European Journal of Cardiovascular Medicine

Fine needle aspiration cytology (FNAC) is a simple cost effective procedure which is being practiced in routine OPD setup and offers a better alternative to excision biopsies.¹ Martin HE and Ellis EB were the first to present a paper on obtaining tissue by needle puncture and aspirations from suspected neoplasms.²  Fine needle aspiration plays a major role in clinical evaluation and surgical planning for referring physicians. Advantages in paediatric population of patients include lack of need for sedation or general anaesthesia.³

Majority of the head and neck lesions are superficial palpable masses and easily accessible. Palpable lesions in head neck region include a wide variety of inflammatory and neoplastic conditions.³  Majority of them belong to lymph nodes, thyroid, salivary glands and skin lesions. FNAC provides a rapid diagnosis with access to perform ancillary techniques and correlation with histopathology in excision biopsies which help clinicians in deciding the mode of treatment. 

FNAC being an inexpensive procedure helps patients from our sector for a rapid diagnosis. This study aims at analysing FNAC reports on palpable head and neck lesions and classifying them based on the organ involved and type of lesions.

This was a retrospective descriptive study of patients who came with lesions of head to neck to our institute Raichur Institute of Medical Sciences (RIMS), Raichur from the period of January 2019 to January 2022. Clinical details and radiological investigations were collected from the case reports maintained in Central Laboratory at RIMS, Raichur. FNAC reports were analysed and classified the lesions according to the recent classification criteria of respective lesions.

Inclusion criteria for the study was all the FNAC reports in the respective period. Exclusion criteria were improperly fixed smears and smears which are inadequate for evaluation. Ethical clearance was obtained from Institutional ethics committee.

Out of the 544 cases available, only 454 cases were included in the study owing to exclusion of inadequate sampling or insufficient material for the reporting. There was female preponderance of 237(52.2%) compared to 217(47.79%) male cases. Majority of the cases belonged to 2nd decade (27.09%) and 3rd decade (24.89%) of life as shown in figure 1.

Palpable head and neck lesions constituted lesions of thyroid, lymph nodes, salivary glands and miscellaneous lesions. Majority of the cases presented with thyroid swellings constituting to 181(39.86%) cases. 144(31.05%) of the lesions were lymph node swellings. Only 14(3.08%) of the salivary glands lesions were noted. Various miscellaneous lesions constituted to 115(25.33%)cases. Distribution of head and neck lesions is represented pictorially in figure 2.

Of the thyroid FNACs, colloid goitre was the lesion most commonly reported with 109(60.22%) cases. Distribution of the number of lesions is given in table 1. 115(63.53%) cases belonged to female patients and 66(36.46%) belonged to male patients. Upon classifying the thyroid lesions based on the Bethesda system, 171(94.47%) cases belonged to category II, 5(2.76%) of the cases belonged to category IV, 5(2.76%) of the cases belonged to category VI.

Table 1: Frequency distribution of thyroid FNACs

Table 2: Frequency distribution of lymph node FNACs

Table 3: Frequency distribution of salivary gland FNACs

Table 4: Frequency of distribution of miscellaneous lesions in head and neck region

Reactive lymphadenitis was the most commonly diagnosed lesion out of all the lymph node FNACs reported constituting upto 57 (39.58%) cases. Metastatic deposits forming secondaries from primary carcinomas at other sites were 34 (23.61%)

cases. Confirmed cases of Tuberculosis lymph node correlated along with CBNAAT reports constituted upto 17 (11.8%) cases. Three malignancies were reported out of which one Non Hodgkin lymphoma and 2 cases of Hodgkin Lymphoma. On application of Sydney system of reporting Lymphnode FNAC cytopathology (table 2), 107(74.3%) cases can be categorised into L2 and 37(25.69%) cases into L5 category.^4,5

There were no malignancies reported in FNAC from salivary glands. 7 cases(50%) were diagnosed as sialadenitis. One case of Warthins tumor and 6 cases of pleomorphic adenoma were reported. Lesions were categorised according to Milan system of reporting cytopathology (table 3).⁶

There were many miscellaneous lesions reported (table 4). 39(33.9%) cases of epidermal cyst followed by 32 (27.83%) cases of suppurative lesion belonged to majority of cases.

Fine needle aspiration cytology (FNAC) is a simple, rapid procedure with minimal trauma helping in better management of the patient. Majority of the head and neck lesions are inflammatory in nature. Among the neoplastic lesions, most of these lesions are benign with only a few malignant lesions.

Majority of the thyroid lesions were benign and could be classified into category II of the Bethesda system. Similar findings were noted in a study by Alshaikh S et al.⁷ All the malignant thyroid lesions were noted in adult population in contrast to a study by Mittra P et al in which a case of papillary carcinoma thyroid was reported in paediatric poulation.⁸ The diagnostic yield of nodular neoplastic lesions of thyroid is better if Bethesda system of reporting is applied according to a systematic review for determining the reliability of FNAC as a single diagnostic modality.⁹

Reactive lymphadenitis was the most common lesion followed by granulomatous and tuberculous lymphadenitis in many of the studies.^1,3,8 FNAC can distinguish tuberculous lymphadenitis from reactive and granulomatous lymphadenitis and thus can be used as a routine screening tool of lymph node swellings in the head and neck region.¹⁰ Metastatic deposits in lymph node was diagnosed in the age group of 50-70 years and most commonly seen in males than females. Most common malignancy noted was squamous cell carcinoma deposits which is in concordance with a study by Shobha SN et al.¹¹The introduction of FNA reduced the number of lymph node biopsies when the numbers of lymph node biopsies before and after the introduction of procedure were compared.¹ A retrospective cross sectional study by Baruah AK et al compared FNAC reports with respective histological diagnosis and calculated malignancy risk which was found to be 33.33%, 8.8%, 56.4%, 83.33%, and 94.74% L1,L2,L3,L4,L5 categories respectively. The proposed Sydney system of reporting and classification of lymph node cytology can help in achieving uniformity and reproducibility.⁴

FNAC is helpful in differentiating sialadenitis from neoplastic lesions of salivary glands. This will help the surgeon to decide the mode of treatment as inflammatory lesions can be treated by conservative treatment.¹ The Milan System for Reporting Salivary Gland Cytopathology (MSRSGC) is introduced to provide uniform system of reporting resulting in better communication and patient care.⁶

Epidermoid cysts are benign lesions, less common in head and neck region and hence commonly misdiagnosed. FNAC helps in reducing the confusion and dilemma associated with clinicoradiological diagnosis.¹²

Few of the other retrospective studies done by Khetrapal S et al in 2015 and Patel JP et al in 2021 reported lymph node lesions more than thyroid lesions. Granulomatous lymphadenitis was the largest subgroup among the lymph node lesions reported in both of the studies.^13,14

A study in Nigeria analysed the accuracy of FNAC head and neck lesions. The overall sensitivity and specificity for cytology was 96.8% and 30.4%, respectively. They concluded that there is need to develop capacity for improved skill in making cytopathologic diagnoses among anatomical pathologists involved in the use of FNAC as diagnostic and screening tool.¹⁵ 

FNAC is an important noninvasive tool for assessing head and neck lesions. Classifying the lesions into inflammatory and neoplastic helps in planning of treatment and categorising them into specific reporting systems helps in standardisation of reports and identifying risks of malignancy.

1. El Hag IA, Chiedozi LC, Reyees FA, Kollur SM. Fine Needle Aspiration Cytology of Head and Neck Masses: Seven Years’ Experience in a Secondary Care Hospital. Acta Cytol 2003;47:387-392.
2. Martin HE, Ellis EB. Biopsy by needle puncture and aspiration. Ann Surg 1930; 92: 169–81.
3. Rapkiewicz A, Thuy B, Simsir A, Cangiarella J, Levine P. Spectrum of Head and Neck Lesions Diagnosed by Fine-Needle Aspiration Cytology in the Pediatric Population. Cancer Cytopathol 2007;114:242-251.
4. Baruah AK, Bhuyan G. Utility of the Sydney system for reporting of lymph node cytology in a tertiary health care setup of North-Eastern India. WCRJ 2022;9:e2459.
5. Al-Abbadi MA, Barroca A, Bode-Lesniewska B, Calaminic M, Caraway NP, Chhieng DF et al. A Proposal for the Performance, Classification, and Reporting of Lymph Node Fine-Needle Aspiration Cytopathology: The Sydney System. Acta Cytologica 2020;64:306–322.
6. Rossi ED, Faquin WC. The Milan System for Reporting Salivary Gland Cytopathology (MSRSGC): An International Effort Toward Improved Patient Care—When the Roots Might Be Inspired by Leonardo da Vinci. Cancer Cytopathol 2018;126(9):756-766.
7. Alshaikh S, Harb Z, Aljufairi E, Almahari SA. Classification of thyroid fine-needle aspiration cytology into Bethesda categories: An institutional experience and review of the literature.Cytojournal 2018;15:4.
8. Mittra P, Bharti R, Pandey MK. Role of Fine needle aspiration cytology in head and neck lesions of paediatric age group. J Clin Diagn Res 2013.June Vol-7(6):1055-1058.
9. Poduval J, Bhat V, Naik P. Reliability of Thyroid FNAC as a Single Diagnostic Modality: A Systematic Review. Indian J Otolaryngol Head Neck Surf 2019;71:S167–S171.
10. Adhikari P, Sinha BK, Baskota DK. Comparison of fine needle aspiration cytology and histopathology in diagnosing cervical lymphadenopathies. AMJ 2011;4(2):97-99.