A.B. Moody

Sonographically Guided Core Biopsy of A Parotid Mass

OBJECTIVE The purpose of this study was to evaluate the accuracy of sonographically guided core biopsy in the evaluation of parotid masses. SUBJECTS AND METHODS Between 1998 and 2004, 135 patients consecutively presenting with a parotid mass were prospectively enrolled into this study. A single operator performed initial diagnostic sonography and then sonographically guided core biopsy using local anesthesia. Biopsy was performed with an 18- or 20-gauge needle and a spring-loaded biopsy gun with a mean of two passes per patient. Outcome measures were accuracy, sensitivity, specificity, and predictive values of sonographically guided core biopsy compared with the final pathologic diagnosis in the surgical group. In the nonsurgical group, final diagnosis was established on the basis of histologic findings after adequate core biopsy and clinical follow-up. RESULTS All sonographically guided core biopsy specimens were considered satisfactory for histologic evaluation. Overall there were 71 benign tumors, 35 malignant tumors, and 29 miscellaneous, nonneoplastic lesions. In 76 (56%) of the 135 patients who underwent surgery, sonographically guided core biopsy and surgical histologic findings were correlated for 74 patients. In two cases sonographically guided core biopsy and surgical histologic findings did not correlate. In one case, the sonographically guided core biopsy finding was mucoepidermoid carcinoma, but the final diagnosis was squamous cell carcinoma. In the other case, the finding at sonographically guided core biopsy was squamous cell carcinoma, but the final diagnosis was mucoepidermoid carcinoma. The treatment of these patients was not affected. Fifty-nine (44%) of the 135 patients avoided surgery. In differentiation of benign from malignant disease, sonographically guided core biopsy had a sensitivity, specificity, and diagnostic accuracy of 100%. Sonographically guided core biopsy also had positive and negative predictive values of 100% in the diagnosis of malignancy. There were no significant complications of sonographically guided core biopsy. CONCLUSION Sonographically guided core biopsy is a highly accurate technique for evaluation of parotid lesions and can be safely performed as an outpatient procedure. Sonographically guided core biopsy has potential advantages over fine-needle aspiration cytologic examination, particularly in the typing and grading of lymphoma and carcinoma and in improved differentiation of reactive nodal hyperplasia from lymphoma. The use of sonographically guided core biopsy may help reduce the need for surgical biopsy and facilitates prompt referral to the appropriate clinical team.

Ultrasound guided Core Biopsy, Fine Needle Aspiration Cytology and Surgical Excision Biopsy in the diagnosis of metastatic squamous cell carcinoma in the head and neck: an eleven year experience.

INTRODUCTION This study aims to review our 11 year experience of diagnosing metastatic squamous cell carcinoma presenting as head and neck lumps. The techniques of Ultrasound guided Core Biopsy (USCB), Fine Needle Aspiration Cytology (FNAC) and Surgical Excision Biopsy (SEB) are compared. MATERIALS AND METHODS All patients with metastatic squamous cell carcinoma (SCC) involving the lymph nodes of the head and neck or parotid gland, diagnosed at Eastbourne District General Hospital between January 1998 and November 2009 were identified. The following data items were collated: biopsy location (e.g. cervical lymph node or parotid), any history of likely primary SCC and site, type of biopsy used to establish a conclusive diagnosis (index diagnostic technique), previous biopsies, the technique and their results, subsequent histology results. RESULTS A total of 90 patients were diagnosed with metastatic squamous cell carcinoma. The index diagnostic technique was USCB in 48 patients, FNAC in 29 and SEB in 13. In 72 (80%) patients the index biopsy was the sole tissue sample taken prior to surgery or other treatment. The remaining 18 patients underwent a total of 22 previous biopsies prior to the index biopsy. 95% (21/22) of these previous biopsies were non-definitive FNAC and 5% (1/22) was a non-definitive USCB. FNACs also demonstrated the highest non-diagnostic rate (42%). The accuracy of USCB and FNAC in correlating with final histopathology was 97% and 85% respectively. CONCLUSIONS USCB demonstrates excellent results in the diagnosis of metastatic SCC in the head and neck with higher accuracy and greater reliability than FNAC.

Ultrasound-guided submandibular gland injection of botulinum toxin for hypersalivation in cerebral palsy

Hypersalivation associated with cerebral palsy may be treated with injection of botulinum toxin A (BTX-A) into the submandibular gland, and the use of ultrasound permits its accurate administration. In our series four patients with cerebral palsy and hypersalivation had bilateral ultrasound-guided injection of BTX-A into the submandibular gland. At 4 weeks there was objective improvement in all patients and subjective improvement in three. The only reported side effect was the temporary inability to retain prosthetic orbital globes in one patient. Ultrasound-guided injection of BTX-A for hypersalivation is effective, and side effects are rare, but they have yet to be fully described.

Establishing an accurate diagnosis of a parotid lump: evaluation of the current biopsy methods – fine needle aspiration cytology, ultrasound-guided core biopsy, and intraoperative frozen section

The optimum technique for histological confirmation of the nature of a parotid mass remains controversial. Fine needle aspiration cytology (FNAC), which has traditionally been used, is associated with high non-diagnostic and false negative rates, and ultrasound (US)-guided core biopsy and frozen section have been explored as alternatives. US-guided core biopsy is more invasive than FNAC, but is safe, well-tolerated, and associated with improved diagnostic performance. Although frozen section offers better specificity than FNAC, it has a number of important drawbacks and cannot be considered as a primary diagnostic tool. US-guided core biopsy should be considered as the initial diagnostic technique of choice, and in units where the accuracy of FNAC is good it can be used when FNAC is equivocal or non-diagnostic.

Ultrasound-guided injection of botulinum toxin A into the submandibular gland in children and young adults with sialorrhoea.

Hypersalivation is a common and distressing complaint in children with neuromuscular disorders such as cerebral palsy. Complications associated with severe drooling include daily changes of clothing, perioral dermatitis, dental problems, dehydration, and aspiration pneumonia, which potentially have a detrimental effect on the quality of life of the patient and carer. In this paper we update our previous work to show the potential benefits of ultrasound-guided injection of botulinum toxin A (BTX-A) into the submandibular gland and report on new patients and follow-up data on the existing group.

Ultrasound-guided core biopsy for investigation of cervical lymph node: chronic lymphocytic leukaemia and metastatic squamous cell carcinoma.

We describe a case in which ultrasound-guided fine needle core biopsy of a cervical lymph node enabled diagnosis of dual disease. Histological examination of the core biopsy confirmed unsuspected chronic lymphocytic leukaemia with an isolated focus of metastatic squamous cell carcinoma (SCC), and enabled optimal preoperative planning of treatment. Such a case is extremely unusual and provides evidence of the accurate diagnosis that can be obtained from nodal investigations using ultrasound-guided core biopsy.

Ultrasound guided core biopsy is the diagnostic tool of choice in salivary gland swellings.

Mehanna and colleagues’ section on obtaining a tissue diagnosis in salivary gland swellings merits further comment.1 Fine needle aspiration cytology (FNAC) has traditionally been the biopsy technique of choice in the parotid glands. It is quick, safe, and can be highly accurate, although it requires optimised conditions to perform well. In clinical practice such conditions are rarely …

Injury to the inferior alveolar and lingual nerves in successful and failed coronectomies: systematic review

The aim of this systematic review was to evaluate the incidence of damage to the inferior alveolar (IAN) and dental nerves in successful coronectomies, and to compare the results with coronectomies that failed. To the best of our knowledge no such analyses have been reported. Between January 1990 and October 2016 we surveyed published papers to find those that examined clinical outcomes after coronectomy. Fourteen met the criteria for final inclusion. Of 2087 coronectomies, 152 failed (7%). Successful procedures were associated with a low overall incidence of injury to the IAN (0.5%) and lingual nerve (0.05%). The incidence of injury to the IAN in failed coronectomies was 2.6%. The incidence of permanent paraesthesia was 0.05% in successful coronectomies and 1.3% in those that failed. No permanent injury to the lingual nerve was reported. Mobility (36%, 55/152) and migration or exposure (33%, 50/152) of roots were the most common underlying causes of failure. Coronectomy seems to be safe, but it depends on the patient and the technique used. To ensure adequate assessment of postoperative complications, we strongly recommend systematic evaluation of the reduction in sensitivity of the lower lip, chin, or tongue, and a standard follow up.

A post-traumatic pulsatile nodule in the right pre-auricular region

A 48 year old window fitter was referred directly from his general practitioner to the maxillofacial department with an eight week history of a painless, slowly enlarging nodule in his right pre-auricular region. He had noticed the lump shortly after a minor bump on his head at work. He was otherwise fit and well. Clinical examination confirmed a 10 mm firm and pulsatile nodule in the pre-auricular region. It was non-tender and non-fixed. Differential diagnoses included epidermal inclusion (sebaceous) cyst and lipoma. However, given his history of minor trauma, the maxillofacial team requested an ultrasound examination to confirm the nature of the lesion before further intervention. Duplex ultrasound examination of the right pre-auricular region showed a pulsatile nodule adjacent to the superficial temporal artery and right parotid gland that contained turbulent arterialised blood flow. Tortuous afferent and efferent arterialised vessels were also seen adjacent to the parotid gland. ### 1. What are the differential diagnoses for a pulsatile mass in this location? #### Answer A pseudoaneurysm of the superficial temporal artery, true aneurysm, arteriovenous malformation, vascular tumour, and mass overlying the artery with transmitted pulsations. #### Discussion From clinical assessment and duplex ultrasound examination, the patient was diagnosed as having a pseudoaneurysm of the right superficial temporal artery. Duplex ultrasound examination of the right pre-auricular region (fig 1⇓) showed a nodule of pulsatility adjacent to the superficial temporal artery and right parotid gland. Fig 1 Duplex ultrasound image of the right pre-auricular region showing a hypoechoic mass (arrowheads) containing central turbulent arterialised blood flow (C). Tortuous afferent (A) and efferent (B) arterial vessels are seen lying adjacent to the right parotid gland (P). The anatomical location of the vessels makes them consistent with the superficial temporal artery …

The diagnostic value of fine needle aspiration in parotid lumps

Mallon DH, Kostalas M, MacPherson FJ et al. The diagnostic value of fine needle aspiration in parotid lumps. Ann R Coll Surg Engl 2013; 95: 258–262 doi 10.1308/003588413X13511609958370