2017 Sec 1 Green Book

Huyett et al

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) 133 (52)

Female

Age (y) of patient at first encounter (n = 257) 0-4

70 (27.2) 47 (18.3) 42 (16.3)

5-8

9-12

13-16 17-21

72 (28)

26 (10.1)

Location by encounter (n = 284) Clinic

66 (23.2) 80 (28.2) 132 (46.5)

OR

IR (US guided)

Ward

6 (2.1)

Anatomic site by FNAB (n = 338) Neck

136 (40.2) 128 (37.9) 36 (10.7)

Thyroid

Preauricular/parotid

Postauricular

32 (9.5)

Abbreviations: FNAB, fine-needle aspiration biopsy; IR, interventional radi- ology; OR, operating room; US, ultrasound.

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

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