Anyone Seen One of These (ENT)?

[GetMeOuttaThisMess]

I was asked by our NP to take a look at an oropharynx earlier this week because she was concerned a young adult female could have a peritonsillar abscess, which she had never seen.  When I looked in the mouth there was no peritonsillar abscess but what I did see on the superior pole of the palatine tonsil on the right was what appeared to be a round globule of adipose tissue.  I went back and told her that it wasn't a peritonsillar abscess and left it to her discretion to determine what to do with the patient.  After giving it some additional thought I believe that what I was seeing might have been a rare schwannoma of the tonsil.  Not at all uncommon with regard to the head/neck region but not common apparently with regard to tonsils.  Anyone else have a differential dx.? Bottom line, ENT referral would be the correct treatment plan so I'm going to check this morning to see what she did with the pt.

[GetMeOuttaThisMess]

Guess not then.  Some might wish to look so you can know what it would look like.  Found out that it was treated as "strep throat".  I politely asked the other provider what they did with the patient as far as follow up and there wasn't a recommendation.  I told them about the differential and that they might wish to recommend that the pt. see an ENT.  During the f/u call the patient allegedly said "I'm not going to spend $180 to go see a specialist."  That is so typical.  Always remember the House of God rule after you document the interaction:  "The patient is the one with the disease."

[mgriffiths]

Why treated as strep throat?  Did the strep culture come back positive?  I know it wasn't you, but so frustrating when antibiotics are just randomly thrown at something unknown.

Cool though about tonsillar schwannoma - hadn't heard that one before.

[GetMeOuttaThisMess]

We don’t have outside lab capability. To answer the question regarding strep, when you factor in a RST sensitivity in adults of 59% and a positive predictive value of 70% I can understand their rationale. I will say that I wouldn’t have called it strep.

 

[mgriffiths]

I meant to say rapid strep when I said culture, but I guess that sort of kinda makes sense.

[Reality Check 2]

Would love to see a pic.

Did it look like this?

[GetMeOuttaThisMess]

No. It was an essentially normal appearing palatine tonsil with an orange (adipose tissue appearance) mass on the superior pole with a diameter approximating a pencil eraser.

[EMEDPA]

12 hours ago, GetMeOuttaThisMess said:

Guess not then.  Some might wish to look so you can know what it would look like.  Found out that it was treated as "strep throat".  I politely asked the other provider what they did with the patient as far as follow up and there wasn't a recommendation.  I told them about the differential and that they might wish to recommend that the pt. see an ENT.  During the f/u call the patient allegedly said "I'm not going to spend $180 to go see a specialist."  That is so typical.  Always remember the House of God rule after you document the interaction:  "The patient is the one with the disease."

AGREE. I always refer weird lesions anywhere in/on the body to the appropriate specialist. had someone with a weird penile lesion a few years ago, which ended up being atypical squamous cell CA

[Marinejiujitsu]

AGREE. I always refer weird lesions anywhere in/on the body to the appropriate specialist. had someone with a weird penile lesion a few years ago, which ended up being atypical squamous cell CA

Yeah, I usually use the "weird lesion? Probably cancer" practice.

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[surgblumm]

It is always interesting to observe the manner that a clinician or multiple clinicians treat a patient. Failure to diagnose is one of the most common entities of malpractice and when in doubt refer to the specialist. some think turfing is a sign of weakness but in my experience it demonstrates integrity. The key issue was dealt with by notifying the patient, documenting your call about their refusal to see the ENT and checking with your fellow provider as we need to care for each other as well as the patient. Documentation of the rapid strep would certainly not hurt the legal medical record as it explains what you were thinking about as one of your differential diagnosis.

[cbrsmurf]

Given her age, malignancy is unlikely, but a possibility.

 

Could be a few things: most likely from your description, a tonsil mucocele (usually soft when you touch w/ finger or probe).  Consider papilloma, tonsil lobule, embedded tonsollith.  Schwannomas are rare in the tonsil, but I guess it's possible. 

 

Did it look like this?:

https://tonsilstoneremedies.net/6042/tonsil-cyst-symptoms-causes-treatment-pictures

[GetMeOuttaThisMess]

Given her age, malignancy is unlikely, but a possibility.
 
Could be a few things: most likely from your description, a tonsil mucocele (usually soft when you touch w/ finger or probe).  Consider papilloma, tonsil lobule, embedded tonsollith.  Schwannomas are rare in the tonsil, but I guess it's possible. 
 
Did it look like this?:
https://tonsilstoneremedies.net/6042/tonsil-cyst-symptoms-causes-treatment-pictures

Looks a lot closer to what I saw.


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[lkth487]

I pride myself for referring rarely for anything in pediatrics,  usually only after I've made the diagnosis and for definitive treatment, but obviously sometimes that's the answer.   It's very annoying to be rotating in a specialty and get a referral for nonsense without any workup. 

[HmTwoPA]

On 5/4/2018 at 9:58 PM, lkth487 said:

I pride myself for referring rarely for anything in pediatrics,  usually only after I've made the diagnosis and for definitive treatment, but obviously sometimes that's the answer.   It's very annoying to be rotating in a specialty and get a referral for nonsense without any workup. 

Pride comes before the fall. Its good to punt something to a specialist when your unfamiliar with it, doesn't waste the patients time (if you try to treat and get the diagnosis or treatment wrong you wasted their time anyway) and the specialist certainly doesn't mind the extra billing. 

[lkth487]

I agree.  

[sas5814]

There is a fine line between pride and arrogance sometimes and there is a line between the lazy "punt" with no workup and seeing something and knowing it needs a specialists evaluation. 

The lesion you are describing (IMHO) needs a biopsy or excision and pathology. Referral would have been exactly what I would have done mostly because any workup I would have been doing would have been lengthening the time between when I first saw him/her and when they reached definitive diagnosis and care.

It's not much different in my current light weight urgent care. I could do a lot more than we do (if I had more diagnostic tools available than I do) but if I know no matter what I do within our capabilities they need more testing or treatment than we can do...why delay getting them to the right place to do half the evaluation? There are, of course, a few exceptions where I need to decide the criticality of the problem before sending them on but mostly I want them where they need to be as fast as I can reasonably get them there.

Thread high-jack complete. Please return to your regular programming.

[GetMeOuttaThisMess]

1 hour ago, sas5814 said:

There is a fine line between pride and arrogance sometimes and there is a line between the lazy "punt" with no workup and seeing something and knowing it needs a specialists evaluation. 

The lesion you are describing (IMHO) needs a biopsy or excision and pathology. Referral would have been exactly what I would have done mostly because any workup I would have been doing would have been lengthening the time between when I first saw him/her and when they reached definitive diagnosis and care.

It's not much different in my current light weight urgent care. I could do a lot more than we do (if I had more diagnostic tools available than I do) but if I know no matter what I do within our capabilities they need more testing or treatment than we can do...why delay getting them to the right place to do half the evaluation? There are, of course, a few exceptions where I need to decide the criticality of the problem before sending them on but mostly I want them where they need to be as fast as I can reasonably get them there.

Thread high-jack complete. Please return to your regular programming.

The problem in this scenario is the fact that the original provider even after being told that "no, it isn't a peritonsillar abscess" didn't recognize it as something needing further assessment.  And this is an individual getting their doctorate supposedly this weekend with less than two years clinical experience.

[lkth487]

12 hours ago, HmTwoPA said:

Pride comes before the fall. Its good to punt something to a specialist when your unfamiliar with it, doesn't waste the patients time (if you try to treat and get the diagnosis or treatment wrong you wasted their time anyway) and the specialist certainly doesn't mind the extra billing. 

I think someone has to be the primary.  In the inpatient setting, sometimes you will have consults who will say and recommend crazy things.  I think you have to take the responsibility to to decide what to ignore and what to follow up on.  You have to remember when consulting specialists that when you're a hammer, everything looks like a nail.  Obviously you don't have the same control in an outpatient setting so it's different.