0:05

Do you remember this case?

0:07

Uh, yes. Uh, I cannot get it right.

0:10

Okay. What did you say? Yeah,

0:13

I, I, I can see the mess, but I never thought of ancy because you still like,

0:18

so to me.

0:20

Yeah. Yeah. So one thing I will say that I've learned over time,

0:23

and this is something from my fellowship, is that fellow,

0:26

the one thing about head and neck is 80% of what we see can either be seen

0:30

directly or palpated. So anytime that you see something like this,

0:35

uh, on imaging features, on imaging,

0:37

sometimes it's hard to distinguish between a benign and a malignant mask.

0:41

And so the way to kind of get around it is,

0:44

it's just best to describe the abnormality. And, um,

0:48

if you wanna say it's benign, that's fine,

0:50

but just realize the imaging findings can be really be non-specific.

0:54

And especially if it's something like this can, that can be seen so easily,

0:58

you just want to say,

0:59

just go ahead and evaluate with direct endoscopy and biopsy as indicated.

1:04

So I agree with you, it doesn't necessarily look super malignant. In fact,

1:08

it was a melanoma melanomas can sort of be slowly growing,

1:12

so they don't tend to have the characteristics of a highly aggressive, you know,

1:16

rapidly turning over mass. So that's why I think it's just best to say, Hey,

1:21

let's just correlate with direct evaluation and biopsy. Does that make sense?

1:26

Yes. So this test is the melanoma. So for T one,

1:30

it doesn't necessarily to be hyper intense for melanoma? Yeah,

1:35

That's a great question. So if it is hyper intense on T one, then it,

1:38

it certainly indicates a melanoma, but not all melanomas are, are,

1:43

have, uh, are high, have high T one signal

1:48

So far our mm-hmm.

1:50

Our job is to just to as to report the extension of the

1:54

tumor to the surgeon.

1:57

Yes. Yes. And then give a reasonable differential diagnosis.

2:01

Okay.

2:02

Yeah.

2:02

And just keep the back of your mind that anything that they can see or feel,

2:06

especially they can see it, you can just, you know,

2:09

correlate with direct endoscopy. And the part of that's, that's,

2:12

that I've noticed, that's important too.

2:14

I don't know what it's like where you are, um, in Malaysia,

2:18

but you know, in the US if it's, if it's referred by a subspecialist,

2:24

then the subspecialist sort of knows what to do. But, you know,

2:28

in the United States, imaging is so common,

2:33

and we have a shortage of physicians that they're more and more

2:37

non-physicians that are seeing patients in offices,

2:41

and they just don't have the experience. It's nothing wrong,

2:44

it's that they're providing more access, which is good.

2:47

But what I've noticed is that we as physicians, we as radiologists,

2:52

really need to be more pers prescriptive because oftentimes the,

2:57

the, the physician extender that's working in the office,

3:00

they need to know whether or not they can treat the patient themselves,

3:02

or do they need to refer it to a subspecialist. And so if you do recommend,

3:08

you know, direct evaluation or potential biopsy,

3:12

then that indicates to the referring provider that they, or the,

3:15

the referring provider that could be a physician extender that they need to

3:18

refer to a subspecialist. So I think more and more, at least my opinion,

3:23

and, um, is that, you know, radiologists,

3:26

we are sort of transitioning more into a gatekeeper role,

3:30

something that was talked about 25 years ago, but I'm starting to see it,

3:33

you know, more and more prevalent, um, that if in a community facing practice,

3:39

are you there?

3:41

Uh, yes.

3:42

Okay. Any

3:43

Comments? Yeah, I agree. Refuse. Now nowadays they, they,

3:47

they do imaging quite often and frequently.

3:51

Yeah. Yeah.

3:53

But it's good for us

3:55

Yeah, exactly.

3:55

To studies. Yeah.

3:58

But, you know, don't, you know, don't hesitate to,

4:01

to recommend something like that.

4:02

I always put it clinically indicated or ask clinically indicated.

4:06

I think in the US if you just say something without some type of modifier,

4:10

you know, you're putting the, the referring physician at medical-legal risk.

4:15

Because if they don't do what you say and something, um, comes out poorly,

4:20

then they're gonna be, um, at medical legal risk.

4:24

So I always say as clinically indicated, and in general, I,

4:27

I don't get any negative comments about that if I do recommend something.

4:32

Okay. For this case, I know these days I noticed there is, um,

4:36

erosion into the inferior, inferior turbinate.

4:39

So that might be a sign of invasive invasiveness of this

4:44

soft tissue.

4:45

Yes. I think that's reasonable. In general,

4:49

you're not gonna have too many benign tumors involved in the TURs or the cy

4:53

nasal cavity.

4:54

Occasionally you'll run into a p polymorphic adenoma or schwannoma,

4:57

but in general it's squamous cell carcinoma or lymphoma,

5:00

or minor salivary gland tumors. So it's better to err on,

5:04

uh, being more, um,

5:07

suggesting the tumor's more aggressive than more benign.