Role of Fine Needle Aspiration Cytology in Head and Neck Lesions of Paediatric Age Group
Purnima Mittra1, Rajni Bharti2, Manmohan Krishna Pandey3
1 Assistant Professor, Department of Pathology, Rohilkhand Medical College and Hospital, Bareilly-243001, U.P., India.
2 Associate Professor, Department of Pathology, S.N. Medical College, Agra-282003, U.P., India.
3 Assistant Professor, Department of Medicine, Rohilkhand Medical College and Hospital, Bareilly-243001, U.P., India.
NAME, ADRES, E-MAIL ID OF THE CORESPONDING AUTHOR: Dr. Purnima Mittra, Assistant Professor, Department of Pathology, Rohilkhand Medical College and Hospital, Bareilly-243001, U.P., India.
Phone: 9411322722
E-mail: panorama.mittra@gmail.com
Context: Fine Needle Aspiration Cytology [FNAC] of the head and neck region is well accepted as a diagnostic procedure. Various studies in the context of FNAC in the head and neck region are available for the adult population, but only few studies are available for the paediatric age group.
Aims: To study the role of fine needle aspiration cytology and its utility in paediatric head and neck lesions.
Settings and Design: This was a hospital based, prospective study.
Method and Materials: Hundred cases of head and neck lesions of the paediatric age group [0-15 years] were studied for cytomorphology through fine needle aspiration cytology and the results were correlated with the histomorphology.
Results: There was a male predominance in the case distribution among both the sexes in children [55%]. The head and neck lesions were most frequent in the age group of 10-15 years, followed by the age group of 5-10 years than the age group of 0-5 years. Lesions in the cervical lymph nodes constituted 81% of the head and neck lesions and 87% of the adequate smears, followed by those in the skin and subcutaneous tissues [3 cases (3.2%)], the thyroid [4 cases (4.3%)] and the salivary gland [1 case (1%)]. 88.17% cases of head and neck lesions in children were diagnosed as benign on their smears and 11.83% cases were diagnosed as malignant, of which 8 cases of malignant lesions were located in the cervical lymph nodes, 1 case was located in the thyroid and 2 cases of malignant lesions were located in the orbits.
Conclusions: FNAC is an important and a non-invasive, investigational tool in children for identifying and planning the medical management of inflammatory and infectious conditions. It helped us in indicating the diagnosis of the lesions in congenital or aquired malformations, cystic lesions and benign neoplastic lesions, in which surgical management were needed and we got confirmations on histological examinations. For the malignant lesions, FNAC was a more important investigation tool than an accurate investigation tool, which suggested about the lesions and guided us to do more advanced specific investigations for obtaining the diagnosis.
INTRODUCTION
Fine Needle Aspiration Cytology (FNAC) is a simple and a rapid diagnostic technique. It is now being considered as a valuable diagnostic aid because of the early availability of results, its simplicity, minimal trauma and the absence of complications. The cytomorphological features collaborate with the histopathology and it has the qualities of a micro-biopsy [1] Ancillary techniques such as flow cytometry, cytogenetics, electron microscopy and cell block preparations with immunocytochemistry can be applied for the characterization of tumours. In addition, their benefits include the lack of sedation or general anaesthesia [2]. For a long time, the application of FNAC was ignored in the Indian and American paediatric literatures. Previous reports have suggested its utility in only a small series of paediatric populations [3–5]. Only few studies which were done on paediatric FNAC have focused exclusively on both the benign and malignant lesions that occur in the regions of the head and neck [6–8]. FNAC of the head and neck region is a generally well-accepted technique that has high specificity [9]. By providing few false-negative diagnosis, the categorization of the lesions into inflammatory/benign and malignant is possible, with a high degree of certainity [10].
With the increasing costs of medical facilities, any technique which speeds up the process of the diagnosis and limits the physical/psychological trauma to the patients, will be of tremendous value. FNAC helps the surgeons in selecting, guiding and modifying the surgical planning in patients who require surgeries or a general clinical management such as the need of an antibiotic treatment and or a neoadjuvent chemotherapy. The present study was designed to study the role of fine needle aspiration cytology and its utility in paediatric head and neck lesions. It also specifies the spectra of the head and neck lesions in the paediatric age group and correlates the cytomorphological features with the histomorphological findings, whenever they are available.
SUBJECTS AND METHODS
The present study was performed in the Department of Pathology, in a tertiary care centre of northern India, on 100 children who were in the age group of 0-15 years, who presented with head and neck lesions, after getting the approval of the ethical committee of the institution, between 01/2/2009 to 30/11/2010 and also with the consent of their parents. A brief clinical history of the patients was taken and examinations of the lesions were done. The patients were placed in comfortable and the most suitable positions. The swellings were made prominent, they were cleaned with 70% isopropyl alcohol and they were aspirated aseptically. Smears were prepared from the materials which were aspirated in the syringes and they were spread over clean glass slides and fixed for staining.
The following staining methods were used
May-Grunwald-Giemsa Staining [11].
Papanicolaou Staining [11].
Ziehl-Neelson Staining [11].
RESULTS
A total of 100 cases of head and neck lesions from patients who were in the age group of 0-15 years were studied through fine needle aspiration cytology smear examinations. The results have been described in [Table/Fig-1,2,3,4,5,6,7 & 8].
Results of FNAC of head and neck lesion of children
| Adequacy | Category | Age distribution | Sex distribution | Nature of lesion |
|---|
| Adequate [93%] | Positive [100%] | 0-5 years [27%] | Male [55%] | Benign [88.17%] |
| Inadequate [07%] | Negative [0%] | 5-10 years [36%] | Female [45%] | Malignant [11.83%] |
| | 10- 15 years [37%] | | |
Distribution of benign and malignant lesions in different organs
| S. no | Site | Adequate Cases | Benign | % | Malignant | % |
|---|
| 1. | Lymph node | 81 | 73 | 91 | 8 | 9 |
| 2. | Thyroid gland | 4 | 3 | 75 | 1 | 25 |
| 3. | Salivary Gland | 1 | 1 | 100 | 0 | 0 |
| 4. | Eyelid and orbit | 2 | 0 | 0 | 2 | 100 |
| 5 | Misc. | 5 | 5 | 100 | 0 | 0 |
| Total | 93 | 82 | | 11 | |
Cytomorphological diagnosis of lesion
| Lymph node | No. 81 | Thyroid | No. 04 | Salivary Gland | No.01 | Eyelid and Orbit | No. 02 | Miscellaneous 05 | No |
|---|
| Reactive hyperplasia | 31 | Hashimoto’s thyroiditis | 01 | Pleomorphic Adenoma | 01 | Embryonal RMS | 01 | Epidermal inclusion cyst | 02 |
| Granulomatous lymphadenitis [with or without caseation] | 23 | Lingual thyroid | 01 | | | Small blue round cell tumor | 01 | Muscle fibromatosis coli | 01 |
| Necrosis and pus | 17 | Thyroglossal duct cyst | 01 | | | | | Hemangioma | 01 |
| Purulent aspirate with coccal aggregates | 02 | Papillary carcinoma of thyroid | 01 | | | | | Lymphangioma | 01 |
| Langerhans cell histiocytosis | 01 | | | | | | | | |
| Hodgkin’s lymphoma | 03 | | | | | | | | |
| Non-Hodgkin’s lymphoma | 02 | | | | | | | | |
| Leukemic infiltrate | 01 | | | | | | | | |
| Metastatic tumor in lymph node [RMS] | 01 | | | | | | | | |
Cytomorphological type in lymph node
| S. No. | Diagnosis | No. of cases | Percentage |
|---|
| Benign lymph node lesions |
| 1. | Reactive follicular hyperplasia | 31 | 42% |
| 2. | Tubercular lymphadenitis | 40 | 55% |
| 3. | Suppurative bacterial lymphadenitis | 02 | 03% |
| Total | | 73 | 100% |
| Malignant lymph node lesions |
| 1. | Hodgkin’s lymphoma | 3 | 37.5% |
| 2. | Non -Hodgkin’s lymphoma | 2 | 25% |
| 3 | Acute leukemic infilterate | 1 | 12.5% |
| 4. | Metastasis from distant organs | 1 | 12.5% |
| 5. | Langerhans cell histiocytosis | 1 | 12.5% |
| Total | | 8 | 100% |
Site and cytomorphological type in malignant lesions
| S. No. | Organ | Diagnosis | No. of cases | %age |
|---|
| 1 | Lymph node | Hodgkin’s lymphoma | 3 | 28% |
| 2 | Lymph node | Non-Hodgkins lymphoma | 2 | 18% |
| 3. | Lymph node | Acute leukemic infiltrate | 1 | 9% |
| 4. | Lymph node | Metastasis from distant organ | 1 | 9% |
| 5. | Lymph node | Langerhans cell histiocytosis | 1 | 9% |
| 6. | Thyroid | Papillary carcinoma | 1 | 9% |
| 7. | Orbit | Embryonal rhabdomyo-sarcoma | 1 | 9% |
| 8. | Orbit | Small round blue cell tumor | 1 | 9% |
| Total | | | 11 | 100% |
Comparative Study of FNAC From Similar Previous Studies
| Amy Rapackwiz et al., [2] | M Jain et al., [12] | H.Mohan et al., [13] | Present study |
|---|
| Study Topics | Spectrum of head and neck lesions diagnosed by fine-needle aspiration cytology in the pediatric population | FNAC as diagnostic tool in pediatric head and neck lesions | Role of FNAC in paediatric lymphadenopathy | Role of FNAC in head & neck lesions of pediatric age group |
| Total no.of cases | 85 cases | 748 cases | 692 cases [584 cervical lymph nodes] | 100 |
| Age group | 0–18 years | 0–12 years | 0–14 years | 0–15 |
| Adequacy of material | | 94% | 93.4% | 93% |
| Age predominance | | | 6–10 years | 10–15 years |
| Sex predominance | Male [69.4%] | | Male :female ratio 1.5: 1 | Male 55% |
| Most common site of lesion | Lymph node cervical 69.4% | Lymph node cervical 81% | Lymph node cervical 84.3% | Lymph node cervical 87% |
| Other sites of lesions | | | | |
| Skin & subcut. tissue | | | | 2.1% |
| Miscellaneous [cystic & soft tissue] | 16 Case [Also in Bone] | 7.6% | | 03.2% |
| Thyroid | | 3.2% | | 04.3% |
| Salivary gland | 2cases | 2.1% | | 01%% |
| Orbital nd eye lid | | 0.2% | | 02.1% |
| Nature of Lesion Benign | 83% | 98.5% | 98.46% | 88.17% |
| Malignant | 17% | 1.5% | 1.54% | 11.83% |
Comparison of Studies of Lymph Nodes of Head & Neck Lesions of Children
| Studies By | Amy Rapackwiz et al., [2] | M Jain et al., [12] | H.Mohan et al., [13] | Present study |
|---|
| Lymph node lesions | 91% of total lesion | 81% of total | 84.3% cervical | 87% |
| Reactive Lymphoid hyperplasia | 66% | 60.6% | 63% | 42% |
| Granulomatous/tubercular lymphadenitis | 15% | 30.5% | 25% | 55% |
| Acute lymphadenitis | 10.1% | 7.1% | 6% | 02% |
| Hodgkin’s lymphoma | 2case | [2case] | 4case | 03% |
| Non Hodgkin’s lymphoma | 3case | 0.8% [5case] | 2case | 02% [2case] |
| Langerhans cell histiocytosis | 5cases [in bone also] | | 1case | 1.2%[1case] |
| Leukemic infiltrates | | 0.6%[4case] | 1case[ALL] | 1 case |
| Metastatic lesions | 02cases[SRBT & PTC ] | | 02Case | 1case[RMS] |
Comparative of Previous Studies in Head & Neck Lesions of Children
| Study | Amy Rapackwiz et al., [2] | M Jain et al., [12] | Present study |
|---|
| Skin & subcut. tissue | *lymphangioma*haemangioma *lipoblastoma
| *Epidermal inclusion cyst *dermoid cyst *infected sebaceous cyst *chronic inflammations
| 2.1% *Epidermal inclusion cyst |
| Miscellaneous [cystic & soft tissue] | 16 Case [Also In Bone]
*langrhans cell histiocytosis *benign myxoid lesion *Spindle cell proliferation *osteosarcoma *Benign cystic teretoma
| 7.6%
*Muscle fibromatosis coli *vascular hammartoma *lymphangioma *fibroma *neurofibroma
| 03.2%
* Muscle fibromatosis coli *Hemangioma *lymphangioma
|
| Thyroid | 1case of Papillary Carcinoma of Thyroid metastasis | 3.2% total
*Euthyroid colloid goiter [12case] *Thyroglossal duct cyst[11case] *Thyroid cyst [1case]
| 04.3% Total
*Hashimoto’s Thyroiditis [01case] *Lingual thyroid [01 case] * Thyroglossal duct cyst [01case] * Papillary carcinoma of thyroid [01case]
|
| Salivary gland | 2cases
*Pleomorphic adenoma [1case] *Mucoepidermoid carcinoma[ 1case]
| 2.1%[ total 15 cases]
*Chronic sialadenitis [4 cases] * Mucus retention cyst [6 cases] *Pleomorphicadenoma [3cases] *Acute abscess[1case] *Normal [1 case]
| 01% of total
*Pleomorphic adenoma [1case]
|
| Orbital and eyelid | — | 0.2%* Tubercular abcess [2case] | 02.1%
*Embryonal RMS[1case] * Small blue round cell tumor[1case]
|
DISCUSSION
The head and neck lesions in children are mostly benign in nature, with a small percentage of malignant lesions which usually present as head and neck masses. A majority of the head and neck masses in children are inflammatory in nature, but other aetiologies include congenital, inflammatory, and euplastic lesions. A persistent adenopathy raises more concerns; especially the enlarged lymph nodes within the posterior triangle or the supraclavicular space, nodes that are painless, firm, and not mobile, or a single dominant node that persists for more than 6 weeks, should all heighten a concern for malignancy [14]. Neoplasms of the head and neck region account for approximately 5% of all the childhood neoplasms of the head and neck [7]. The global literature delineates the common paediatric head and neck tumours as lymphomas (59%), rhabdomyosarcomas (13%), thyroid tumours (10%), nasopharyngeal carcinomas (5%), neuroblastomas (5%), non-rhabdomyosarcoma soft-tissue sarcomas (4.5%), salivary gland malignancies (2.5%), and malignant teratoma (1%)[15].
The most common sites for the occurrence of head and neck masses in the paediatric age group in our study were the lymph nodes, which were mostly inflammatory in nature [reactive hyperplasia and tubercular lymphadenitis]. The other sites of the lesions were the thyroid, the soft tissues and subcutaneous tissues , the eyelids and the orbits and the salivary gland . Our study yielded results which were similiar to those of previous studies which were done on role of FNAC in the diagnoses of head and neck lesions of children.
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