Introduction
The presence of a head and neck swelling is a frequent reason for the patient to visit an Otorhinolaryngology or surgery consultation across all age groups. Swelling in head and neck region ranges from as simple as a reactive hyperplasia of lymph node to malignancies and can have serious implications due to complex anatomy of the region and the presence of multiple anatomical, physiological tissues which result in distinct pathology and prognosis. Head & neck neoplasms account for 23% of all cancer in males and 6% in females in the Indian subcontinent.1, 2 FNAC is a simple, quick and cost effective method for diagnosis as swellings in this region are superficial in location and hence easily accessible. The swellings in the head and neck region may arise from the cervical lymph nodes, thyroid gland, major salivary gland, tumours of skin and soft tissue structures. Deeper structures can also be assessed easily by USG or CT guided FNAC. 1 FNAC of head and neck region is a well accepted technique with high specificity for diagnosis. It reduces the rate of diagnostic exploratory procedures and provides an early differential diagnosis of benign from malignant lesions.
Material and Methods
The study was conducted in a zonal hospital from Aug 2021 to Aug 2022. It was a prospective observational study where FNAC done in 120 patients with lesions in head and neck region were studied. A detailed history taking and clinical evaluation was done with relevant questions regarding cause, family history of tuberculosis and history of sexual exposure for syphilis and AIDS. The procedure was done in the Department of Pathology. All patients were explained about the procedure in complete detail. The procedure was performed without any local or regional anaesthesia by a trained pathologist. The area of interest was cleaned with spirit, lesion was palpated and fixed with fingers. 23 Gauge needle and 10 ml disposable syringe was used for aspiration of material from the swelling. Plunger of the needle was retracted and many passes were done till sufficient material was obtained in the needle hub. Air was draw out in the syringe and after attaching the needle the aspirated material was scattered on the glass slide and a smear was made. The cytological smears stained with May Grunwald Giemsa and 95% alcohol fixed smears were stained with papanicolaous stains. Lymph node swellings with suspicion of tuberculosis on history and clinical evaluation were additionally stained with ZN stain. The slides were examined under the microscope and cytological findings were recorded.
Results
A total of 120 cases of fine needle aspirations on palpable head & neck lesion were performed over a period of one year in a zonal care hospital and the study population included both females (61.15%) and males (38.84%). The various pathologies are tabulated (Table 1) which show that thyroid lesions (31.66%) were predominant followed by lymph node swellings (29.16%), soft tissue (28.33%) and salivary gland swelling (3.33%) in that sequence. Amongst the thyroid lesions which are tabulated (Table 2), 84.21% cases were colloid goitre, 7.89% cases were of Hashimoto’s thyroiditis, 5.26% were follicular neoplasm and 2.63% were papillary carcinoma of thyroid. Amongst the lymph node swellings which are tabulated (Table 3), 13 cases (36.11%) were reactive /nonspecific pathology, 12 cases (33.33%) were tuberculous granulomatous lymphadenitis, 16.66% were suppurative lymphadenitis. In the malignant lesions of lymph nodes, metastatic deposit of carcinoma and poorly differentiated carcinoma were most common (13.88%) and lymphoma cases were nil. Soft tissue and miscellaneous lesions constituted 34 cases which are tabulated (Table 5), out of which 61.76% were of lipoma followed by epidermal cyst (32.35%) and hematoma (5.88%). Salivary gland lesions constituted 04 cases which are tabulated (Figure 6) with pleomorphic adenoma and chronic sialadenitis having equal distribution.
Table 1
Differential diagnosis of head and neck swellings
|
Differential Diagnosis |
Number of cases |
Percentage |
|
Thyroid |
38 |
31.66 |
|
Lymph node |
35 |
29.16 |
|
Soft tissue & Misc |
34 |
28.33 |
|
Salivary gland |
04 |
3.33 |
|
No opinion |
09 |
7.5 |
|
Total |
120 |
99.98 |
Table 2
Differential diagnosis of thyroid swellings
|
Benign nodular goitre |
32 |
84.21 |
|
Hashimoto thyroiditis |
03 |
7.89 |
|
Follicular lesion |
02 |
5.26 |
|
Malignant |
01 |
2.63 |
|
Total |
38 |
99.99 |
Table 3
Differential diagnosis of lymph node lesions
|
Reactive lymphadenitis |
13 |
36.11 |
|
Tubercular lymphadenitis |
12 |
33.33 |
|
Suppurative lymphadenitis |
06 |
16.66 |
|
Metastasis |
05 |
13.88 |
|
Lymphoma |
00 |
00.00 |
|
Total |
36 |
99.98 |
Table 4
Gender distribution of Tubercular lymphadenitis
|
Male |
05 |
41.66 |
|
Female |
07 |
58.33 |
|
Total |
12 |
99.98 |
Table 5
Soft tissue & misc lesions
|
Lipoma |
21 |
61.76 |
|
Epidermal cyst |
11 |
32.35 |
|
Hematoma |
02 |
5.88 |
|
Total |
34 |
99.99 |
Discussion
Fine needle aspiration cytology offers a very high degree of reliability, accuracy and feasibility when performed by well trained and experienced cytologist. In this study involving 120 cases of various head and neck lesions, the results were compared with similar studies in the literature. In our study, we observed that head and neck swellings are more common in females as compared to males, which is in contrary to Rathod et al 3 where males were affected more than females. Amongst various pathologies of head and neck, in our study we observed that thyroid swellings were the commonest. Colloid goitre was the predominant pathology in benign lesions of thyroid followed by Hashimoto’s thyroiditis, follicular neoplasm and papillary carcinoma of thyroid in that sequence. Similar findings are observed in other studies.1, 2, 4 In this study it was observed that female sex was predominantly affected in thyroid lesions and this fact is collaborated by other studies like Rathod et al.3 In our study, thyroid lesions were predominantly found in young adults (age group of 20-30 years) while Charry A et al5 found the maximum number of thyroid cases in the age group of 20-40 years with female to male ratio of 4:1 and in our study the female to male ratio was 7:1. Chronic non specific lymphadenitis is the commonest cause for cervical lymphadenopathy followed by tubercular lymphadenitis and metastasis from head and neck malignancies.5, 6 El-Hag et al in their study sample of 225 FNACs of head and neck swellings found that reactive/non-specific lymphadenitis is the commonest cause of neck masses accounting for 33% of cases followed by tubercular lymphadenitis (21%) and malignant lesions (13%) in that sequence.7 In this study, similar results were observed with reactive lymphadenitis/non specific lymphadenitis being the most common pathology in cervical lymph node accounting for 36.11% of cases followed by tubercular lymphadenitis constituting 33.33% cases and malignant /metastasis lesion comprising of 13.88%. Abba et al8 reported that females were more frequently affected by tubercular lymphadenopathy accounting for 68% of all cases compared to males which were 32%. Similar result was noted in this study with tubercular lymphadenitis involving females patients more (58.33%) as compared to males (41.66%). In the head and neck region, the posterior neck is the commonest site from where lipoma arises.9 The exact cause of lipoma is unknown while some potential causes are hereditary, obesity, diabetes mellitus, trauma, radiation exposure, endocrine disorder, insulin injections and corticosteroids. 10 Jasani et al11 in their study observed that benign soft tissue neoplastic lesions were more common in head and neck than malignant soft tissue neoplasm. In our study, similar result was noted as benign lipomatous lesions constituted 64.76% of cases followed by epidermal cyst (32.35% c) and hematoma (5.88%). Mesenchymal malignant cases were nil. Bhagat et al12 also in their study reported neoplastic lesions in 63% of cases with lipoma as the predominant benign tumor and squamous cell carcinoma being the commonest malignant lesion. FNAC is a useful tool for sub-typing parotid gland lesions, however its accuracy and sensitivity is variable. Alghamdi et al in their study 13 reported that the overall sensitivity and specificity of FNAC for salivary gland masses are 90.3% and 100% respectively. In our study, pleomorphic adenoma & sialadenitis (acute & chronic) were the commonest benign lesions in salivary glands. These findings are similar to other studies in the literature. Bhagat et al12 in their study also found pleomorphic adenoma as the predominant salivary gland lesion. Rathod et al3 have reported that benign neoplastic lesions in the salivary gland were the predominant finding followed by non specific inflammatory lesions and malignancy. Contrary to above mentioned studies, Chauhan et al14 in their study observed that chronic sialadenitis was the commonest lesion in followed by pleomorphic adenoma. Fernandes et al6 found pleomorphic adenoma as the commonest benign lesion in salivary gland and the commonest malignant lesion was mucoepidermoid carcinoma.
Conclusion
Our study found that FNAC is rapid, simple & cheap diagnostic modality with overall diagnostic accuracy of more than 90% in differentiating non-neoplastic from neoplastic lesions in the head and neck region. Thus with clinical evaluation, FNAC can be recommended as first line investigation in the diagnosis and management of head and neck lesions. It also helps the surgeon to select, guide and modify surgical planning in patients requiring surgery. It is a very safe OPD procedure and saves the expenditure of hospitalization and also all the morbidities associated with exploratory diagnostic excision biopsy.
