Keynote @ International Congress of Medical Image - Albert Einstein Hospital

1. Thiago Julio, MD
D I A G N Ó S T I C O P O R I M A G E M

2.  Deep-seated head and neck lesions,
which were traditionally evaluated by surgical
means, are now accessible with less
invasive image-guided percutaneous
needle biopsy techniques.
D I A G N Ó S T I C O P O R I M A G E M

3.  CT:
 High spatial and contrast resolution
 Allows excellent delineation of intervening vital structures,
permitting safe biopsy path planning
 Imaging modality of choice for biopsies of deep-seated
head and neck lesions
 US:
 Superficial targets
 Transoral approach (endocavitary)
 Puncture point planning
 Doppler
D I A G N Ó S T I C O P O R I M A G E M

4.  Major complications are rare.
 The potential of major vascular injury with the small-caliber biopsy
needles is extremely low.
 Minor complications:
 Pain
 Vasovagal reaction
 Minor infection
 Minor bleeding
 Familiarity with the cross-sectional anatomy and careful
attention to planning the needle path minimize the chances of
clinically significant hemorrhage.
D I A G N Ó S T I C O P O R I M A G E M

5. think for nine seconds
and then act

7. Strategy !
 Tactical:
 triangulation method
 change in the degree of neck side flexion
 multimodality
 Technical:
 20 – 22G
 blunt
 F ine-tunning
D I A G N Ó S T I C O P O R I M A G E M

8. Hawkins-Akins blunt needle
D I A G N Ó S T I C O P O R I M A G E M

11. Anatomy
 Suprahyoid
 Infrahyoid
 Each one requires different percutaneous biopsy approaches.

12. Approaches
Skull base, head, and suprahyoid
neck lesions (including upper cervical
vertebrae):
Infrahyoid neck and lower cervical
vertebrae lesions:
 Subzygomatic
 Retromandibular
 Paramaxillary
 Submastoid
 Transoral
 Posterior approaches
 Anterolateral
 The needle advance between the
carotid sheath and airway.
 Posterolateral
 The needle advanced posterior to
the carotid sheath.
 Posterior
D I A G N Ó S T I C O P O R I M A G E M

13. Transfacial paramaxillary approach
 Safe access to lesions located:
 Infrazygomatic portion of the
masticator space
 Posterior portions of the
parapharyngeal and
pharyngeal mucosal spaces
 Carotid sheath space
 Deep portion of the parotid space

14. The needle is inserted through the buccal
space inferior to the zygomatic
process of the maxilla and advanced
posteriorly between the maxilla and mandible
• It is important to avoid the
facial artery, which
courses in the buccal space
• Changing the angulation
of the needle can be
necessary

15.  Limitations for needle trajectory and angulation:
 Shape and size of the adjacent bones:
 Posterolateral wall of the maxillary antrum
 Alveolar ridge
 Lateral pterygoid plate
 Anterior margin of the mandibular ramus
 In patients with a large maxillary antrum, the space between the
maxilla and the mandible may be very narrow, limiting needle placement.
D I A G N Ó S T I C O P O R I M A G E M

16.  Female
 64
 History of breast and thyroid cancer
 PET-CT: high metabolic activity on right
retropharingeal cervical lymph node
D I A G N Ó S T I C O P O R I M A G E M

17. T1
T2 fat sat
Vol fat 3D Gd DWI ADC

20.  Female, 21 years old.
 Headache, left earache and tinnitus.
 Alveolar soft tissue sarcoma.

21. Subzygomatic approach
 Safe access to lesions located:
 Masticator space
 Parapharyngeal and
pharyngeal mucosal spaces
 Retropharingeal space
 Prevertebral space
D I A G N Ó S T I C O P O R I M A G E M

24.  easy angulation of the needle in various directions (anterior,
posterior, cranial, or caudal)
 access to multiple target sites
 the needle traverses the masticator and parapharyngeal
spaces
D I A G N Ó S T I C O P O R I M A G E M

26. Retromandibular approach
 Safe access to lesions located:
 Parapharyngeal and
pharyngeal mucosal spaces
 Deep parotid space
 Retropharingeal space
D I A G N Ó S T I C O P O R I M A G E M

27. transparotid

30. Transoral approach
 general anesthesia
 supine position
 mouth opener
 retractor or nasal tube
 antibiotics
D I A G N Ó S T I C O P O R I M A G E M

31.  Particularly useful for lesions in
the posterior pharyngeal
mucosal and part of the
retropharyngeal space
and the prevertebral
portion of the
perivertebral space
 These lesions are difficult to
access with other
approaches.
D I A G N Ó S T I C O P O R I M A G E M

32.  This approach can also be used
for sampling lesions at:
 Anterior arch of C1
 The odontoid and body
of C2
 It can be also used to access the
foramen ovale and other
skull base lesions by using
cranial needle angulation.
D I A G N Ó S T I C O P O R I M A G E M

35. Infrahyoid Neck and Lower Cervical Vertebrae
Lesions

37. Take Home Messages
 Deep head and neck lesions may be accessed by using a variety of
percutaneous approaches, each one with its own set of advantages and
limitations.
 The location and extent of the lesions and their relationship to
adjacent structures influence the choice of the needle path.
 Familiarity with head and neck anatomy and careful planning of the
procedure are necessary for a biopsy that is both precise and safe.
D I A G N Ó S T I C O P O R I M A G E M

38. References
 Percutaneous biopsy of head and neck lesions with CT guidance: various
approaches and relevant anatomic and technical considerations. Gupta S et al.
Radiographics 2007 Mar-Apr;27(2):371-90.
 The Buccal Space: A Doorway for Percutaneous CT-Guided Biopsy of the
Parapharyngeal Region. Tu AS et al. AJNR Am J Neuroradiol 19:728–731, April 1998.
 CT-Guided Percutaneous Biopsies of Head and Neck Masses. Gatenby RA et al.
Radiology 146: 717-719, March 1983.
 Biopsy of Parapharyngeal Space Lesions. Yousem DM et al. Radiology 1994; 193:619-
622.
 Percutaneous CT-Guided Aspiration of Deep Neck Abscesses. Poe LB et al. AJNR Am J
Neuroradiol 17:1359–1363, August 1996.
 CT-Guided Aspirations in the Head and Neck: Assessment of the First 216 Cases.
Sherman PM et al. AJNR Am J Neuroradiol 25:1603–1607, October 2004.
 Computed tomography guided needle biopsy: experience with 1,300 procedures.
Chojniak R et al. Sao Paulo Med J. 2006; 124(1):10-4.
D I A G N Ó S T I C O P O R I M A G E M

39. Thanks !
 @thiago37
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