Head and neck surgeon Wojtek Mydlarz provides a recap of the recommendations for parotid tumor management that he shared during the American Academy of Otolaryngology–Head and Neck Surgery Annual Meeting 2022. He advises physicians to review and consider patient history, physical exam, imaging results and biopsy findings, as well as any gut feeling elicited when viewing a patient’s presentation in totality.
Hello to everyone. My name is Vojtech Mid Lash. I'm ahead. Next surgical oncologist at johNS Hopkins University School of Medicine and I want to give you a quick recap of a seminar we held at the National academy meeting in philadelphia on sort of what every otolaryngologist should know about. Prodded tumor management. Again, obviously complex issue. We can spend a week to have a seminar on this, but I think it it can we can we can hit some highlights and some big points in terms of trying to how to move through the work of the management of these patients and get them through the treatment they may need or may not need. Uh, I think the main issue is again, that there's, you know, 30 or 40 tumor types, whether they're primary tumors of the gland or they're spreading to the lymph nodes of the gland, as we all know. The good news is that most of our benign but not all. And I think that's the challenge is trying to figure out which are the ones that we need to worry more about sort of do more of a workout but also obviously do a different type of treatment for them. So the key things we sort of handled as a, as a panel. So really have a systematic approach to these. I think having looking at the history in terms of the timing of symptoms, trajectory of symptoms, what symptoms they are, the exam sort of what you find on the exam. Not only by palpitation but also visualization. That includes sort of a part of that is also imaging what imaging you choose in terms of how to work these up. Then. Obviously biopsy, I think we all decided not decided. We all agreed that really these days that all these tumors are, most of these tumors should really be receiving a fine needle aspiration or biopsy attempt to get more. Again, there's some there's some challenges with that, but then putting all that together and sort of the art of medicine. Right. They got feeling as to when you may need to worry about a certain tumor and how you should approach it. So it's sort of an important part. So I'll just bring to the goal overall sort of the flow of these and sort of how we think about it. So in terms of history, so the type of symptoms, right? Feeling changes, sensation changes, weakness, paralysis, trees mus. Right. That's the one that really worries me on the exam. Is that mobile now? Does it feel inflamed? Um Is there overlying skin changes obviously are the length notes involved or are words? I mean those are all things that should make you sort of think about other things then, then there's obviously imaging. I think the imaging M. R. I. I think we all agree that it's probably the gold standard the best oftentimes these patients come to you with a ct scan, we showed pictures of sort of what the cT would show what the M. R. I would show and would really change your approach to the sun. You worry factor based on what the M. R. I. Really shows things the things that the M. R. I. Can help us look at really the infiltration and the quality of the capsule of the tumor, the density of the tumor looking at A. D. C. Mapping which is part of the diffusion weighted imaging. A lot of the M. R. I. Machines. And now most radiologists will comment on that is when you see these higher density lesions are the ones that you need to worry more about malignancy. The other one is obviously the biopsy and these are the places where I think we're still learning more. There's the new milan grading system of these tumors. And the issue is again trying to figure out what those categories mean. They're trying to copy what they did for the thyroid side of pathology and sort of extend that over to salary. But I think there's good data for it. But the ones that we struggle with are obviously the a tip of unknown significance or a U. S. Or the salivary gland. New classes of unknown malignant potential a lot to say about the sums these are the ones that we need to sort of worry about. And I think it all deserves a discussion with the pathologist to make sure that they not only give you the category they give you any psychologic information on the and the nuclear power. The cells. Are there any worrisome sort of findings even if minimal and then sort of what they think kind of push them to give you a differential what they can tell you based on what they saw on the biopsy. And then of course there's the gut feeling right there, putting everything together and putting all three things that history and exam may worry more than what the imaging on the side of pathology shows. With plenty of examples of that where the worry was was welcomed, meaning the pathology was different than what the imaging and the side of pathology showed. But there was worrisome symptoms and sort of trajectory things and on exam findings that that warranted more of an aggressive approach to these. So these are all things that you know, listen to your gut feeling, this will help sort of counsel you with the patients, but also their family members and sort of help you kind of work through the workflow in getting patients to the right surgery. And I think those are really the the main points of the seminar took a lot of great questions went over some cases as well to sort of show a lot of these changes and challenges that we all face