraclinical Diagnosis
After analyzing on need or no need for paraclinical
diagn...
Paraclinical Diagnostic Process - Selection
SELECTION PROCESS
Options Benefit Risk Cost Availability
1
2
3
Tumors of the P...
Paraclinical Diagnostic Process - Selection
SELECTION PROCESS
Options Benefit Risk Cost Availability
1- Watchful monitorin...
Paraclinical Diagnostic Process - Selection
Tumors of the Parotid Gland
How to Manage
Objective: To increase the degree of...
Paraclinical Diagnostic Process - Selection
Tumors of the Parotid Gland
How to Manage
Objective: To increase the degree of...
Paraclinical Diagnostic Process - Selection
Tumors of the Parotid Gland
How to Manage
Objective: To increase the degree of...
Paraclinical Diagnostic Process - Selection
Tumors of the Parotid Gland
How to Manage
Objective: To increase the degree of...
Paraclinical Diagnostic Process - Selection
Tumors of the Parotid Gland
How to Manage
Objective: To increase the degree of...
Paraclinical Diagnostic Process - Selection
Tumors of the Parotid Gland
How to Manage
Objective: To increase the degree of...
Paraclinical Diagnostic Process – Selection
Indication Advisory
Watchful monitoring
•If suspicion for malignancy is low – ...
Paraclinical Diagnostic Process – Selection
Indication Advisory
Needle Evaluation + Biopsy
•If a parotid cyst is probable ...
Paraclinical Diagnostic Process – Selection
Indication Advisory
Open Biopsy
•If there is a need for a definitive histologi...
Paraclinical Diagnostic Process – Selection
Indication Advisory
Frozen-section Biopsy
•If there is a need for a definitive...
Paraclinical Diagnostic Process – Selection
Indication Advisory
X-ray
•If sialolithiasis is suspected
•If there is a need ...
Paraclinical Diagnostic Process – Selection
Indication Advisory
Sialography
•If sialolithiasis is suspected
•If there is a...
Paraclinical Diagnostic Process – Selection
Indication Advisory
Ultrasound
•If the organ or tissue of origin of the periau...
Paraclinical Diagnostic Process – Selection
Indication Advisory
CT-Scan
•If there is a need for highly refined information...
Paraclinical Diagnostic Process – Selection
Indication Advisory
MRI
•If there is a need for highly refined information com...
Paraclinical Diagnostic Process - Selection
SELECTION PROCESS
Options Benefit Risk Cost Availability
1
2
3
Tumors of the P...
Tumors of the Parotid Gland
How to Manage
Paraclinical Diagnosis
After analyzing the BRCA for the options on paraclinical
...
Paraclinical Diagnostic Process - Interpretation
DATA NEEDED
PRIMARY CLINICAL DIAGNOSIS
SECONDARY CLINICAL DIAGNOSIS
RESUL...
Paraclinical Diagnostic Process - Interpretation
INTERPRETATION PROCESS
CORRELATE
RESULT OF PARACLINICAL DIAGNOSTIC PROCED...
Paraclinical Diagnostic Process - Interpretation
INTERPRETATION PROCESS
INCONGRUENT - MAKE A DECISION!
(Accept or Hold!)
T...
Tumors of the Parotid Gland
How to Manage
Paraclinical Diagnosis
After interpreting the result of the paraclinical diagnos...
Treatment Process - Selection
DATA NEEDED
PRETREATMENT DIAGNOSIS
SEVERITY OR STAGE
GOALS AND OBJECTIVES
TREATMENT OPTIONS
...
Treatment Process - Selection
SELECTION PROCESS
Options Benefit Risk Cost Availability
1
2
3
Tumors of the Parotid Gland
H...
MANAGEMENT OF A PATIENT
PROBLEM-SOLVING AND DECISION-MAKING
GOALS
RESOLUTION OF HEALTH PROBLEM
LIVE PATIENT
NO COMPLICATIO...
Treatment Process - Selection
SELECTION PROCESS
Treatment Benefit Risk Cost (PhP) Availability
Options
1 most effective ac...
Treatment Process - Selection
SELECTION PROCESS
Treatment Benefit Risk Cost (PhP) Availability
Options
1 as effective as 2...
Treatment Process - Selection
SELECTION PROCESS
Treatment Benefit Risk Cost (PhP) Availability
Options
1 as effective as 2...
Tumors of the Parotid Gland
How to Manage
Treatment
Guidelines
Parotitis, acute
Parotitis, chronic
Parotid abscess
Parotid...
Tumors of the Parotid Gland
How to Manage
Treatment
Guidelines
Parotitis, acute
Viral – mumps
NO antibiotics needed
Sympto...
Tumors of the Parotid Gland
How to Manage
Treatment
Guidelines
Parotitis, acute
Bacterial
Antibiotics (BRCA) – Gram (+) an...
Tumors of the Parotid Gland
How to Manage
Treatment
Guidelines
Parotitis, chronic, nonspecific
Antibiotics (BRCA) – Gram (...
Tumors of the Parotid Gland
How to Manage
Treatment
Guidelines
Parotid abscess, bacterial
Drain
Antibiotics (BRCA) – Gram ...
Tumors of the Parotid Gland
How to Manage
Treatment
Guidelines
Parotid tumor, benign
Watchful waiting, if chosen
Excision ...
Tumors of the Parotid Gland
How to Manage
Treatment
Guidelines
Parotid tumor, malignant, resectable
Wide Excision – subtot...
Tumors of the Parotid Gland
How to Manage
Treatment
Guidelines
Parotid tumor, malignant, resectable
Wide Excision – subtot...
Tumors of the Parotid Gland
How to Manage
Treatment
Guidelines
Parotid tumor, malignant, difficult or non-resectable
Radio...
Treatment Process - Selection
Tumors of the Parotid Gland
How to Manage
Parotid Cancer, Mucoepidermoid, Superficial Lobe, ...
Treatment Process - Selection
Tumors of the Parotid Gland
How to Manage
Parotid Cancer, Mucoepidermoid, Superficial Lobe, ...
Tumors of the Parotid Gland
How to Manage
Treatment
After the options of the treatment have been analyzed,
ADVISE patient ...
Referral - When to Refer?
All physicians, both certified and not yet certified,
must know their limitations.
Only they the...
Referral - To Whom to Refer?
Referral must be made to somebody
who may or can solve the patient’s
health problem
rationall...
Tumors of the Parotid Gland
How to Manage
Referral
After the options of referral have been analyzed,
ADVISE patient and re...
Tumors of the Parotid Gland
How to Manage
Surgical Treatment
Assuming a surgical treatment will be done.
How to manage it!
Surgical Treatment
Process
PREOP PREPARATION
Tumors of the Parotid Gland
How to Manage
Surgical Treatment Process - Preop
Preparation
• INFORMED CONSENT
• PSYCHOSOCIAL SUPPORT
• OPTIMIZATION
• SCREENING
• OPER...
Surgical Treatment Process - Preop
Preparation
• INFORMED CONSENT
• PSYCHOSOCIAL SUPPORT
Tumors of the Parotid Gland
How t...
Management of a Surgical Patient [Process]
Surgical Treatment
Process
INTRAOP
MANAGEMENT
Surgical Treatment Process - Intraop Mgt
PHASES
• INCISION
• EXPOSURE
• INTRAOP EVALUATION
• OPERATIVE PROCEDURE PROPER
• ...
Surgical Treatment Process - Intraop Mgt
Quality Standards:
GENTLE
METICULOUS and PRECISE
NO IATROGENIC INJURIES
NO UNNECE...
Surgical Treatment
Process
POSTOP CARE
Tumors of the Parotid Gland
How to Manage
Surgical Treatment Process - Postop Care
•SUPPLY BASIC NEEDS OF PATIENT
• COMFORT
• ANALGESICS
• FLUID AND ELECTROLYTES
• ...
Surgical Treatment
Process
POSTOP FOLLOW-UP
PLAN
Tumors of the Parotid Gland
How to Manage
Surgical Treatment Process - Postop Follow-
up Plan
OBJECTIVES:
• EVALUATE TREATMENT OUTCOME
• PROVIDE PSYCHOSOCIAL SUPPOR...
Surgical Treatment Process - Postop Follow-
up Plan
FF-UP FREQUENCY GUIDELINES: CONSIDER
• USUAL COURSE OF DISEASE
• PERSO...
Tumors of the Parotid Gland
How to Manage
Reynaldo O. Joson, MD, MSc Surg
0918-804-03-04
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Tumors of the Parotid Gland - How to Manage

  1. 1. Tumors of the Parotid Gland How to Manage Reynaldo O. Joson, MD, MSc Surg April 18, 2014
  2. 2. Tumors of the Parotid Gland How to Manage Managing tumors of the parotid gland will always be a challenge! Inexactness of medicine as a science No two patients are the same No two physicians are the same
  3. 3. Tumors of the Parotid Gland How to Manage Managing tumors of the parotid gland will always be a challenge! to Primary Health Care Physicians General Surgeons – Head and Neck Surgeons Other Head and Neck Surgeons and Specialists Pathologists Radiologists
  4. 4. Tumors of the Parotid Gland How to Manage Managing tumors of the parotid gland will always be a challenge! to Primary 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
  5. 5. Tumors of the Parotid Gland How to Manage Managing tumors of the parotid gland will always be a challenge! To Radiologists •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
  6. 6. Tumors of the Parotid Gland How to Manage Managing tumors of the parotid gland will always be a challenge! To Pathologists •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
  7. 7. Tumors of the Parotid Gland How to Manage Managing tumors of the parotid gland will always be a challenge! to General Surgeons – Head and Neck Surgeons Other Head and Neck Surgeons and Specialists Greatest Challenge Clinician – Diagnostician – Therapist - Adviser
  8. 8. Tumors of the Parotid Gland How to Manage 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)
  9. 9. Tumors of the Parotid Gland How to Manage 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.
  10. 10. Tumors of the Parotid Gland How to Manage 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
  11. 11. Tumors of the Parotid Gland How to Manage 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
  12. 12. Tumors of the Parotid Gland How to Manage 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
  13. 13. Tumors of the Parotid Gland How to Manage 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
  14. 14. Tumors of the Parotid Gland How to Manage Clinical Diagnosis Pattern Recognition Parotitis, acute Parotitis, chronic Parotid abscess Parotid hemangioma / lymphangioma Parotid cyst Parotid mass, benign pleomorphic adenoma Parotid mass, Warthins’ tumor, papillary cystadenoma lymphomatosum Parotid cancer Parotid lymphoma others
  15. 15. Tumors of the Parotid Gland How to Manage 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 • Look for pattern for inflammatory tumors – swelling with no dominant mass, pus, erythema, severe tenderness (parotitis, parotid abscess)
  16. 16. Tumors of the Parotid Gland How to Manage 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 • 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.
  17. 17. Tumors of the Parotid Gland How to Manage 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 • If no pattern for malignant tumors, settle for nonmalignant or benign tumors (especially so if the tumor feels cystic – parotid cyst)
  18. 18. Tumors of the Parotid Gland How to Manage 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
  19. 19. Tumors of the Parotid Gland How to Manage Clinical Diagnosis After using the clinical diagnostic process, come out with primary and secondary clinical diagnoses. Examples: Primary: Parotid tumor, right, parotid abscess Secondary: Parotid tumor, right, malignant Primary: Parotid tumor, left, benign, pleomorphic adenoma Secondary: Parotid tumor, left, malignant
  20. 20. Tumors of the Parotid Gland How to Manage Clinical Diagnosis After using the clinical diagnostic process, come out with primary and secondary clinical diagnoses. Examples: Primary: Parotid tumor, left, benign, pleomorphic adenoma Secondary: Soft tissue mass, preauricular, left, lipoma Primary: Parotid tumor, left, benign, pleomorphic adenoma Secondary: Lymph node, preauricular, left, metastatic from nasopharyngeal ca
  21. 21. Tumors of the Parotid Gland How to Manage Clinical Diagnosis After using the clinical diagnostic process, come out with 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 (10%)
  22. 22. Tumors of the Parotid Gland How to Manage Clinical Diagnosis After using the clinical diagnostic process, come out with 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%)
  23. 23. Tumors of the Parotid Gland How to Manage Clinical Diagnosis After 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.
  24. 24. Tumors of the Parotid Gland How to Manage Paraclinical Diagnosis Diagnosis derived after the clinical diagnosis with the use of paraclinical diagnostic procedures. Decision-making: • Indication • Selection • Interpretation
  25. 25. Paraclinical Diagnostic Process - Indication PROCESSING OF DATA CERTAINTY OF CLINICAL Dx 1O Dx 60% 99% needed not needed TREATMENT PLAN FOR 1O & 2O Dx Different Same needed not needed Tumors of the Parotid Gland How to Manage
  26. 26. Tumors of the Parotid Gland How to Manage Paraclinical Diagnosis After analyzing on need or no need for paraclinical diagnostic procedure, ADVISE patient and relative on recommendation and bases and SECURE an informed consent.
  27. 27. Paraclinical Diagnostic Process - Selection SELECTION PROCESS Options Benefit Risk Cost Availability 1 2 3 Tumors of the Parotid Gland How to Manage OBJECTIVES: Increase degree of certainty of diagnosis and extent OUTPUT EXPECTED MOST COST-EFFECTIVE DIAGNOSTIC PROCEDURE (with room for “initial” testing and respect for patient’s concerns)
  28. 28. Paraclinical Diagnostic Process - Selection SELECTION PROCESS Options Benefit Risk Cost Availability 1- Watchful monitoring 2- Needle Evaluation + Biopsy 3- Open Biopsy 4- Frozen-section Biopsy 5- Ultrasound 6- X-ray 7-Sialography 8- CT Scan 9- MRI Tumors of the Parotid Gland How to Manage
  29. 29. Paraclinical Diagnostic Process - Selection Tumors of the Parotid Gland How to Manage 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 fee P600 RA Needle evaluation + biopsy Direct exam Gross character and biopsy (benign vs malignant) 90% Pain, infection, seeding Procedure Expense P6T RA
  30. 30. Paraclinical Diagnostic Process - Selection Tumors of the Parotid Gland How to Manage 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 Needle evaluation + biopsy Direct exam Gross character and biopsy (benign vs malignant) 90% Pain, infection, seeding Procedure Expense P6T RA Open biopsy (non-frozen) Direct exam Gross character and biopsy (benign vs malignant) 98% Scar, pain, infection, seeding P15T RA
  31. 31. Paraclinical Diagnostic Process - Selection Tumors of the Parotid Gland How to Manage 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 Open biopsy (non-frozen) Direct exam Gross character and biopsy (benign vs malignant) 98% Scar, pain, infection, seeding P15T RA Frozen biopsy Direct exam Gross character and biopsy (benign vs malignant) 98% Scar, pain, infection, seeding P30T (lab, anesthesia, operating room) RA
  32. 32. Paraclinical Diagnostic Process - Selection Tumors of the Parotid Gland How to Manage 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 X-ray Indirect exam- Calcification- stone 1% Radiation P300 RA Sialography Indirect exam Stone; obstructed duct 1% Radiation, pain P9T NRA
  33. 33. Paraclinical Diagnostic Process - Selection Tumors of the Parotid Gland How to Manage 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 Ultrasound Indirect exam Cystic – benign Ill-bordered solid - malignant 60% Necrosis P2T RA CT Scan Indirect exam Border and extent 70% Radiation, dye reaction, if used claustrophobia P10T RA
  34. 34. Paraclinical Diagnostic Process - Selection Tumors of the Parotid Gland How to Manage 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 CT Scan Indirect exam Border and extent 70% Radiation, dye reaction, if used claustrophobia P10T RA MRI Indirect exam Border and extent 80% Side effect of magnet Dye reaction P15T RA
  35. 35. Paraclinical Diagnostic Process – Selection Indication Advisory Watchful monitoring •If suspicion for malignancy is low – below 10% •If there is patient’s informed refusal for other diagnostic procedures Tumors of the Parotid Gland How to Manage
  36. 36. Paraclinical Diagnostic Process – Selection Indication Advisory Needle 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 Tumors of the Parotid Gland How to Manage
  37. 37. Paraclinical Diagnostic Process – Selection Indication Advisory Open Biopsy •If there is a need for a definitive histologic diagnosis Tumors of the Parotid Gland How to Manage
  38. 38. Paraclinical Diagnostic Process – Selection Indication Advisory Frozen-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 Tumors of the Parotid Gland How to Manage
  39. 39. Paraclinical Diagnostic Process – Selection Indication Advisory X-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 Tumors of the Parotid Gland How to Manage
  40. 40. Paraclinical Diagnostic Process – Selection Indication Advisory Sialography •If sialolithiasis is suspected •If there is a need to assess the ductal system of the parotid gland Tumors of the Parotid Gland How to Manage
  41. 41. Paraclinical Diagnostic Process – Selection Indication Advisory Ultrasound •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 Tumors of the Parotid Gland How to Manage
  42. 42. Paraclinical Diagnostic Process – Selection Indication Advisory CT-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 • Tumors of the Parotid Gland How to Manage
  43. 43. Paraclinical Diagnostic Process – Selection Indication Advisory MRI •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 Tumors of the Parotid Gland How to Manage
  44. 44. Paraclinical Diagnostic Process - Selection SELECTION PROCESS Options Benefit Risk Cost Availability 1 2 3 Tumors of the Parotid Gland How to Manage OBJECTIVES: Increase degree of certainty of diagnosis and extent OUTPUT EXPECTED MOST COST-EFFECTIVE DIAGNOSTIC PROCEDURE (with room for “initial” testing and respect for patient’s concerns)
  45. 45. Tumors of the Parotid Gland How to Manage Paraclinical Diagnosis After analyzing the BRCA for the options on paraclinical diagnostic procedure, ADVISE patient and relative on recommendation and bases and SECURE an informed consent.
  46. 46. Paraclinical Diagnostic Process - Interpretation DATA NEEDED PRIMARY CLINICAL DIAGNOSIS SECONDARY CLINICAL DIAGNOSIS RESULT OF PARACLINICAL DIAGNOSTIC PROCEDURE Tumors of the Parotid Gland How to Manage
  47. 47. Paraclinical Diagnostic Process - Interpretation INTERPRETATION PROCESS CORRELATE RESULT OF PARACLINICAL DIAGNOSTIC PROCEDURE WITH PRIMARY AND SECONDARY CLINICAL DIAGNOSIS CONGRUENT - ACCEPT INCONGRUENT - MAKE A DECISION! (Accept or Hold!) Tumors of the Parotid Gland How to Manage
  48. 48. Paraclinical Diagnostic Process - Interpretation INTERPRETATION PROCESS INCONGRUENT - MAKE A DECISION! (Accept or Hold!) Tumors of the Parotid Gland How to Manage 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.
  49. 49. Tumors of the Parotid Gland How to Manage Paraclinical Diagnosis 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 SECURE an informed consent.
  50. 50. Treatment Process - Selection DATA NEEDED PRETREATMENT DIAGNOSIS SEVERITY OR STAGE GOALS AND OBJECTIVES TREATMENT OPTIONS Tumors of the Parotid Gland How to Manage
  51. 51. Treatment Process - Selection SELECTION PROCESS Options Benefit Risk Cost Availability 1 2 3 Tumors of the Parotid Gland How to Manage OBJECTIVE: To resolve the patient’s health problem OUTPUT EXPECTED MOST COST-EFFECTIVE TREATMENT PROCEDURE ACHIEVEMENT OF GOALS OF PATIENT MANAGEMENT!
  52. 52. MANAGEMENT OF A PATIENT PROBLEM-SOLVING AND DECISION-MAKING GOALS RESOLUTION OF HEALTH PROBLEM LIVE PATIENT NO COMPLICATION NO DISABILITY SATISFIED PATIENT NO MEDICOLEGAL SUIT
  53. 53. Treatment Process - Selection SELECTION PROCESS Treatment Benefit Risk Cost (PhP) Availability Options 1 most effective acceptable 2000 available 2 effectivity <1 >3 acceptable 3000 available 3 least effective acceptable 4000 available Which is the most cost-effective treatment option? Option 1 Tumors of the Parotid Gland How to Manage
  54. 54. Treatment Process - Selection SELECTION PROCESS Treatment Benefit Risk Cost (PhP) Availability Options 1 as effective as 2 acceptable 8000 available 2 as effective as 1 acceptable 4000 available Which is the more cost-effective treatment option? Option 2 Tumors of the Parotid Gland How to Manage
  55. 55. Treatment Process - Selection SELECTION PROCESS Treatment Benefit Risk Cost (PhP) Availability Options 1 as effective as 2 more complication 8000 available 2 as effective as 1 acceptable 4000 available Which is the more cost-effective treatment option? Option 2 Tumors of the Parotid Gland How to Manage
  56. 56. Tumors of the Parotid Gland How to Manage Treatment Guidelines Parotitis, acute Parotitis, chronic Parotid abscess Parotid hemangioma / lymphangioma Parotid cyst Parotid mass, benign pleomorphic adenoma Parotid mass, Warthins’ tumor, papillary cystadenoma lymphomatosum Parotid cancer Parotid lymphoma others
  57. 57. Tumors of the Parotid Gland How to Manage Treatment Guidelines Parotitis, acute Viral – mumps NO antibiotics needed Symptomatic treatment Non-pharmacologic – warm compress for pain; sponge bath for fever; etc. Pharmacologic prn – analgesics; antipyretics Soft diet if there is pain on chewing Rest and watchful waiting for spontaneous recovery from infection
  58. 58. Tumors of the Parotid Gland How to Manage Treatment Guidelines Parotitis, acute Bacterial Antibiotics (BRCA) – Gram (+) and Gram (-) microbes Investigate and remove cause (example: sialolithiasis) Symptomatic treatment Non-pharmacologic – warm compress for pain; sponge bath for fever; etc. Pharmacologic prn – analgesics; antipyretics Soft diet if there is pain on chewing Rest and watchful waiting for recovery from infection
  59. 59. Tumors of the Parotid Gland How to Manage Treatment Guidelines Parotitis, chronic, nonspecific Antibiotics (BRCA) – Gram (+) and Gram (-) microbes, if needed Investigate and remove cause (example: sialolithiasis) Symptomatic treatment Non-pharmacologic – warm compress for pain; sponge bath for fever; etc. Pharmacologic prn – analgesics; antipyretics Soft diet if there is pain on chewing Rest and watchful waiting for recovery from infection
  60. 60. Tumors of the Parotid Gland How to Manage Treatment Guidelines Parotid abscess, bacterial Drain Antibiotics (BRCA) – Gram (+) and Gram (-) microbes Investigate and remove cause (example: sialolithiasis) Symptomatic treatment Non-pharmacologic – warm compress for pain; sponge bath for fever; etc. Pharmacologic prn – analgesics; antipyretics Soft diet if there is pain on chewing Rest and watchful waiting for recovery from infection
  61. 61. Tumors of the Parotid Gland How to Manage Treatment Guidelines Parotid tumor, benign Watchful waiting, if chosen Excision – subtotal parotidectomy; total parotidectomy if whole gland is involved
  62. 62. Tumors of the Parotid Gland How to Manage Treatment Guidelines Parotid tumor, malignant, resectable Wide 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
  63. 63. Tumors of the Parotid Gland How to Manage Treatment Guidelines Parotid tumor, malignant, resectable Wide 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
  64. 64. Tumors of the Parotid Gland How to Manage Treatment Guidelines Parotid tumor, malignant, difficult or non-resectable Radiotherapy vs chemotherapy Surgery if lesion becomes resectable
  65. 65. Treatment Process - Selection Tumors of the Parotid Gland How to Manage Parotid Cancer, Mucoepidermoid, Superficial Lobe, Resectable Objective: 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 Anesthesia Facial nerve palsy P100T RA Radiotherapy 70% LLL Radiation P100T RA Chemotherapy 30% LL Side effects drug P120T RA Alternative medicine 1% Shortest L Side effects P120T RA
  66. 66. Treatment Process - Selection Tumors of the Parotid Gland How to Manage Parotid Cancer, Mucoepidermoid, Superficial Lobe, Resectable Objective: 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 RA Total parotidectomy 5% Same Facial nerve palsy (90%) More expensive RA
  67. 67. Tumors of the Parotid Gland How to Manage Treatment After the options of the treatment have been analyzed, ADVISE patient and relative on Proposed treatment with bases and SECURE an informed consent.
  68. 68. 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. Tumors of the Parotid Gland How to Manage
  69. 69. 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, and who has a good track record of handling the kind of problem on hand. Tumors of the Parotid Gland How to Manage
  70. 70. Tumors of the Parotid Gland How to Manage Referral After the options of referral have been analyzed, ADVISE patient and relative on need of referral if needed and with bases and SECURE an informed consent.
  71. 71. Tumors of the Parotid Gland How to Manage Surgical Treatment Assuming a surgical treatment will be done. How to manage it!
  72. 72. Surgical Treatment Process PREOP PREPARATION Tumors of the Parotid Gland How to Manage
  73. 73. Surgical Treatment Process - Preop Preparation • INFORMED CONSENT • PSYCHOSOCIAL SUPPORT • OPTIMIZATION • SCREENING • OPERATIVE MATERIALS Tumors of the Parotid Gland How to Manage See Preoperative and Preanesthetic Evaluation or Risk Assessment and Management PCS Guidelines (Non-cardiac surgery) ASA Practice Advisory for Preanesthetic Evaluation (2011) – No routine!
  74. 74. Surgical Treatment Process - Preop Preparation • INFORMED CONSENT • PSYCHOSOCIAL SUPPORT Tumors of the Parotid Gland How to Manage Risk Information - parotidectomy Facial nerve palsy (temporary or permanent) Frey’s Syndrome Numbness of ear (great auricular nerve transection) Bleeding Infection Anesthestic Risk Information – neck dissection Numbness
  75. 75. Management of a Surgical Patient [Process] Surgical Treatment Process INTRAOP MANAGEMENT
  76. 76. Surgical Treatment Process - Intraop Mgt PHASES • INCISION • EXPOSURE • INTRAOP EVALUATION • OPERATIVE PROCEDURE PROPER • HEMOSTASIS CHECK • CORRECT COUNT • WOUND CLOSURE Tumors of the Parotid Gland How to Manage
  77. 77. Surgical Treatment Process - Intraop Mgt Quality Standards: GENTLE METICULOUS and PRECISE NO IATROGENIC INJURIES NO UNNECESSARY MOVES EVERY MOVE HAS A REASON! Tumors of the Parotid Gland How to Manage
  78. 78. Surgical Treatment Process POSTOP CARE Tumors of the Parotid Gland How to Manage
  79. 79. Surgical Treatment Process - Postop Care •SUPPLY BASIC NEEDS OF PATIENT • COMFORT • ANALGESICS • FLUID AND ELECTROLYTES • NUTRITION •SUPPORT ORGAN FUNCTION •WOUND CARE •MONITORING FOR COMPLICATIONS •ADVICE ON • HOME CARE • FOLLOW-UP PLAN Tumors of the Parotid Gland How to Manage
  80. 80. Surgical Treatment Process POSTOP FOLLOW-UP PLAN Tumors of the Parotid Gland How to Manage
  81. 81. Surgical Treatment Process - Postop Follow- up Plan OBJECTIVES: • EVALUATE TREATMENT OUTCOME • PROVIDE PSYCHOSOCIAL SUPPORT MONITORING GUIDELINE: PHYSICAL EXAMINATION SYMPTOM-DIRECTED INVESTIGATION Tumors of the Parotid Gland How to Manage
  82. 82. Surgical Treatment Process - Postop Follow- up Plan FF-UP FREQUENCY GUIDELINES: CONSIDER • USUAL COURSE OF DISEASE • PERSONALITY OF PATIENT • PATIENT’S CONVENIENCE Tumors of the Parotid Gland How to Manage
  83. 83. Tumors of the Parotid Gland How to Manage Reynaldo O. Joson, MD, MSc Surg 0918-804-03-04
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