An oncology expert witness discusses a case involving delayed diagnosis of Squamous cell carcinoma of the base of the tongue. This case involves a forty-six-year-old male patient who underwent a root canal and antibiotic treatment for an abscess under the care of an endodontist. The patient’s pain and infection continued following treatment so he sought medical advice at an urgent care center. In early January 2010, the patient called the dental office where he underwent treatment complaining of swelling on the left side of his face. The receptionist insisted it was normal and to call back if it did not go away in a week or so. The patient saw another dentist again in February, as he needed a crown put on the tooth with the root canal. The tooth was still infected even after two months of antibiotic treatment. The dental notes state that the dentist fitting the crown contacted the endodontist to ask if the persistent infection was normal and according to the notes he said yes, it is normal in a “large infection”. The patient presented to his urgent care provider that same week complaining of a sore throat. Those medical records indicate he had a swollen lymph node which was painful to the touch, on the left side of his neck. He was told to continue treating the tooth with antibiotics. In May 2010, the patient noticed the left lymph node was hard and very pronounced. The patient presented to his endocrinologist who he was seeing for Type 1 diabetes who immediately scheduled a needle biopsy of the enlarged lymph node. The biopsy was suspicious and an urgent CT scan was ordered. The patient was diagnosed around in July 2010 with squamous cell base of tongue cancer, and was later staged as 4A, with a primary lesion at base of tongue of 4 cm +, and nodes throughout the tonsils, the throat, epiglottis.
Question(s) For Expert Witness
1. Do you treat patients with oral cancers, such as cancer of the base of the tongue?
2. Should the long term infection have raised suspicion of more serious pathology and prompted referral for further evaluation?
3. If the cancer has been diagnosed when the patient initially presented, could the outcome have been better?
Expert Witness Response E-008038
I frequently treat patients with oral cancer/head and neck cancer. Since this was a base of tongue tumor we would typically classify this as an oropharyngeal cancer. The long term infection can raise suspicion of a more serious pathology, but one has to look at the details. It can be hard to differentiate, but there are certain red flags. If the cancer had been diagnosed when the patient initially presented, the outcome may have been better. I would have to review the specifics of the case before making an assessment of whether the duration of infection should have prompted an earlier evaluation. It is always difficult to assess causality even when the standard of care has not been met. The prognosis is clearly related to the stage of disease and even patients with stage 4A have a cure rate.
About the author
Dr. Faiza Jibril
Dr. Faiza Jibril has extensive clinical experience ranging from primary care in the United Kingdom, to pediatrics and child abuse prevention at Mount Sinai Hospital, to obstetrics in Cape Town, South Africa. Her post-graduate education centered on clinical research and medical ethics. Dr. Jibril is currently Head of Sales in the US and Canada for Chambers and Partners - a world leading legal ranking and insights intelligence company.
