Percutaneous Biopsy of Head and Neck Lesions with CT Guidance: Various Approaches and Relevant Anatomic and Technical Considerations

Abstract

Deep-seated head and neck lesions, which traditionally were evaluated by surgical means, are now accessible with less invasive computed tomography-guided percutaneous needle biopsy techniques. Major vessels, the trachea, and osseous structures like the maxilla, mandible, and vertebrae often preclude direct access to these lesions. It is important to understand the anatomy relevant to safe access route planning and the techniques, advantages, and limitations associated with various approaches used for percutaneous biopsy of head and neck lesions. For biopsy of suprahyoid head and neck lesions, including those of the skull base and upper cervical vertebrae, various approaches such as the subzygomatic, retromandibular, paramaxillary, submastoid, transoral, and posterior approaches can be used. Lesions in the infrahyoid portion of the neck and lower cervical vertebrae can be accessed with the anterolateral approach (between the airways and the carotid sheath), posterolateral approach (posterior to the carotid sheath), and direct posterior approach. The location and extent of the lesions and their relationship to adjacent structures influence the choice of the trajectory to use. Careful planning of the procedure and considerable familiarity with head and neck anatomy are necessary for a biopsy that is both precise and safe.

Interventional Neuroradiology of the Head and Neck

“…Most of biopsies can be performed with local anesthesia and conscious sedation, but transoral biopsies of prevertebral and upper cervical vertebral lesions need general anesthesia. 1 A coaxial needle technique is very useful, with placement of an 18-to 19-gauge guiding (introducer) needle close to the target mass and subsequent advancement of the biopsy needle into the mass. We use thin 20-to 22-gauge Chiba or Franseen needles for obtaining aspirates for the cytologic analysis and, if required, 20-gauge cutting needles for obtaining core specimens.…”

“…Injury to vascular structures and nerves can be avoided by using the Hawkins-Akins needle (Meditech, Westwood, Mass) with a blunt trocar. 1,3,4 Modifications of the head position and opening the jaw with a bite block can be very helpful in permitting and facilitating access to many sites in the head and neck (Fig 1A). For example, mild hyperextension of the head can provide easier access to the skull base lesions via a paramaxillary or transbuccal approach.…”

“…A detailed discussion of these approaches is beyond the scope of this article. However, the interested reader is referred to a recent article by Gupta et al, 1 which discusses different approaches along with their particular anatomic considerations.…”

“…2,5 Minor complications include pain, limited infection, or bleeding and vasovagal reactions. 1 Injury to blood vessels and nerves is a theoretic concern but is very rarely encountered if careful attention is paid to needletrajectory planning and small-caliber needles are used.…”

MRI-guided biopsy and aspiration in the head and neck: evaluation of 77 patients

“…Even though in experienced hands, non-image guided biopsy maybe successfully performed in superficial head and neck lesions, imaging guidance may be preferred to improve accuracy and minimize potential complications, especially for deep seated and poorly palpable lesions, and for lesions in close vicinity to neurovascular structures [2,3].…”