DISCUSSION
There are sparse descriptions in the literature regarding endopharyngeal
ultrasonographic techniques8,9,10. All such descriptions have employed
rigid endocavitary probes, which
suffer from limitations in: 1) the anatomic regions accessible to line
of sight through the oral
aperture and 2) cumbersome size. Here, we present EPhus and EPhUS-guided
FNA as a safe and minimally invasive technique for assessing and
sampling parapharyngeal lesions not accessible by transcutaneous FNA.
While EPhUS requires specialized equipment, the procedure is straight
forward for surgeons familiar with endoscopy of the upper aerodigestive
tract and ultrasonography. Most hospitals which provide multispecialty
care are equipped with the necessary endoscopes to perform EPhUS. In
this case example, a lesion of the carotid space, was successfully
visualized and sampled by EPhUS. Additional spaces, which have
traditionally proved hard to access by transcutaneous image (US or CT)
guided FNA, yet are accessible by EPhUS include the parapharyngeal,
retropharyngeal and pterygomandibular spaces (Figures 2A-B).
In conclusion, EPhUS and EPhUS guided FNA can be a safe, minimally
invasive approach for visualization and biopsy of lesions in the
parapharyngeal, retropharyngeal and pterygomandibular spaces, which have
traditionally been difficult to access with transcutaneous image guided
FNA.
REFERENCES :
- Kane D, Grassi W, Sturrock R, Balint PV. A brief history of
musculoskeletal ultrasound:‘From bats and ships to babies and hips’.
Rheumatology. 2004 Jul 1;43(7):931-3.
- Mcivor NP, Freeman JL, Salem S, Elden L, Noyek AM, Bedard YC.
Ultrasonography and ultrasound‐guided fine‐needle aspiration biopsy of
head and neck lesions: a surgical perspective. The Laryngoscope. 1994
Jun;104(6):669-74.
- Rintoul RC, Glover MJ, Jackson C, Hughes V, Tournoy KG, Dooms C,
Annema JT, Sharples LD. Cost effectiveness of endosonography versus
surgical staging in potentially resectable lung cancer: a health
economics analysis of the ASTER trial from a European perspective.
Thorax. 2014 Jul 1;69(7):679-81.
- Gu P, Zhao YZ, Jiang LY, Zhang W, Xin Y, Han BH. Endobronchial
ultrasound-guided transbronchial needle aspiration for staging of lung
cancer: a systematic review and meta-analysis. European journal of
cancer. 2009 May 1;45(8):1389-96.
- Steinfort DP, Hew MJ, Irving LB. Bronchoscopic evaluation of the
mediastinum using endobronchial ultrasound: a description of the first
216 cases carried out at an Australian tertiary hospital. Internal
medicine journal. 2011 Dec;41(12):815-24.
- Fornage BD, Edeiken BS, Clayman GL. Use of transoral sonography with
an endocavitary transducer in diagnosis, fine-needle aspiration
biopsy, and intraoperative localization of retropharyngeal masses.
American Journal of Roentgenology. 2014 May;202(5):W481-6.
Figure legends
Figure 1. A 61-year-old woman with an incidentally found left neck mass.
- Contrast-enhanced CT demonstrates a well-demarcated lesion
(arrows ) with a punctate calcification (arrowhead )
displacing the internal and external carotid arteries anteromedially
and internal jugular vein posterolaterally. Note the lesion is
surrounded by great vessels, preventing percutaneous biopsy.
- Post-contrast fat-suppressed T1-weighted MR image demonstrates a
rim-enhancing, predominantly non-enhancing lesion (arrows ) with
a nodular enhancement (arrowhead ) at its medial portion, which
may be an ideal site for biopsy.
- Fast-field echo MR image demonstrates foci of susceptibility effect
(arrowheads ) within the lesion (arrows ), suggestive of
microhemorrhage.
- A Crow-Davis is used to expose the pharynx. An assistant works to keep
the bronchoscope in position.
- The endoscope is equipped with a 7.5 MHz convex ultrasound probe and a
needle that is delivered through the working channel of the scope.
- Endoscopic Doppler ultrasonography demonstrates the lesion
(arrows ) and surrounding internal and external carotid vessels
(arrowheads ).
- Intra-procedure ultrasonography demonstrates needle (arrows )
inserted into the lesion for sampling.
Figure 2. Examples of lesions that may be accessed by EPhUS guided FNA
- A 53-year-old man with laryngeal cancer. Contrast-enhanced CT
demonstrates a borderline-enlarged round retropharyngeal node with
ill-defined boundary (arrow ).
- A 73-year-old woman with mandibular cancer status post resection and
reconstruction. Contrast-enhanced CT demonstrates a peripherally
enhancing lesion (arrow ) at the medial and posterior aspect of
the right medial pterygoid muscle, concerning for recurrence.