How Standard Is “Standard of Care”?

Dr. Donald added that, “It all depends on how well the patient likes you and respects you. I underplay the malignancy part, and don’t talk about national statistics. I do tell them about scarring. They’re quite concerned about that.”

Standards for Surgery

Dr. Persky asked the panel to talk about their surgical practices on patients similar to the woman in his case study. Dr. Donald reported that he obtains frozen sections on all patients he operates on. “My colleagues do not do this,” he said. “We only have about two or three [technicians] we can really count on to diagnose the samples correctly.”

Dr. Persky asked the panel if they use facial nerve monitoring during procedures. No one on the panel uses it regularly, but the audience was in favor of it.

Continuing with his case study, Dr. Persky told the panel that when the patient was incised, the mass turned out to be low-grade carcinoma. “The facial nerve is involved intimately with the tumor,” he said. “What do you do?”

“I like to get a biopsy and have the diagnosis before sacrificing the nerve,” said Dr. Descher. Dr. Smith said he would “definitely do a frozen section before sacrificing it. I’ve had a couple that were not malignant. Unless it’s definitive, I would stop.”

Fine Needle Aspirations

Dr. Persky went on to lead the panel in a discussion of fine needle aspirations, asking them to review a different case study: A 52-year-old man presents with a six-month history of a slowly enlarging, painless right parotid mass. FNA shows lymphoid tissue. “Most of us would take out that mass anyway,” said Dr. Persky.

Regarding FNAs, he continued, the American Head and Neck Society (AHNS) practice guidelines dictate that “If the parotid mass is mobile, discrete, and confined to the superficial lobe, no pre-operative FNA is necessary unless the patient’s medical condition is such that a general anesthetic would be very risky and a priority needs to be established.” This was obviously contrary to what the panel believed in as standard of care.

Furthermore, American Academy of Otolaryngology-Head and Neck Surgery clinical indicators for parotidectomy call FNAs, ultrasounds, CT scans, and MRIs “optional tests.” Dr. Persky pointed out, however, that this “represents guidelines only, this does not represent standard of care.”

Facial Nerve Monitoring

The AHNS guidelines do not mention facial nerve monitoring, Dr. Persky pointed out. “The literature shows that there is no difference in postoperative CN VII integrity” with facial nerve monitoring,” he added.