Missed Parotid Tumor

Case #173

A man in his 60s went to see an ENT physician (Dr. C) due to chronic ear pain.

A CT soft tissue neck was ordered, which was done at a nearby imaging center.

The ENT physician was particularly worried about a parotid gland tumor, and she noted this on the order.

The impression (written by radiologist Dr. J) mentioned normal anatomic structures of the neck, including normal appearance of the parotid and submandibular glands.

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The patient was treated for possible parotitis, and his symptoms improved.

He was told to come back if anything worsened.

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Over a year later, he returned with worsening ear pain.

Workup ultimately revealed a salivary gland tumor in the right parotid.

The patient underwent several surgical procedures, chemotherapy, and radiation therapy.

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A lawsuit was filed against both the ENT physician and radiologist for missing the tumor on the initial head CT.

The plaintiff’s ENT expert wrote the following opinion:

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A second ENT expert was also hired to opine about the consequences of the delayed diagnosis:

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The plaintiff also hired a radiologist who stated that the asymmetry between the two parotid glands should have been apparent.

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The defense hired an expert to defend the radiologist, noting the numerous difficulties in identifying the lesion:

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The defense also hired an ENT expert

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The plaintiff offered to settle with each defendant for $2,000,000.

A confidential settlement was reached and the lawsuit was withdrawn.

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MedMalReviewer Analysis:

1. Generally speaking, it’s a wise idea to review the images of any study you order. The ordering physician has a better understanding of the clinical situation and may be able to detect subtle findings that a radiologist may not appreciate. Professional and respectful skepticism about a radiologist’s report can save a patient from a bad medical outcome and avoid years of anguish for both the clinician and radiologist.

2. One of the main issues that contributed to this bad outcome was the fact that the ENT physician did not have easy access to the images. She received the written report but would have had to formally request access to the images through a burdensome process. This is a systems-level issue that creates barriers to providing good care. EMRs should automatically make these images available across healthcare systems, and the failure of our national leadership to mandate this contributes to numerous medical errors.

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If you’re interested in reading another case about head and neck oncology, check out this malpractice case regarding an HPV+ retropharyngeal squamous cell carcinoma.

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If you’re interested in reading another case involving a missed radiology read and poor communication between clinicians and consultants, check out this malpractice case regarding a vertebrobasilar stroke after a chiropractic adjustment.