Biopsy, Fine Needle, Neck Mass
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Fine needle biopsy (FNB) is a procedure in which a small-caliber needle is placed into a mass, cellular material is removed, and a cytologic diagnosis is rendered. [1] It is widely accepted as one of the most useful diagnostic procedures in the evaluation of neck masses. Fine needle biopsy helps to distinguish inflammatory, reactive, or cystic lesions from neoplasms as well as benign neoplastic lesions from malignant ones. Fine needle biopsy is relatively safe, simple, and cost-effective, and it is well-tolerated by most patients. However, close attention must be paid to proper technique to ensure accurate results.
Fine needle biopsy can be performed with or without aspiration. Both techniques are described here. The more commonly used aspiration technique uses syringe-created negative pressure as well as the shearing effect of the needle to collect material from the biopsied lesion. In contrast, Zajdela et al described a technique in which only a bare fine needle without suction was used to obtain material from the target lesion. [2] This nonaspiration technique, also called the Zajdela (pronounced zidel-a) or fine-needle capillary method, relies on capillary action to draw the sheared cells within the small-caliber needle. [3, 4]
Advocates for the nonaspiration (Zajdela) technique believe that grasping the needle hub directly improves operator sensitivity in placing the needle tip within a small lesion. They also believe that less bleeding occurs with the nonaspiration technique, an advantage in the biopsy of more vascular tissue such as the thyroid gland. [4, 5] Studies have shown no statistically significant difference between aspiration and nonaspiration techniques in the successful retrieval of cytologic material. [5]
The neck is the part of the body that separates the head from the torso. The Latin-derived term cervical means “of the neck.” The neck supports the weight of the head and is highly flexible, allowing the head to turn and flex in different directions.
The midline in front of the neck has a prominence of the thyroid cartilage termed the laryngeal prominence, or the so-called “Adam’s apple.” Between the Adam’s apple and the chin, the hyoid bone can be felt; below the thyroid cartilage, a further ring that can be felt in the midline is the cricoid cartilage. Between the cricoid cartilage and the suprasternal notch, the trachea and isthmus of the thyroid gland can be felt.
The quadrangular area is on the side of the neck and is bounded superiorly by the lower border of the body of the mandible and the mastoid process, inferiorly by the clavicle, anteriorly by a midline in front of the neck, and posteriorly by the trapezius muscle.
The image below depicts the anterior cervical muscles.
For more information about the relevant anatomy, see Neck Anatomy.
Fine needle biopsy is the most useful procedure indicated in the evaluation of neck masses. [6] Virtually any mass that is either palpable or identified by an imaging technique can be sampled. Conditions amenable to diagnosis by fine needle biopsy include, but are not limited to, the following: [5]
Lymph nodes – Reactive changes, lymphoma, metastatic cancer
Thyroid gland – Solitary or dominant nodule, suspected malignancy, lymphoma, and nontoxic goiter versus autoimmune thyroiditis [7]
Salivary glands –Benign and malignant neoplasms, lymphoma, inflammatory lesions, and cysts [8]
Cystic lesions of the neck – Branchial cleft and thyroglossal duct cysts [9]
Miscellaneous – Parathyroid neoplasms, dermoid cysts, and teratomas
Fine needle biopsy should not be used indiscriminately. It should be performed with a reasonable expectation of receiving useful information. Clinically insignificant small nodes, vague indurations or asymmetries, and other minor abnormalities are not indications for fine needle biopsy. However, note that a negative report can be reassuring to apprehensive patients. [10]
See the list below:
No absolute contraindications exist to performing fine needle biopsy of neck masses.
However, a mass in the area of the carotid bifurcation may represent a carotid body tumor, and many clinicians are reluctant to biopsy these lesions. [1] Serious complications and one death have been reported following fine needle biopsy of carotid body tumors. [5] These lesions are better identified by imaging. Currently, MRI is the study of choice, followed by contrast-enhanced CT. Angiography is useful if the diagnosis is obscure or if embolization is contemplated. [11]
Fine needle biopsy can be performed without increased concern in patients taking aspirin or nonsteroidal anti-inflammatory drugs (NSAIDS).
Patients with bleeding disorders or those on anticoagulant therapy should receive appropriate medical consultation prior to fine needle biopsy. The decision whether to suspend anticoagulant medication must be made on a case-by-case basis. If the anticoagulant cannot be stopped safely, consideration should be given to using the smallest diameter needle possible, limiting the number of passes performed, and using ultrasonographic guidance to identify and avoid small vessels. [12]
The use of local anesthesia prior to fine needle biopsy (FNB) of neck masses is at the discretion of the practitioner.
Some authors do not recommend the use of local anesthesia prior to fine needle biopsy, especially for superficial masses. [1, 4, 5] They note that the injection of local anesthetic can cause as much pain as the fine needle biopsy itself. Additionally, infiltration of local anesthesia might make a small mass more difficult to palpate. One author recommended placement of a small ice pack on the overlying skin prior to biopsy. [13] For children, application of a topical anesthetic 30-60 minutes before the procedure can reduce pain and anxiety. [14] For more information, see Topical Anesthesia.
Other authors argue that the use of local anesthesia reduces patient discomfort and anxiety. Lidocaine 1-2% with or without 1:100,000 epinephrine is the agent of choice. The anesthetic is slowly infiltrated through a 30-gauge needle into the uppermost portion of the subcutaneous fat plane and allowed to back-infiltrate the dermal nerves, thus avoiding a painful dermal wheal. [15] Usually, cutaneous anesthesia is all that is needed to provide for a painless fine needle biopsy. Occasionally, deeper infiltration of anesthetic is needed if the target mass is inflamed. For more information, see Infiltrative Administration of Local Anesthetic Agents.
A committee report from the 2007 National Cancer Institute Thyroid Fine-Needle Aspiration State of the Science Conference provides an outstanding detailed description of local anesthetic technique for fine needle biopsy of the thyroid gland. [15]
Equipment is depicted in the image below and includes the items listed.
See the list below:
Needles: Most authors use 22- to 27-gauge needles of appropriate length [1, 5, 6, 10, 15] with clear or translucent hub.
Syringe, 10-mL (if aspiration technique used): Larger syringes have not been shown to provide greater suction. [4]
Pistol grip syringe holder (if aspiration technique used): This is highly recommended and allows more uniform suction and easier manipulation of the needle.
Pad or skin swab prepared with alcohol or iodine
Glass slides
Gauze sponge
See the list below:
The goal of positioning in a fine needle biopsy of the neck is to provide good access to the target mass with maximum comfort for the patient. In most cases, the patient in placed in the supine position.
In fine needle biopsy of the thyroid gland, most authors recommend placing a pillow under the patient’s shoulders. This extends the cervical spine and thins the soft tissue over the thyroid gland. [4] The needle is directed somewhat medially toward the nodule, away from the direction of the carotid artery. A thyroid nodule in the posterior part of a lobe can be made more accessible if the larynx is pushed toward the same side. [5]
The position of the patient for obtaining a biopsy of the lymph nodes of the neck varies. Nodes become more or less palpable according to the rotation of the head and flexion or extension of the neck.
Submandibular gland masses or lymph nodes of the submandibular space may require bimanual palpation. The index and middle fingers of the nondominant hand are placed in the mouth and push the mass inferiorly while the thumb stabilizes the mass externally. The dominant hand is free to use the needle/holder. [5]
See the list below:
Obtain informed consent. Patients should be advised of the very small possibility of infection or hematoma.
Label specimen slides with the patient’s identification before the procedure is begun.
Place the patient in the proper position.
Clean the skin overlying the target mass with a pad or swab prepared with alcohol (or povidone-iodine [Betadine]), then dry with sterile gauze.
Administer local anesthesia, if desired.
The aspiration technique is shown in the video below.
See the list below:
Fix the target mass between 2 fingers of the nondominant hand.
Advance the needle, attached to the syringe, into the mass. Do not apply suction during the advancement.
Once the needle tip is within the mass, apply suction by pulling back on the plunger of the syringe.
While maintaining suction, move the needle rapidly back and forth with short strokes within the mass.
Release negative pressure after sampling is completed and before withdrawing the needle from the mass.
Withdraw the needle. The cytologic specimen is within the needle and, perhaps, the hub of the needle.
Once withdrawn, detach the syringe from the needle. Fill the syringe with air and then reattach it to the specimen-containing needle.
Expel the specimen onto a glass microscope slide as described below.
The Zajdela technique is shown in the video below.
See the list below:
Fix the target mass between 2 fingers of the nondominant hand.
Hold the needle by the hub between the thumb and index finger.
Advance the needle into the target mass.
Move the needle back and forth within the mass with short, rapid strokes. Simultaneously, move the needle in a rotary clockwise-counterclockwise motion.
Withdraw the needle.
Attach an air-filled syringe, with the plunger already retracted, to the specimen-containing needle.
Expel the specimen onto a glass microscope slide as described below.
See the list below:
Expel the specimen onto a microscope slide. Keep the needle tip in contact with the slide to allow placement of a concentrated droplet and avoid spraying of the specimen. Spraying of the specimen is undesirable because it can result in desiccation of the specimen.
Residual material remaining in the hub of the needle, if desired, can be removed with a needle, endocervical brush, or fine wooden stick and placed on the slide.
See the list below:
The goal of smearing is to provide a monolayer of cells for microscopic examination.
Several methods of smearing have been described, the most common being the “one-step” and “two-step” techniques. The technique selected depends on the consistency of the specimen and the preference of the individual preparing the slide.
One-step technique, shown below
See the list below:
This technique is more frequently used if the specimen is semisolid or small in volume.
Place the specimen at the labeled end of the specimen slide.
Hold the specimen slide with the labeled end (and specimen) uppermost. Hold the spreading slide perpendicular to the specimen slide. Hold the lower edge of the spreading slide in contact with the specimen slide in a hingelike fashion below the specimen.
Rotate the upper edge of the spreading slide toward the specimen so that the spreading slide gently covers the specimen. Pull the spreading slide downward over the specimen slide in one smooth motion, with a very slight smearing pressure.
Two-step technique, shown below
See the list below:
The two-step technique is more frequently used if the specimen is more liquid.
Place the specimen at the labeled end of the specimen slide.
Hold the spreading slide parallel to and at a 45-degree angle to the specimen slide. Place one end of the spreading slide in contact with the specimen slide just below the specimen.
Draw the spreading slide just into contact with the specimen, permitting the drop of material to spread along the line of contact by surface tension. Particles of tissue will be concentrated along this line of contact. Then move the spreading slide away from the labeled end to approximately the midpoint of the specimen slide, drawing the tissue particles with it.
Quickly lift the spreading slide from the specimen slide, leaving most of the tissue particles at the mid-point of the specimen slide. Hold the specimen slide vertically for several seconds with the labeled end at the bottom, allowing some of the fluid to drain away from the tissue particles.
Place the spreading slide perpendicular to the specimen slide and smear the line of tissue particles as described in the one-step technique.
See the list below:
The clinician performing the fine needle biopsy must consult closely with the cytopathology laboratory regarding their preferred handling of the slides that hold the smeared specimen.
The 2 basic techniques for processing and staining specimens are wet fixation and air-drying. These methods are somewhat complementary. Many authorities use both for the same specimen, though the exclusive use of either method is acceptable. [1, 4, 5, 10]
The stains used for each technique are different.
Wet-fixation technique
The wet-fixation technique includes immersion of the slide into 95% ethanol or use of a spray fixative. Immersion in 95% ethanol works well, though entails some inconvenience in the storage and transportation of the liquid fixative.
Spray fixatives generally consist of ethyl alcohol or isopropyl alcohol mixed with polyethylene glycol. The alcohol quickly evaporates, leaving the smeared specimen covered with the glycol. Treated slides can then be easily stored, mailed, or immediately processed.
Prior to staining, the glycol coating must be removed with a 10-minute soak in 95% ethanol. [4]
Stains specific to the wet-fixation technique include Papanicolaou and hematoxylin-eosin (H&E).
Air-drying technique
The smeared slide is processed simply by allowing it to air-dry.
For optimal results, drying should occur quickly. [4] Many laboratories use a hair-dryer or hand-held air fan to speed drying.
Stains specific to the air-drying technique include Wright-Giemsa and Diff-Quick (a modified Wright-Giemsa stain).
Liquid-based preparation
If the practitioner performing the fine needle biopsy does not have immediate access to a cytopathology laboratory and is not skilled in conventional smear preparation, then rinsing of the biopsied material into a liquid medium is easy and reasonable. [15]
Examples of liquid-based collection vials include ThinPrep and SurePath.
Clear communication with the cytopathology laboratory where the specimens are to be processed is essential. Though many cytopathologists prefer to interpret conventionally smeared specimens, studies comparing the 2 methods for adequacy of specimen have shown mixed results. Many laboratories use liquid-based collection in addition to smears or as the sole preparation method. [15]
See the list below:
Most authorities recommend that a minimum of 2, and preferably 3, needle passes be performed for each mass to be biopsied. [1, 3, 6, 13]
Authorities differ as to whether the needle, when moved back and forth within the mass, should be moved in different directions or along the same tract during the biopsy passes. Those advocating that the direction of the needle not be changed suggest that this technique reduces tissue trauma with subsequent hemorrhage and dilution of the aspirated material. [1, 5, 14]
Cystic lesions (eg, branchial cleft cysts, thyroglossal duct cysts, thyroid cysts) can be not only diagnosed but also treated when drained by fine needle aspiration. [6] A larger needle can be used to evacuate the fluid. A few direct smears of the aspirated cystic fluid should be made and the rest sent to the laboratory in a sterile container for examination of the centrifuged sediment. After emptying the cyst, biopsy should be performed on any residual mass to avoid missing a cystic carcinoma. [1, 5, 16]
No significant difference in diagnostic yield from fine needle biopsy was noted when 21-gauge needles were compared to 23- and 25-gauge needles. [17, 18] Additionally, 23-gauge needles were found to cause less pain than 21-gauge needles in fine needle biopsies performed without local anesthesia. [17]
If a large mass (>3 cm) is biopsied, material should be obtained from the margin of the mass as well as the center. Large masses often have hemorrhage and necrosis in the center. Diagnostic cells can often be obtained from the margins.
Smeared large tissue fragments stain poorly and add little useful information. They should be placed in formalin for cell block preparation. [10]
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Fine needle biopsy (FNB) of the neck has a very low morbidity rate. In several large studies, only a limited number of minor complications were noted. [19] Severe complications are rare.
Hematoma is the most common significant complication. [12] Most hematomas are small and resolve without treatment. At least two cases of severe hematomas with airway compromise requiring surgical intervention following fine needle biopsy of the thyroid gland have been reported. [20, 21] The risk of hematoma is believed to be reduced by the use of needles 23 gauge in size or smaller. Direct pressure at the biopsy site after the procedure is also recommended. [15]
Infection following fine needle biopsy of the neck is rare. Two cases of intrathyroid abscesses requiring surgical intervention following fine needle biopsy have been reported. [22, 23] Alcohol or iodine skin preparation is recommended prior to fine needle biopsy to minimize the chance of infection. Iodine preparation may be preferred in deep neck biopsies, in patients with poor hygiene or an overlying dermatitis, and in immunocompromised patients. [15]
Recurrent laryngeal nerve paralysis following fine needle biopsy of the thyroid gland is rare. One review of more than 10,000 biopsies reported 4 patients with vocal cord paralysis after fine needle biopsy of thyroid nodules. Change of voice in the patients occurred 1 or 2 days after fine needle biopsy, and the vocal cord paralysis was confirmed by flexible laryngoscopy. The paralysis in all patients resolved spontaneously within 6 months. [24]
Puncture of the trachea during fine needle biopsy of the thyroid gland can cause coughing and mild hemoptysis. These symptoms are short-lived, and the patient recovers within a few minutes. [5]
In a small number of cases, fine needle biopsy has been associated with infarction and subsequent necrosis of the biopsied neck mass. Most published cases of infarction followed fine needle biopsy of the thyroid gland. The incidence of clinical regression of thyroid nodules clearly attributable to fine needle aspiration (FNA) alone is approximately 1.2%. Although the majority of cases have involved Hurthle cell neoplasms, a significant number have occurred in papillary carcinomas. [25] Such postbiopsy necrosis may also interfere with subsequent histologic interpretation. [10] Infarction after fine needle biopsy has also been encountered in a pleomorphic adenoma and a Warthin’s tumor of the parotid gland. [25]
Needle-tract seeding of malignant cells resulting from fine needle biopsy is a theoretical concern but appears to be very rare and clinically insignificant when needles 23 gauge or smaller are used. [1, 26] Needle-tract seeding has been microscopically identified in cases of cervical lymph node metastasis of adenocarcinoma and squamous cell carcinoma, as well as in papillary carcinoma of the thyroid. In all cases, 21-gauge needles had been used in the biopsy. However, whether such needle-tract seeding has clinical significance is not clear. [26, 27] Nonetheless, using needles 23 gauge or smaller when possible may be prudent.
One fatality resulting from a fine needle biopsy of a neck mass has been reported. The death followed fine needle biopsy of a carotid body tumor. The immediate cause was thrombosis of the adjacent internal carotid artery. [28] For this reason, most clinicians are reluctant to perform fine needle biopsy when a diagnosis of a carotid body tumor is suspected. These and other glomus tumors are better identified by imaging. Currently, MRI is the imaging study of choice followed by contrast-enhanced CT. Angiography remains useful if the diagnosis is obscure or if embolization is contemplated. [11]
One case of monocular blindness was reported following fine needle biopsy of a mass near the carotid arterial tree in an elderly man with preexistent severe atherosclerotic carotid disease. The blindness was believed to result from an embolism to a retinal artery. [19]
Amedee RG, Dhurandhar NR. Fine-needle aspiration biopsy. Laryngoscope. 2001 Sep. 111(9):1551-7. [Medline].
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Kraft M, Lang F. A modified technique of ultrasound-guided fine-needle aspiration in the diagnosis of head and neck lesions. Laryngoscope. 2006 Mar. 116(3):497-8. [Medline].
Stanley MW, Lowhagen T. Basic Techniques. Fine Needle Aspiration of Palpable Masses. Boston, MA: Butterworth-Heinemann; 1993. 18-56.
Orell SR, Sterrett GF, Walters MN, Whitaker D. The techniques of FNA cytology. Manual and Atlas of Fine Needle Aspiration Cytology. 3rd ed. London, England: Churchill Livingstone; 1999. 12-13.
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Tangpricha V, Chen BJ, Swan NC, Sweeney AT, de las Morenas A, Safer JD. Twenty-one-gauge needles provide more cellular samples than twenty-five-gauge needles in fine-needle aspiration biopsy of the thyroid but may not provide increased diagnostic accuracy. Thyroid. 2001 Oct. 11(10):973-6. [Medline].
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John Boone, MD Consulting Staff, Department of Otolaryngology, Naval Hospital Oak Harbor
John Boone, MD is a member of the following medical societies: American Academy of Otolaryngology-Head and Neck Surgery
Disclosure: Nothing to disclose.
David P Mullin, MD Staff Physician, Department of Otolaryngology Head and Neck Surgery, Naval Medical Center, San Diego
David P Mullin, MD is a member of the following medical societies: American Academy of Otolaryngology-Head and Neck Surgery
Disclosure: Nothing to disclose.
Mary L Windle, PharmD Adjunct Associate Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference
Disclosure: Nothing to disclose.
Arlen D Meyers, MD, MBA Professor of Otolaryngology, Dentistry, and Engineering, University of Colorado School of Medicine
Arlen D Meyers, MD, MBA is a member of the following medical societies: American Academy of Facial Plastic and Reconstructive Surgery, American Academy of Otolaryngology-Head and Neck Surgery, American Head and Neck Society
Disclosure: Serve(d) as a director, officer, partner, employee, advisor, consultant or trustee for: Cerescan;RxRevu;Cliexa;Preacute Population Health Management;The Physicians Edge<br/>Received income in an amount equal to or greater than $250 from: The Physicians Edge, Cliexa<br/> Received stock from RxRevu; Received ownership interest from Cerescan for consulting; for: Rxblockchain;Bridge Health.
Arlen D Meyers, MD, MBA Professor of Otolaryngology, Dentistry, and Engineering, University of Colorado School of Medicine
Arlen D Meyers, MD, MBA is a member of the following medical societies: American Academy of Facial Plastic and Reconstructive Surgery, American Academy of Otolaryngology-Head and Neck Surgery, American Head and Neck Society
Disclosure: Serve(d) as a director, officer, partner, employee, advisor, consultant or trustee for: Cerescan;RxRevu;Cliexa;Preacute Population Health Management;The Physicians Edge<br/>Received income in an amount equal to or greater than $250 from: The Physicians Edge, Cliexa<br/> Received stock from RxRevu; Received ownership interest from Cerescan for consulting; for: Rxblockchain;Bridge Health.
Biopsy, Fine Needle, Neck Mass
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