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Nonvascular Interventions ofHead
andNeck
ShwaitSharma, AshuSeithBhalla,
AnthoniBalaSubashree, PriyankaNaranje,
andSmitaManchanda
36
Key Messages
1. Image-guided biopsy is a precise and minimally invasive
percutaneous technique to obtain tissue diagnosis in head
and neck pathologies.
2. CT-guided biopsy is the modality of choice for tissue
sampling of deep-seated head and neck lesions.
3. Ultrasound is the leading modality for biopsy of supercial head and neck lesions like thyroid, parotid, and
supercial cervical nodes.
4. MRI with its superior contrast resolution and lack of ionizing radiation seems a promising alternative to CTguided sampling in deep-seated head and neck lesions.
However, signicantly higher cost, limited expertise, and
need for MR-compatible hardware remain the main drawbacks in resource-poor areas.
5. Planning technically challenging percutaneous biopsy of
supercial and deep-seated head and neck lesions requires
robust knowledge of relevant head and neck anatomy
including various approaches for biopsy.
6. Most biopsies are done under local anesthesia except for
the transoral approach where general anesthesia is required.
7. Ultrasound-guided drainage of head and neck abscess is a
minimally invasive and cost-effective technique in draining deep neck infections without recurrence and with
minimal to nil risk to neurovascular structures of head
and neck.
8. Image-guided sclerotherapy is a less invasive and relatively safe percutaneous technique for the treatment of
low-ow vascular malformations and cystic lesions of the
head and neck.
9. Epithelial-lined cystic lesions are pathologically distinct
from endothelial-lined vascular malformations, and
reports of the use of sclerotherapy for treatment are limited and need further validation.
S. Sharma · A. S. Bhalla (*) · A. B. Subashree · P. Naranje ·
S. Manchanda
Department of Radiodiagnosis and Interventional Radiology, All
India Institute of Medical Sciences, Delhi, India
36.1 Introduction
Interventional radiology in the head and neck region includes
nonvascular interventions (biopsy/ne needle aspiration
cytology using USG or CT guidance; sclerotherapy using
USG guidance, percutaneous ultrasound-guided drainages)
and vascular interventions (angioembolization in head and
neck bleeding, embolization of tumors, and arteriovenous
malformations).
The vascular interventions of the head and neck are cov-
ered in Chap. 15.
36.2 Image-Guided Needle Biopsy ofHead
andNeck Lesions
Image-guided biopsy is a precise and minimally invasive
percutaneous technique to obtain tissue diagnosis in head
and neck pathologies. Image-guided tissue sampling is a precise and preferred technique over open surgical biopsy
nowadays.
CT-guided biopsy is the modality of choice for tissue
sampling of deep-seated head and neck lesions [1–8].
Excellent ability of CT to delineate vital soft tissue, air-lled
viscera, and bones is the key to planning an approach to otherwise surgically inaccessible deep-seated head and neck
lesions.
Planning of needle trajectory with CT guidance is a safe
and precise alternative to open surgical biopsy and ultrasoundguided sampling. However, high cost, lack of expertise, limited availability, and ionizing radiation exposure are potential
concerns which limit its widespread use [1, 9, 10].
Ultrasound is the leading modality for biopsy of supercial
head and neck lesions like thyroid, parotid, and supercial cervical nodes. Easy availability, low cost, lack of radiation exposure, dynamic imaging capabilities, and excellent soft tissue
and vascular delineation give ultrasound supremacy in image-
© The Author(s), under exclusive license to Springer Nature Singapore Pte Ltd. 2024
S. H. Chandrashekhara (ed.), Textbook of Interventional Radiology, https://doi.org/10.1007/978-981-97-9601-4_36
445
446
S. Sharma et al.
guided biopsy of supercial lesions. However, acoustic artifacts from bone and air-lled structures limit its role in
deep-seated head and neck lesions [11–13, 16].
MRI with its superior contrast resolution and lack of ionizing radiation seems a promising alternative to CT-guided
sampling in deep-seated head and neck lesions. Signicantly
higher cost, limited expertise, and need for MR-compatible
hardware remain the main drawbacks in resource-poor areas.
Also, longer acquisition times and lack of open- conguration
MR scanners have limited the role of MRI in image-guided
biopsies [13–16].
36.3 CT-Guided Biopsy
36.3.1 Pre-Procedure Planning andNeedle
Selection
When a requisition for head and neck lesion biopsy is
received, a careful review of pre-biopsy cross-sectional
images is done to determine the lesion location, and an
approach to biopsy is planned. The patient is routinely given
short admission for a few hours on the day of the procedure.
Prior screening for any coagulopathy is done. Kidney function tests as deemed necessary may be done before the procedure if intravenous contrast administration is planned
during the biopsy. Most biopsies are done under local anesthesia except for the transoral approach where general anesthesia is required. A pre-anesthetic check-up is done in cases
posted under general anesthesia.
We use a semi-automatic, dual-throw coaxial biopsy gun
to take samples from head and neck lesions. This coaxial
technique allows for taking multiple samples from the same
initial guide needle. An 18 or 19G thin wall guide needle is
placed in the target lesion followed by a sampling of tissue
with the biopsy gun via the needle (coaxial technique). For
FNAC of lesion a smaller size needle, usually 20 or 22 G
gives sufcient sample for analysis [1, 14–18].
36.3.2 Complications
CT-guided biopsy of head and neck lesions is a safe technique associated with a low complication rate (less than
1%). Minor pain at the puncture site can be averted with
the adequate application of LA pre-procedure. Analgesics
post- procedure is seldom required. Puncture site bleeding
is minimal in patients with normal coagulation proles and
is controlled with adequate compression post-procedure.
The infection rate is almost nil owing to the use of sterile
techniques during the procedure. A transoral biopsy is
done under appropriate antibiotics cover to prevent
infection.
Other potential complications associated with the
CT-guided biopsy are the same as with any other procedure
such as vasovagal and allergic reactions. Rare complications
include arterial injury with severe hemorrhage and even
death. Nerve injuries are usually transient [1, 13, 16–18].
36.3.3 Technical Approaches
Planning technically challenging percutaneous biopsy of
supercial and deep-seated head and neck lesions requires
robust knowledge of relevant head and neck anatomy. To
understand and plan the needle trajectory, the head and neck
region is divided into suprahyoid and infrahyoid regions.
Localization of the lesion to relevant head and neck space
and its relationship to surrounding soft tissue structures and
bones is vital in deciding on an image-guided approach to
the lesion.
36.3.4 Approach toSuprahyoid Lesions
Various approaches to target suprahyoid lesions including
skull base and upper cervical vertebra include the subzygomatic, retromandibular, para maxillary, submastoid, transoral, and posterior approaches.
36.3.4.1 Subzygomatic Approach (Fig.36.1)
This approach is appropriate to access masticator, para pharyngeal, pharyngeal mucosal retropharyngeal, and prevertebral space lesions. Cranially located lesions in the
suprazygomatic region including the skull base can also be
accessed with a minor craniocaudal tilt of the needle.
In this approach, the needle trajectory passes via a mandibular notch, a wide fossa between the mandibular coronoid process anteriorly mandibular condyle posteriorly and
the superior border of the ramus of mandible inferiorly.
Opening of mouth partially using a bite block can be done
to further widen the space in clinically relevant situations
[1, 3, 16].
Even in expert hands, risk of injury to adjacent vital structures, including the mandibular branch of the trigeminal
nerve, the internal maxillary artery, and its branches including the middle meningeal artery and the pterygoid venous
plexus, is a theoretical possibility with this approach.
36.3.4.2 Retromandibular Approach (Fig.36.2)
The retromandibular, also called the transparotid approach,
is mainly used to sample lesions in deep parotid space, parapharyngeal space, pharyngeal mucosal space, and lower retropharyngeal space. Also, lesions within carotid space can
be sampled if the mass is causing medial displacement of
carotid vessels.
36 Nonvascular Inter ventions ofHead andNeck
abc
def
447
Fig. 36.1 CT guided biopsy—subzygomatic approach. CT reveals
an ill-dened lesion (solid black arrow in a) in the right infratemporal fossa with bony hyperostosis (b, c). The needle is inserted below
the right zygomatic arch (d) and is advanced anterior to the right
In this approach, the patient lies supine with their head
turned to the opposite side to make space for needle trajectory. The presumed tract is in between the mandible anteriorly, mastoid process posteriorly, and via the posteriorly
located parotid gland. This narrow space offers little room
for needle manipulation and exposes vital structures to possible injury. So careful planning and expertise are critical for
taking adequate samples.
We should be cautious not to injure great vessels of the
neck which are near needle trajectory in this space.
The internal carotid artery, external carotid artery, retromandibular vein, and branches of the facial nerve within the
parotid gland are the potential at-risk structures while sampling via retromandibular approach. Also needling of deeper
lesions within the parapharyngeal and retropharyngeal
spaces via this approach may jeopardize branches of the
mandibular nerve and internal maxillary artery while they
course through this region [1, 16].
36.3.4.3 Paramaxillary Approach
This approach is ideal for sampling lesions in infra- zygomatic
masticator space as well as posterior portions of parapharyngeal and pharyngeal mucosal spaces. In addition, lesions in
the lateral portion of retropharyngeal space, within the prevertebral portion of the peri vertebral space, in the carotid
mandibular condyle (e). After verication of accurate position, the
co- axial biopsy needle was introduced and multiple passes were
taken (f). Biopsy revealed meningioma
space and the deep portion of parotid space can be sampled
[1, 19, 20]. With a cranial tilt of the needle at the entry point,
this approach can be used to sample lesions in the anterior
arch of C1, odontoid process, the body of C2, as well as
lesions in the skull base and foramen ovale [21].
Anatomy of surrounding bones like size and shape of the
maxillary alveolar ridge, lateral pterygoid plate, mandibular
ramus, and posterolateral wall of maxillary antrum usually
preclude sampling from medial retropharyngeal and prevertebral spaces and an anteromedial portion of para pharyngeal
and pharyngeal mucosal spaces.
The patient lies supine on the table with head turned to the
opposite side and the needle is introduced inferior to the
zygomatic process in buccal space and directed posteriorly
in between the maxilla and mandible. For sampling lesions
in the masticator space, the needle is passed through the buccinator or anterior portion of the masseter. To take a biopsy
from posterior lesions, the needle is advanced via pterygoid
muscles and parapharyngeal space to access C1 and C2 vertebrae. Skull base and foramen ovale lesion biopsy require
mild hyperextension of the patient neck and cranial angulation of needle at the entry point.
Key structures at risk of injury while sampling include
facial artery in buccal space and deeper carotid artery,
branches of the mandibular and maxillary nerves in mastica-
448
ab
Fig. 36.2 CT-guided
biopsy—Retromandibular
approach. (a and b) CT—Soft
tissue window reveals a mass
in right parapharyngeal and
masticator space (asterisk in
a), anterior to styloid process
with obliteration of
parapharyngeal fat (arrow in
b). In the retromandibular
approach, a needle was
inserted behind the ramus of
the mandible as shown in
image c, and advanced
anterior to styloid process till
the soft tissue lesion (d)
S. Sharma et al.
c d
tor space, pterygoid venous plexus, and internal maxillary
artery [1, 16].
The potential at-risk structure in this approach is the vertebral artery while sampling lesions at the level of the C1-C2
vertebra. Planning a biopsy on a post-contrast scan to delin-
36.3.4.4 Submastoid Approach
The submastoid, also called as retroparotid approach, is
best suited for sampling lesions in the carotid space
which displaces carotid vessels medially and in the
anterolateral portion of the perivertebral space that displaces carotid vessels anteriorly. Lesions in parapharyngeal space can also be accessed via this approach.
However, deeper lesions within pharyngeal, pharyngeal
mucosal, and retropharyngeal spaces are usually not
approachable via this route.
The patient is positioned prone or in a supine position
with the head turned to the opposite side. The biopsy trajectory is posterior-anterior or latero-medial via the sternocleidomastoid muscle and posterior to the parotid.
eate the vessels separately obviates the risk of vascular injury
to a large extent [1, 16].
36.3.4.5 Transoral Approach
This approach offers safe access for percutaneous sampling
of lesions in retropharyngeal space, prevertebral portion of
peri-vertebral space, posterior pharyngeal mucosal space,
and lesions involving anterior portions of C1 and C2 vertebrae and odontoid process.
The procedure is done under GA with appropriate antibiotic cover. Supine position with open mouth is maintained
and a needle is passed in between the uvula and tongue to
puncture the posterior pharyngeal wall after adequate application of local anesthetic to pharyngeal wall.
ab
cd
36 Nonvascular Inter ventions ofHead andNeck
449
Practically there is no vital structure at risk while sampling lesions via this approach. However, care should be
taken to avoid the potential risk of injury to the spinal cord at
C1 and C2 vertebral levels [1, 16, 22, 23].
36.3.4.6 Posterior Approach (Figs.36.3
and36.4)
As the name suggests, this approach is used to take samples
from masses located in posterior and lateral portions of perivertebral space. Lesions involving the spinous process, lamina and articular pillars of the upper cervical vertebra, as well
as occipital condyle and lateral masses of C1 and C2 can be
sampled.
A prone or decubitus position is required for sampling
and a needle is passed posterior-anteriorly through the posterior neck muscle to approach the lesion.
The vertebral artery after exiting from the C1 foramen
courses posteriorly along the upper surface of the C1 lamina;
therefore, targeting lesions involving the lateral mass of the
C1 needle should be passed under the lamina to avoid injury
to the artery. Planning on a post-contrast scan further reduces
the risk of vertebral artery injury [1, 16].
36.3.5 Approach toInfrahyoid Neck Lesions
Various approaches to target infrahyoid including lower cervical vertebral lesions include anterolateral, posterolateral,
and posterior approaches [1, 24–27].
36.3.5.1 Anterolateral Approach
This approach is ideal for lesions between the carotid sheath
and the airway. Access to lesions in retrotracheal, paraesophageal, anterior perivertebral space, and lower cervical vertebrae including disks is possible as disks anteriorly are not
covered by uncovertebral joints. Lesions involving the transverse process of the lower cervical vertebrae are also amenable to sampling with this approach.
The needle trajectory lies anterior to the sternocleidomastoid muscle, directed posteromedially between the carotid
sheath and airway. At-risk soft tissues with this approach
include the hypopharynx, pyriform fossa, and esophagus.
The needle can be passed through the thyroid gland to
approach the lesion without much risk.
Utmost care should be taken to avoid injury to the vertebral artery as it passes into the base of the transverse process
Fig. 36.3 Soft tissue lesion
carotid and paraspinal space.
CT soft tissue (a) and bone
window (b) reveal an
ill-dened relatively
homogeneous lesion (asterisk
in a and b) in the right carotid
space, jugular foramen, and
paraspinal space. On
post-contrast T1W axial (c)
and coronal (d) images, the
lesion shows heterogeneous
enhancement along with
encasement (asterisk in c) of
the internal carotid artery and
internal jugular vein
abc
ef
d
S. Sharma et al.
Fig. 36.4 CT-guided biopsy—posterior approach (same patient as
Fig. 36.3). CT shows an ill-dened relatively homogeneous lesion
(asterisk in a and b) predominantly in the right paraspinal space. Markers
are placed with the patient in a prone position. A needle is inserted
through the right paravertebral muscles (c) and is advanced further till
of the C6 vertebra and then cranially through the transverse
foramen of the cervical vertebra.
Other potential structures at risk of injury include superior
and middle thyroid vessels, superior and inferior laryngeal
nerves, the inferior loop of the hypoglossal nerve, and cervical ganglia of the sympathetic nervous system [1, 16, 25–27].
36.3.5.2 Posterolateral Approach
The posterolateral approach is best suited for taking samples
from lesions in the prevertebral and lateral paraspinal portions
of the paravertebral space. Also, lesions involving lower retropharyngeal, posterior cervical spaces, and posterior elements
of the lower cervical vertebrae are accessible with this approach.
The patient can be placed in the supine, prone, or lateral
decubitus position depending on the site of the lesion. The
needle trajectory passes through the sternocleidomastoid
muscle and posterior cervical space. Deep within the needle
lies posterior to the carotid sheath and tracks anteromedially
or posteromedially depending upon lesion location and size.
needle (arrow in e) was introduced and its tip was advanced within the
lesion and multiple passes were taken. Post-biopsy check CT revealed
few air foci (arrow in f) within the lesion. Biopsy revealed chronic
inammatory inltrates with no granuloma/malignant cells
The risk of injury to the vertebral artery can be reduced by
using intravenous contrast [1, 16, 26].
36.3.5.3 Posterior Approach
Technical aspects and target areas covered remain the same
as in suprahyoid pathologies. Potential risk of injury to vertebral artery should be avoided by planning an approach on a
post-contrast scan.
To conclude, CT-guided biopsy is the precise and minimally invasive percutaneous technique to obtain tissue diagnosis in head and neck pathologies and is associated with
almost nil risk in expert hands.
36.4 Ultrasound-Guided Biopsy/FNAC
Image-guided biopsies in the head and neck can be performed
using multiple modalities. US is the primary modality used to
guide sampling of the supercial neck lesions. Dynamic
36 Nonvascular Inter ventions ofHead andNeck
451
imaging capability with in-plane localization of needle at
almost any angle, vascular visualization with Doppler, easy
availability, low cost, and radiation-free modality are some of
the primary advantages of ultrasound. However, ultrasoundguided sampling is technically challenging and requires a
skillful operator. Also, acoustic artifacts from adjacent airlled viscera and bony structures limit its role in imageguided sampling of deeper lesions. Nevertheless, ultrasound
is advocated for biopsies of supercial as well as clearly visible deep head and neck lesions [16].
36.4.1 Screening forUltrasound-Guided
Sampling
Screening patients for necessity and feasibility of
US-guided biopsy is done prior to booking for the procedure. Cross- sectional imaging if available aids in corroboration of screening ultrasound ndings and helps to plan
biopsy areas within the target lesion. The biopsy is done
from viable areas to increase sampling yield. Pre-procedure
coagulogram and platelets are routinely advised. Supercial
biopsies are done under local anesthesia. Sedation is preferred in pediatric patients over general anesthesia owing to
short procedure time. At our institute, we admit patients for
a few hours on the day of the procedure usually for postprocedure monitoring. As with CT-guided biopsies, we use
a semi-automatic, dual-throw coaxial biopsy gun to take
samples from head and neck lesions. The advantage of
coaxial technique includes multiple sampling from the
same initial guide needle. An 18 or 19G thin wall guide
needle is used to target the biopsy of the supercial head
and neck lesion. For FNAC, a smaller size needle usually
20 or 22G with suction syringe is used.
Major limiting factor of using US for biopsy of deeper
head and neck lesions is difculty in clearly visualizing the
biopsy needle which can be partially reduced by wiggling
the needle tip in the tissue or injecting small amount of air
through the needle tip by rapidly advancing and withdrawing
the stylet in the needle lumen or by injecting small amounts
of normal saline containing microbubbles into the surrounding tissue.
Also, several improved designs of the needle to make
them more echogenic and readily visible in tissue are available [16, 28–30].
36.4.2 Anatomy andLesion Localization
Robust knowledge of head and neck anatomy is key in planning an approach to biopsy. Determining the organ of origin
and relationship of lesion to adjacent vital organs on screening ultrasound aids in deciding needle trajectory for biopsy
so that yield is maximized and complications minimized. It
also avoids potential pathological misdiagnosis.
The expected trajectory and biopsy needle throw is always
planned away from vital structures as much as possible to
keep the risk of inadvertent injury to adjacent vital organs
low. Technical expertise is key in achieving a smooth and
atraumatic needle pass into the target tissue.
For ease of understanding, head and neck anatomy is
divided into zones; each with key anatomic structures and
relevant pathologies. It is pertinent to mention that although
discussed separately, many of these key anatomic areas are
contiguous and lesion can span more than one anatomic area
if large.
36.4.2.1 Parotid Space (Fig.36.5)
The chief contents of parotid space include the parotid gland
with intraparotid lymph nodes, facial nerve, external carotid
artery, and retromandibular vein. The adjacent bony structures in this space with ramus of mandible anteriorly and
mastoid posteriorly limit space available to biopsy deepseated lesions with ultrasound guidance. Doppler is helpful
in delineating the course of major vessels within the parotid
and serves as an anatomic landmark for the facial nerve
which lies lateral to the retromandibular vein within the
parotid.
Parotid has a bright and echogenic appearance on ultrasound. This makes needle visualization and tracking little
difcult as it courses within the normal parotid. Fatty
replacement of parotid further brings down the utility of
ultrasound in deeper lesions. Normal intra-parotid nodes
have an echogenic fatty hilum which helps to differentiate
them from abnormal metastatic nodes and other hypoechoic
lesions in this space. Facial nerve injury is the primary concern while sampling parotid lesions especially during biopsy.
36.4.2.2 Bucco-Masseteric Region (Fig.36.6)
This is the supercial cheek region and includes masseter
muscle in supercial masticator space posteriorly and the
buccal space with its buccinator muscle, buccal fat pad, and
parotid duct more anteriorly. Parotid duct courses in the
space below the zygomatic arch should be kept in mind to
avoid inadvertent injury to the duct. CT/MRI evaluation of
masses in the region before biopsy planning is necessary to
evaluate the deep extent and origin.
36.4.2.3 Submandibular Space (Fig.36.7)
This space contains the submandibular gland below the oor
of mouth. The facial vein lies supercial and lateral to gland
and masses within this space displace the vein laterally while
the facial artery courses within the space. Unlike parotid, no
nodes are present within the submandibular gland and
hypoechoic lesions are suspicious for malignancy. Also
enlarged nodes outside the gland draining the surrounding
452
ab
cd
Fig. 36.5 USG-guided
biopsy from intraparotid
lesion. USG reveals enlarged
bilateral parotid glands with
multiple hypoechoic lesions
within (asterisk in a).
USG- guided biopsy was done
using a 22G needle (arrow in
b) from the lesion revealing
lymphoid tissue with reactive
follicles and numerous
eosinophils in the
interfollicular area
S. Sharma et al.
Fig. 36.6 USG-guided
FNAC buccomasseteric
region. X-ray mandible (a)
and CT (b) reveal a large
ill-dened soft tissue lesion
(asterisk in a and b) involving
the left lower gingivobuccal
sulcus with erosion of the left
ramus of the mandible. Gray
scale and Doppler (c) USG of
the same lesion reveal an
ill-dened lesion with few
bony fragments within and no
signicant internal
vascularity. A 23G needle is
inserted within the lesion
using USG guidance with its
tip (d) in the lesion. FNAC
revealed squamous cell
carcinoma
area of the anterior face including the oral cavity, paranasal
sinuses, and orbits are common.
a b
ing hypoglossal and lingual nerves are at risk of injury
while sampling lesions in submental space. Access to
lesions deep in the oral cavity can be achieved especially
36.4.2.4 Submental Space, Floor ofMouth,
andOral Cavity
in patients with difculty in opening mouth due to disease
process.
The submental space is present at the oor of the mouth in
between the anterior bellies of the digastric muscles and
below the mylohyoid sling. The lymph nodes in this space
drain the anterior portion of the face. This approach can
also be used to access the sublingual space anteriorly and
root of tongue posteriorly. Lingual artery and accompany-
36.4.2.5 Carotid Space
Lesions in carotid space include the neurogenic tumors and
nodes. Neurogenic tumors like paraganglioma are vascular and
can secrete catecholamines. So biopsy/FNAC is not done due
to risk of inadvertent bleeding and catecholamine secretion.
36 Nonvascular Inter ventions ofHead andNeck
abc
de
453
Fig. 36.7 USG-guided biopsy of cervical lymph nodes. USG reveals
an enlarged nodal mass (arrow in a) with few calcic foci within (asterisk in b) at level I.A 22G co-axial needle was inserted into the lesion
36.4.2.6 Laryngeal Mass (Fig.36.8)
Frequently the recurrent mass lesions in post-operative postirradiated neck are a diagnostic challenge. Inability to access
via FOL or negative biopsies are indications for imageguided biopsy in such cases.
via in-plane technique under USG guidance as shown by the clinical
image (d) and the biopsy gun was introduced (e) and multiple passes
were taken
36.4.2.7 Thyroid Lesions (Fig.36.9)
FNAC of thyroid lesions is one of the most commonly
performed procedures. FNAB with a 22 G gun is also
described with repeated negative FNAC or Bethesda 4
lesions [16].