215 / 232
was no difference in the number of nondiagnostic results by
anesthesia group (8 in topical/no-anesthesia group vs 12 in
GA/sedation,
P
= .416), but only 5 of these 20 used image
guidance.
Safety Profile
The overall complication rate was 2.1%. All 6 of the com-
plications occurred in nonthyroid HNM patients undergoing
FNAB in the clinic with topical anesthesia only. Vasovagal
response was seen in 2 patients after successful FNAB.
Both patients were discharged home in good condition from
the otolaryngology clinic. Two patients (aged 5 and 9 years)
could not have all FNAB passes completed due to discom-
fort. One procedure was terminated due to equipment fail-
ure. One lesion was too small to be successfully targeted
and has been followed clinically. Mild FNAB site ecchymo-
sis was not considered a complication but rather an expected
occurrence. In comparison, there was a 9.1% complication
rate in the 77 surgeries performed, including hypertrophic
scar/alopecia, neck abscess, neck seroma, incomplete resec-
tion, inadvertent pharyngotomy, and Horner’s syndrome.
General Anesthesia
Of the FNABs, 73% were performed with GA or sedation.
Overall, there was no statistically significant difference in
the age of those requiring GA vs topical anesthesia alone
(9.3
6
5.5 vs 9.5
6
5.6 years old,
P
= .410), but this find-
ing is skewed by the use of GA for all but 3 thyroid
FNABs. Excluding the thyroid and concurrent thyroid-
lymph node FNAB, 66 (39%) FNAB encounters were
performed with topical or no anesthesia and 105 (61%) with
GA or sedation, and a younger average age was found in
the heightened GA/sedation group (6.3
6
4.8 vs 8.5
6
5.4
years,
P
= .006).
Surgical Decision Making
Seventy-seven patients (27.0%) underwent surgery after an
FNAB encounter, with 11.7% (n = 9) of these procedures
following negative FNAB results. When combined with the
nonsurgical cases, 9 of the 191 patients (4.7%) had a surgi-
cal intervention following FNAB results that did not indi-
cate a need for surgery. Therefore, FNAB results assisted in
the decision making to avoid surgery in 95.3% of patients in
whom it was not considered appropriate.
Discussion
Pediatric HNMs are a commonly encountered finding with a
broad differential diagnosis confronting pediatricians and
otolaryngologists alike. The diagnostic challenge is distinct
from the adult HNM in that only 4% to 11% of pediatric
neck masses are found to be malignant, whereas in adults,
this figure is over 60%.
20-24
Our overall incidence of malig-
nancy in nonthyroid FNAB was 3.6%. This does, however,
likely represent an overestimate of the true incidence of
pediatric nonthyroid HNM malignancy, as typically only
persistent or otherwise worrisome masses undergo FNAB or
surgical excision, especially at a tertiary referral hospital.
Furthermore, congenital lesions such as branchial cleft
anomalies and lymphatic malformations tend to not undergo
FNAB given characteristic physical exam and imaging
findings.
The opposite scenario is seen in pediatric thyroid nodules—
namely, they are far less common than in adults but more
commonly malignant. Recent studies suggest that 16% to 26%
(17% in this study) of pediatric thyroid nodules are malignant,
which compares to 5% in adults.
6,25-27
Therefore, to ensure
adequate sampling as well as increase patient comfort while
undergoing a deeper FNAB, virtually all thyroid FNABs at
our institution are performed under GA in the IR suite with
ultrasound guidance.
Diagnostic Accuracy
Sensitivity reported in our study and others is dependent on
surgical histopathologic results to validate true positives and
false negatives. The overall sensitivity in this study (93.5%)
is similar to previous studies, which have shown rates of
93.3% to 100%, indicating reliability in both small and
large series as well as all head and neck locations.
10,14,15
Specificity, however, is more limited by the fact that most
‘‘benign’’ or negative FNAB results will not undergo sur-
gery. Our pathologically confirmed specificity was 64.3%
but represents only 14 cases. Working under the assumption
that patients who have clinical resolution or nonprogression
of disease confirms a negative FNAB, our specificity was
97.7%. Slightly higher overall sensitivity and specificity
were seen in nonthyroid FNABs (
Table 2
), which is also
seen in the adult population.
3
Table 1.
Characteristic of Patients and FNABs.
Characteristic
No. (%)
Sex by patient (n = 257)
Male
124 (48)
Female
133 (52)
Age (y) of patient at first encounter (n = 257)
0-4
70 (27.2)
5-8
47 (18.3)
9-12
42 (16.3)
13-16
72 (28)
17-21
26 (10.1)
Location by encounter (n = 284)
Clinic
66 (23.2)
OR
80 (28.2)
IR (US guided)
132 (46.5)
Ward
6 (2.1)
Anatomic site by FNAB (n = 338)
Neck
136 (40.2)
Thyroid
128 (37.9)
Preauricular/parotid
36 (10.7)
Postauricular
32 (9.5)
Abbreviations: FNAB, fine-needle aspiration biopsy; IR, interventional radi-
ology; OR, operating room; US, ultrasound.
Huyett et al
193