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22 Ultrasound imaging, including ultrasound-guided biopsy

occurs rarely and any solid component which appears to

contain microcalcification (i.e. suggestive of papillary
carcinoma) should undergo sampling.

Dermoids can be identified by their site, i.e. either midline

or peri-orbital. In the peri-orbital region, they are typically
(60 per cent) found in the upper outer quadrant of the orbit.
These lesions arise from sequestration of the ectoderm from
adjacent sutures, most commonly the frontozygomatic
suture. Dermoid cysts arise from more than one germ cell
layer and therefore will contain one or more dermal adnexal
structures. Sebaceous glands, hair and fat are commonly
found in dermoids, but they may also be purely cystic. They
may therefore have a heterogenous appearance with the
presence of fat manifesting as a fluid/fluid level or often as
rounded echogenic masses within the cyst (representing
sebaceous rests within the dermoid). The typical location
for midline cysts is in the submental region either superficial
or deep to mylohyoid.

Infection in the submandibular region frequently arises from

dental disease. Ultrasound can differentiate between infection
with a fluid component (abscess) and cellulitis, and identify
associated lymphadenopathy and venous thrombosis.

Ultrasound-guided fine needle aspiration and

core biopsy
Ultrasound is a very useful adjunct in percutaneous
sampling procedures, allowing direct visualization of the

1.2.9 Ultrasound-guided fine needle aspiration showing

reflective surface of the needle.

needle and structures to be avoided (such as vessels). A

metallic needle is a reflective surface and if placed parallel or
slightly oblique to the transducer surface the needle will be
imaged as a very reflective or echogenic structure (Figure
1.2.9). Thus the needle must be in the plane of the
ultrasound beam and as parallel to the probe surface as
possible in order to optimally visualize it.


It is essential that the patient and operator are comfortable
when carrying out either FNA or core biopsy in the neck.
Keeping the probe, needle, ultrasound monitor and patient
in a tight arc in front of the operator is essential. For biopsy
in a lesion in the left neck of a patient, the operator should
move to the patients left, allowing the probe, needle and
monitor to lie in a comfortable parallel field of view. If
necessary, for example for a lesion in the posterior triangle,
the patient should lie on their side in order to allow easy
access for a shallow approach.
Percutaneous biopsy is an outpatient procedure, but it is
prudent to ask the patient to wait for 510 minutes postbiopsy, to check for possible haematoma.
Ultrasound guidance should allow a variety of sampling
techniques to be performed, but if there is a good local
cytology service, FNA under ultrasound control may be all
that is required. However, where lymphoma is considered
as a possible diagnosis, core biopsy undoubtedly has a
superior role. Many centres are now able to diagnose and
type lymphoma on core biopsy, using flow cytometry
techniques, avoiding open biopsy and significantly reducing
referral to treatment time.
For many conditions, e.g. squamous cell carcinoma
lymph node metastases, FNA will be the initial sampling
technique. Core biopsy may be reserved as a second-line test
when cytology is unable to provide the answer. Some
authors advocate the use of core biopsy as a universal firstline investigation, pointing out the fallibility of cytology for
certain conditions. However, many others believe that
squamous cell carcinoma can be seeded during
percutaneous wide bore needle biopsy in the neck. The
decision as to which technique to use for sampling neck
masses will be influenced by local practice.
A skilled operator should be able to carry out FNA using
aspiration and non-aspiration techniques, and if core biopsy
can additionally be mastered then there will be few
conditions in the head and neck that cannot be sampled
under ultrasound control, allowing rapid diagnosis in
patients who present with neck masses.