eMedicine Specialties > Otolaryngology and Facial Plastic Surgery > Head & Neck Surgery

Fine-Needle Aspiration of Neck Masses

Author: Jonas T Johnson, MD, FACS, Professor and Chairman, Department of Otolaryngology, University of Pittsburgh School of Medicine; Professor, Department of Radiation Oncology, Professor, Department of Oral Maxillofacial Surgery, University of Pittsburgh School of Dental Medicine
Coauthor(s): Lee Zimmer, MD, PhD, Staff Physician, Department of Otolaryngology, University of Pittsburgh Medical Center
Contributor Information and Disclosures

Updated: Jan 14, 2008

Introduction

Physicians are often asked to evaluate a patient with a solitary neck mass. Clinical evaluation of a solitary neck mass can be difficult because of the extensive differential diagnoses (listed below). An important factor in determining the differential diagnoses is the age of the patient. Individuals younger than 40 years are overwhelmingly diagnosed with benign processes such as congenital and inflammatory lesions. In patients older than 40 years, the differential diagnoses shift, as more than 60% of lesions are associated with malignancy.

Differential diagnoses of neck masses
  • Metastatic
    • Squamous cell carcinoma (SCC)
    • Adenocarcinoma
    • Undifferentiated carcinoma
    • Melanoma
  • Primary
    • Thyroid
    • Lymphoma
    • Salivary gland neoplasia
    • Lipoma
    • Angioma
    • Paraganglioma
    • Rhabdomyosarcoma
  • Congenital
    • Thyroglossal duct cysts
    • Brachial cleft cysts
    • Sebaceous cysts
    • Lymphangioma
    • Hemangioma
    • Dermoid cysts
    • Ectopic thyroid
    • Laryngocele
    • Thymic cysts
  • Inflammatory
    • Lymphadenopathy
    • Viral
    • Bacterial
    • Granulomatosis
    • Tuberculous
    • Sarcoid
    • Fungal
    • Cat scratch
    • Sialadenitis

Evaluation of a patient with a neck mass should always begin with a thorough history, followed by a complete head and neck examination. The entire mucosal surface of the upper aerodigestive tract requires special attention. If the physical examination does not explain the neck mass, a fine-needle aspiration (FNA) of the neck mass may be performed. If the mass is believed to be a metastatic lesion, a panendoscopy of the aerodigestive tract is warranted.

FNA for cytologic evaluation of a neck mass was first reported by Kun in 1847. However, the procedure did not gain wide acceptance in medicine at that time. In the 1930s, Memorial Sloan Kettering rediscovered the utility of needle biopsy of head and neck masses. The use of large-bore needles at that time led to frequent complications, one of which was occasional seeding of the tumor along the biopsy tract. The frequent morbidity associated with this procedure prevented widespread acceptance of this technique in other centers of America. A resurgence of FNA occurred in the 1950s, led by physicians in Sweden. FNA was commonly used for cytologic examination of metastatic lesions in the neck with excellent results. Since then, FNA of solitary neck masses has become a well-accepted, safe, and cost-effective procedure in the diagnosis of neck masses.

FNA allows the pathologist to see the cells aspirated from the lesion. It does not allow evaluation of the morphology. In some instances, these cells can be evaluated by flow cytometry or with immunologic markers. In every circumstance, FNA is a test and should be interpreted with the entire clinical circumstances. False-negative and false-positive FNA results are reported in almost every series.

Method

Fine-needle aspiration (FNA) is a simple office procedure that requires a few minutes to complete. It is ideal to have the cytotechnologist and pathologist available at the time of the aspiration. This allows an immediate assessment of the adequacy of the specimen.  If insufficient cells have been obtained, the aspirate can be repeated. Sometimes the diagnosis can be made immediately. 

An important step in FNA is patient positioning. The patient is positioned to allow the most optimal digital palpation of the mass. A 23-gauge needle is commonly used. Larger needles may be used, but they involve a higher risk of complication and may result in contaminating the specimen with red blood cells. The skin that overlies the mass is prepared with a prepackaged, sterile, alcohol preparation sponge that contains 70% isopropyl alcohol. For right-handed surgeons, the mass is grasped with the left hand and held in a fixed and stable position.

Topical or infiltrative anesthesia may be used. A 10-mL disposable syringe with an attached 23-gauge needle is placed just under the skin surface. Negative suction is applied to the syringe. Adequate negative pressure is created and maintained with the syringe plunger pulled back to 10 mL. The mass is entered, and multiple passes are made without exiting the skin surface. Approximately 6 passes through the mass are recommended. If a cyst is encountered, it should be completely evacuated, with fluid and capsules sent for cytology. The vacuum on the syringe is then released, and the skin is exited.

A small drop of aspirated fluid is placed on a glass slide (see Image 2). A smear is made by laying another glass slide on top of the drop of fluid and pulling the slides apart to spread the fluid (see Image 1). Wet smears are placed in 95% ethyl alcohol and treated with the Papanicolaou technique and stains. These stains offer excellent cellular detail and may indicate the cellular origin of a metastatic tumor. Specimens should be air dried and prepared for Wright-Giemsa stain when the differential diagnosis includes salivary, lymphoproliferative, and/or fatty tumors.

The following common technical errors lead to inadequate specimens:

  • Aspirating a mass without a syringe holder
  • Aspirating a mass without moving the needle back and forth through the specimen (to dislodge the cells)
  • Aspiration of air after the biopsy is completed and the needle is withdrawn, allowing the small specimen to be lost in the syringe.

Other nontechnical errors of specimen collection include the collection of necrotic and/or fibrotic specimens.

Some debate exists about what constitutes an adequate specimen for cytopathological diagnosis by FNA. At least several clusters of 8-10 cells are needed for interpretation. A review of the literature reveals that 7-45% of FNA specimens are inadequate for pathological diagnosis.1,2 The Papanicolaou society states that inadequate specimens should not exceed 15%.

When aspirates are placed on slides, clusters of cells form. Clusters contain approximately 10 cells. In a 1997 review of FNA of breast masses, Layfield and colleagues indicated that FNA smears with 6 or more cell clusters decrease the false-negative rate to 2.1% and decrease the percentage of inadequate specimens to 13.7%.3 However, if slides that contain fewer than 6 clusters of breast tissue were excluded, 40% of true-negative and 4.5% of true-positive slides would be lost to analysis. The authors conclude that sampling adequacy should be based on the confidence of needle placement, cell preservation, and correlation with clinical findings.

Advantages Over Open Biopsy

Fine-needle aspiration (FNA) has several advantages over excisional biopsy. In today's economic environment, cost savings is an important consideration in medicine. The cost of FNA in the office varies from $75 to $350 depending on the study source and whether or not the pathology fees are included. In contrast, the cost of an excisional biopsy ranges from $1200-2500. The cost is even higher if a hospital stay is required.

FNA is also more convenient for patients and their families. The procedure requires only an office visit with minimal loss of time from work. On the other hand, excisional biopsy often requires time off from work, preoperative blood tests, and often, radiographic and cardiac testing. Furthermore, surgery exposes patients to the risks of anesthesia, postoperative infection, and the possibility of tumor seeding (see below). A percentage of patients may require overnight admission to the hospital and extra time from work.

Questions arise as to whether FNA and/or excisional biopsies can lead to tumor seeding along the needle tract. Studies have demonstrated significant tumor spillage following large-bore tissue core biopsies. Tumor seeding requires creation of larger soft tissue deficits to remove the tumor in its entirety. Furthermore, tumor seeding in avascular planes renders cells more resistant to radiotherapy and chemotherapy.

In 1983, Ryd and colleagues demonstrated 100-10,000 tumor cells in the needle tract of mouse hind legs following FNA (with a 21-gauge needle) of tumors labeled with iododeoxyuridine I 125 (125-IUDR).4 This risk of tumor spillage during FNA has not been confirmed in human studies. In 1985, Qizalbash and colleagues lined FNA biopsy tracts in humans with India ink.5 On subsequent excision and histologic examination, no tumor cells were identified along the needle tract. Several large studies sampling parotid, prostate, renal cell carcinoma, and breast masses suggest that FNA is not associated with significant needle tract seeding.

Excisional biopsy may also interfere with further treatment. Incorrectly placed biopsy incisions may make subsequent neck dissection and/or excision difficult. In 1991, Birchall and colleagues demonstrated that 6 of 10 patients undergoing excisional biopsy of masses experienced complications in relation to the biopsy. These complications included compromise of later tumor resection, extra excision of skin and adjacent soft tissue, tumor fungation, and local recurrence in the neck wound after surgery. They further demonstrated that a systematic examination of head and neck masses including a thorough history and physical examination, FNA, and panendoscopy would have, in most cases, revealed the primary tumor. In 1978, McGuirt and McCabe demonstrated a higher incidence of wound necrosis, local recurrence, and distant metastases if excisional biopsies were performed alone rather than at the time of definitive treatment.6

Limitations of Fine-Needle Aspiration

Fine-needle aspiration (FNA) for head and neck masses has several limitations. Failure to establish an accurate diagnosis may be because of sampling error. In these circumstances, repeat aspiration is suggested, and excisional biopsy may be considered. Personnel responsible for handling, processing (experienced cytotechnologist), and reading (cytopathologist) FNA samples must be well trained. Interobserver variability must be minimized. In 1989, Peters and colleagues demonstrated an interobserver variability of 8% in diagnosis of FNA specimens, with a specificity of 96% and a sensitivity of 97%.7 FNA was most accurate at diagnosing epithelial cysts and epidermoid malignancies. FNA was least effective at distinguishing lymphoid hyperplasia and chronic inflammation from lymphoma.

If any questions exist regarding interpretation of the aspirate, decisions on surgery, radiation, and chemotherapy should be deferred until the mass is accurately diagnosed. Finally, using FNA under the appropriate conditions is important. FNA complements clinical diagnosis and should not be considered a substitute for a thorough history and physical examination.

General Results of Fine-Needle Aspiration

As mentioned in the beginning of the article, interest in fine-needle aspiration (FNA) in the diagnosis of neck masses has increased. Scandinavian success with FNA has been replicated by several large American studies for the head and neck. In 1982, Frable and Frable reviewed the success of FNA in 567 patients with neck masses.8 Since then, multiple reports of experience with FNA in the diagnosis of head and neck lesions have been published.  Sensitivity and specificity rates are approximately 85-90%.7  This means the incidence of false-negative and false-positive results range from 10-15%. FNA is not a substitute for excisional biopsy but should be considered an additional diagnostic tool to be used concurrently with patient history, physical findings, and laboratory tests.

Selective use of ultrasound (US) or CT guidance may greatly enhance the accuracy of FNA. Either modality allows more precise localization of lesions and may facilitate more accurate positioning of the needle to aspirate the capsule in lesions with central necrosis. Many authors have called attention to the fact that cystic metastasis from the Waldeyer ring (the tonsil and tongue base) may result in false-negative aspirates if the central cystic portion is aspirated.9

Selective Results With Fine-Needle Aspiration

Although fine-needle aspiration (FNA) may not be the method of choice for all neck masses, studies demonstrate a specific advantage of FNA for the diagnosis of several specific disease entities. In 1990, Schwarz and colleagues demonstrated that FNA had an overall sensitivity of 92% and a 100% positive predictive value for the diagnosis of squamous cell carcinomas (SCCs) of the head and neck.10 In a 1991 report, Birchall and colleagues further demonstrated that FNA of neck masses was 100% specific for SCCs of the neck.11 The predictive power of FNA in diagnosing head and neck SCCs allows physicians to narrow the search for the primary tumor.

Furthermore, FNA can be a powerful tool for diagnosing cervical recurrence of head and neck SCCs without the financial costs and the morbidity of excisional biopsy. Gourin and Johnson report FNA results in 12 patients with cystic metastasis.12 False-negative aspirates were encountered in 5 (42%). In each case, the diagnosis was made by excisional biopsy. The presence of a thick-walled cyst should raise clinical concern for this entity. 

The prevalence of thyroid nodules may approach 70% in the population.13  Incidence varies by age and method of detection. Incidence of carcinoma in thyroid nodules varies from 3-5%. Approximately 10-26% of all patients with thyroid malignancies present with an isolated neck mass.

Many studies have examined the use of FNA in the diagnosis of masses suspicious for thyroid malignancies. In 1991, Klemi and colleagues examined 186 aspirates from the thyroid gland.14 Among histology-confirmed cases, FNA of thyroid nodules had a specificity of 100%, sensitivity of 55%, and accuracy of 95%. In 1985, Jayarman and colleagues studied 308 cases of solitary thyroid nodules with FNA.15 The pathological diagnosis was correctly established from aspirates in 207 of 216 (95.8%) colloid adenomatous goiters. Hashimoto thyroiditis was diagnosed in 7 of 10 patients. Follicular adenomas were diagnosed as follicular neoplasms in 11 of 11 patients. However, only 4 of 19 follicular carcinomas were accurately diagnosed using FNA. The false-negative rate for follicular carcinoma varies from 2.4-5.3%.

Without the tumor capsule, the angioinvasive character of follicular carcinoma cannot be determined. The difficulty in distinguishing benign from malignant has led to the term follicular neoplasm. Because of the difficulty in differentiating follicular adenoma from well-differentiated follicular carcinoma with FNA, the presence of a follicular neoplasm with FNA is an indication for thyroid surgery.

Use of FNA for isolated salivary gland masses is broadly accepted. Nevertheless, surgeons are cautioned to interpret the result of FNA with the clinical situation. Both false-negative and false-positive results are encountered. Interpretation of salivary gland pathology is more unusual (may be "pleomorphic") and requires greater experience than some other neck masses. 

In 2000, Costas et al studied 112 aspirations from salivary glands. Their results were less rewarding, with a sensitivity and specificity of 84.8% and 93.7%, respectively. Cohen et al (2004) reported FNA in 169 salivary masses.16 A satisfactory specimen was obtained in 89%. In lesions found to be malignant on final histologic examination, positive and negative predictive values were 84% and 77%, respectively. These results suggest that FNA alone may not be sufficient to rule out salivary malignancies and that further clinical evaluation, including surgical resection, may be necessary. Most reports acknowledge a low but important incidence of false-positive aspirates. These authors warn that the predictive value of a negative aspirate is low. When clinical suspicion warrants it, further sampling (eg, excisional biopsy) is appropriate.
 
When cytologic evaluation suggests a lymphoid lesion, further study may be essential to rule out lymphoma. Although FNA is 98% specific for the absence of tumor and 95% sensitive for the presence of tumor in neck masses, improper diagnosis may be encountered in patients with lymphoma and lymphadenitis.

In 1988, Carter and colleagues examined 158 FNA specimens from 143 patients.17 Two of the 118 needle aspirates diagnosed as lymphoma were falsely positive, while 3 of 13 diagnosed as suspicious for lymphoma were found to be benign. In only 85% of specimens, the histologic subclassification of lymphoma with FNA was identical to the histologic subclassification on excisional biopsy. The accurate cellular diagnosis of lymphoma depends on changes in lymph node architecture, specifically the ablation of germinal centers, follicles, and subcapsular sinuses. However, when the previous cytoarchitecture of a lymphoma specimen is known, FNA is reliable in predicting recurrence.

Some reports have suggested that Hodgkin lymphoma can be accurately diagnosed by FNA. Hodgkin lymphoma is suggested by the presence of Reed-Sternberg cells in the setting of numerous lymphocytes on FNA. However, because this cell type is found in other conditions (eg, non-Hodgkin disease of the large-cell type), pathological identification of Hodgkin disease still requires additional tissue for surrounding cellular elements.

The role of FNA in the diagnosis of non-Hodgkin lymphoma is controversial. The diagnostic yield of FNA is low because differentiating non-Hodgkin lymphoma from lymphocytic thyroiditis and anaplastic thyroid carcinoma is difficult. Future studies that combine FNA with flow cytometry and immunohistochemistry may increase the accuracy of lymphoma diagnosis without the need for excisional biopsies.

Flow cytometry uses a beam of laser light to identify cell surface antigens. Tagged antibodies bind to cell surface antigens on lymphocytes, allowing the identification of non-Hodgkin lymphoma. Recently, flow cytometry has been used to help diagnose pathology on FNA. Cannon and Richardson in 2000 retrospectively examined the use of FNA and flow cytometry in 11 cases of isolated neck masses diagnosed as lymphoma.18 FNA of the 1 patient with Hodgkin disease favored a mesenchymal neoplasm, and flow cytometry findings were noncontributory. In the other 10 patients, FNA indicated lymphoma in 7, and flow cytometry revealed clonal lymphocytic abnormalities in all 10, but open biopsies were obtained to more accurately characterize these lymphoid proliferations.

FNA is routinely used for the histologic diagnosis of isolated neoplastic neck masses. However, use of FNA in the diagnosis of inflammatory lesions has been limited. FNA could likely be used to isolate individual organisms or at least allow for the culture of an offending organism. An array of case reports and case series has demonstrated a use for FNA in the diagnosis of infectious diseases of the neck. A few of the causes identified include Staphylococcus aureus, Escherichia coli, and Bacteroides fragilis; Cryptococcus, Mycobacterium, Coccidioides, Bacteroides, Streptococcus, Haemophilus, Pseudomonas, and Citrobacter species; and Cytomegalovirus infection, syphilis, and actinomycosis.

Tuberculous lymphadenitis often manifests in the head and neck. FNA specimens have cytologic evidence consistent with tuberculosis. Eighty percent of FNA specimens positive for tuberculosis have been confirmed by open biopsy. FNA histology includes granulomatous inflammation and/or caseation necrosis. Cultures from 80% of specimens are positive for tuberculosis. The sensitivity of FNA for tuberculosis increased from 70-90% when combined with skin testing. Further studies are warranted to examine the role of FNA in the diagnosis of tuberculosis and other inflammatory lesions of the head and neck.

Fine-Needle Aspiration in Pediatric Patients

Neck masses in children differ from those in adults. Children present more frequently with reactive inflammatory lymphadenopathy. Primary or secondary malignant involvement is rare in children. Unfortunately, the literature on fine-needle aspiration (FNA) in children is limited by small study size and varying results. Few studies have examined the utility of FNA in children with masses in the head and neck.

In 1991, Silverman and colleagues examined 135 FNA specimens from multiple body sites in children.19 FNA had a sensitivity of 90.6%, a specificity of 100%, and a positive predictive value of 100%. They concluded that FNA allowed definitive diagnosis and therapy for malignant and/or infectious lesions in children. These conclusions cannot be carried over to head and neck lesions because only 7 FNA specimens were from the head and neck. However, the results lend support for further investigation of using FNA for the diagnosis of head and neck masses in the pediatric population.

Multimedia

Photograph showing the smear technique for platin...
(Enlarge Image)
Media file 1: Photograph showing the smear technique for plating a sample aspirate. After a small drop of fluid is placed on a glass slide, a second slide is used to smear the aspirate evenly over the surface of the slide. The slide is then prepared for cytologic evaluation.
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Photograph showing the smear technique for platin...

Photograph showing the smear technique for plating a sample aspirate. After a small drop of fluid is placed on a glass slide, a second slide is used to smear the aspirate evenly over the surface of the slide. The slide is then prepared for cytologic evaluation.

Photograph showing an aspirate being placed on a ...
(Enlarge Image)
Media file 2: Photograph showing an aspirate being placed on a glass slide. After the 20-mL disposable syringe with an attached 21-gauge needle is placed under the skin surface and the mass is aspirated, a small drop of aspirated fluid is placed on a glass slide.
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Photograph showing an aspirate being placed on a ...

Photograph showing an aspirate being placed on a glass slide. After the 20-mL disposable syringe with an attached 21-gauge needle is placed under the skin surface and the mass is aspirated, a small drop of aspirated fluid is placed on a glass slide.

Keywords

fine-needle aspiration for neck masses, FNA, fine needle aspiration, fine-needle aspiration and biopsy, fine-needle aspiration biopsy, neck masses, solitary neck mass, Hodgkin lymphoma, Hodgkin’s lymphoma, neck tumor, neck cancer

 


More on Fine-Needle Aspiration of Neck Masses

References
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Further Reading

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Keywords

fine-needle aspiration for neck masses, FNA, fine needle aspiration, fine-needle aspiration and biopsy, fine-needle aspiration biopsy, neck masses, solitary neck mass, Hodgkin lymphoma, Hodgkin’s lymphoma, neck tumor, neck cancer

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Contributor Information and Disclosures

Author

Jonas T Johnson, MD, FACS, Professor and Chairman, Department of Otolaryngology, University of Pittsburgh School of Medicine; Professor, Department of Radiation Oncology, Professor, Department of Oral Maxillofacial Surgery, University of Pittsburgh School of Dental Medicine
Jonas T Johnson, MD, FACS is a member of the following medical societies: Allegheny County Medical Society, American Academy of Otolaryngology-Head and Neck Surgery, American Association for Cancer Research, American Bronchoesophagological Association, American College of Surgeons, American Head and Neck Society, American Laryngological Association, American Laryngological Rhinological and Otological Society, American Medical Association, American Radium Society, American Rhinologic Society, American Society of Clinical Oncology, Association of Military Surgeons of the US, Pennsylvania Medical Society, and Society of University Otolaryngologists-Head and Neck Surgeons
Disclosure: Nothing to disclose.

Coauthor(s)

Lee Zimmer, MD, PhD, Staff Physician, Department of Otolaryngology, University of Pittsburgh Medical Center
Lee Zimmer, MD, PhD is a member of the following medical societies: American Academy of Otolaryngology-Head and Neck Surgery
Disclosure: Nothing to disclose.

Medical Editor

David J Terris, MD, FACS, Porubsky Professor and Chairman, Department of Otolaryngology, Medical College of Georgia
David J Terris, MD, FACS is a member of the following medical societies: Alpha Omega Alpha, American Academy of Otolaryngology-Head and Neck Surgery, American Association for the Advancement of Science, American Bronchoesophagological Association, American College of Surgeons, American Head and Neck Society, Federation of American Societies for Experimental Biology, International Association of Endocrine Surgeons, Phi Beta Kappa, Radiation Research Society, Society of University Otolaryngologists-Head and Neck Surgeons, and Triological Society
Disclosure: Nothing to disclose.

Pharmacy Editor

Francisco Talavera, PharmD, PhD, Senior Pharmacy Editor, eMedicine
Disclosure: Nothing to disclose.

Managing Editor

Nader Sadeghi, MD, FRCS(C), Associate Professor of Surgery, Director of Head and Neck Surgery, Department of Surgery, Division of Otolaryngology, George Washington University
Nader Sadeghi, MD, FRCS(C) is a member of the following medical societies: American Academy of Otolaryngology-Head and Neck Surgery, American Head and Neck Society, Federation of Medical Specialists in Quebec, and Royal College of Physicians and Surgeons of Canada
Disclosure: Nothing to disclose.

CME Editor

Christopher L Slack, MD, Otolaryngology-Facial Plastic Surgery, Private Practice, Associated Coastal ENT; Medical Director, Treasure Coast Sleep Disorders
Christopher L Slack, MD is a member of the following medical societies: Alpha Omega Alpha, American Academy of Facial Plastic and Reconstructive Surgery, American Academy of Otolaryngology-Head and Neck Surgery, and American Medical Association
Disclosure: Nothing to disclose.

Chief Editor

Arlen D Meyers, MD, MBA, Professor, Department of Otolaryngology-Head and Neck Surgery, 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, and American Head and Neck Society
Disclosure: Advanced Headache Intervention Consulting fee Consulting; Covidien Corp Consulting fee Consulting

 
 
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