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Otolaryngology–Head and Neck Surgery 154(5)

GA (6.3 vs 8.5 years, P = .006), our experience was that many children of all ages were able to successfully undergo FNAB in the clinic with topical anesthesia alone. We there- fore feel that general anesthesia is unnecessarily overused and that there is even the opportunity to perform thyroid FNAB with ultrasound guidance in an awake child or ado- lescent, as is common practice in adults. Nevertheless, par- ental preference, coordination with other procedures, or a perceived inability to tolerate an awake FNAB can drive the desire for a higher level of anesthesia in the OR or IR suite. Surgical Decision Making If the fundamental goal of FNAB is to provide a diagnosis that will influence management, there is a significant gain to be made in avoiding unnecessary surgery and associated complications in children with benign or nonsurgical condi- tions. Over the course of the 7-year study, surgery occurred only 9 times following the 191 negative FNAB results. Stated alternatively, negative FNAB results assisted in avoiding unnecessary surgery in 95.3% of patients in whom it was not indicated. In these 9 cases, the decision to pro- ceed with surgery was guided by parental concern or the clinical judgment of the treating physician. Final histo- pathology concurred with the initial FNAB cytopathology in all 9 of these cases. Six of the cases occurred in the first 4 years of the study, whereas only 3 were in the last 3 years, indicating a possible increased clinician (and conceivably parental) confidence in FNAB results. Aside from the avoided morbidity and mortality of sur- gery, the cost savings are potentially significant. For exam- ple, our institution charges $320.00 for an FNAB and $1203.00 for a simple excisional lymph node biopsy, excluding the cost of anesthesia ($550.00/hour), OR time ($740/hour), and a hospital room ($1017.10/day). The cost differences are obviously more pronounced when the sur- gery being considered is a total thyroidectomy or superficial parotidectomy. Limitations This study has several limitations that are inherent in its retro- spective nature. First, the lack of standardization of the enrolled patients is reflective of both the diversity of pediatric HNM and the variable diagnostic and treatment approaches by different physicians. For example, in the routine lateral neck mass consis- tent with BLN, there was significant variation in the use, dura- tion, and timing of antibiotic treatment, making uniform indications for FNAB challenging in the retrospective study. In these instances, FNAB was only offered once the child was deemed a potential surgical candidate, had an atypical presenta- tion, or had an unclear diagnosis. Another limitation to this study is the lack of universal follow-up. All patients with nega- tive FNAB results are instructed to follow up if the HNM per- sists or concerns remain. If no follow-up in our system was pursued, the child was assumed to have resolution and was counted as a clinical true negative. Even still, if these cases are excluded from the analysis, the overall specificity of FNAB is 96.2%. Despite these limitations, this study was able to

demonstrate that FNAB in children is highly accurate and safe in a wide range of head and neck anatomic locations, diagnoses, and ages. Conclusion Fine-needle aspiration biopsy is a safe, well-tolerated, and accurate means of diagnosing pediatric HNM of thyroid and nonthyroid origin. Given that few nonthyroid pediatric HNMs are malignant, FNAB plays an important role in pro- viding reassurance to obviate the need for unnecessary sur- gery in benign HNM. Pediatric thyroid malignancies, on the other hand, are not infrequent, and TBSRTC should be applied to the pediatric population with the caveat that a higher degree of suspicion should be present when FNAB result is indeterminate. When this triage or stratification of pediatric HNM is employed, it potentially reduces both sur- gical morbidity and the burden on health care resources.

Acknowledgments We thank Li Wang and Dan Winger.

Author Contributions Phillip Huyett , study design, data acquisition, analysis and inter- pretation, manuscript drafting, final manuscript approval; Sara E. Monaco , study design, data acquisition and interpretation, manu- script drafting and revisions, final manuscript approval; Sukgi S. Choi , data interpretation, manuscript drafting and revisions, final manuscript approval; Jeffrey P. Simons , study design, data interpre- tation, manuscript drafting and revisions, final manuscript approval.

Disclosures Competing interests: None. Sponsorships: None.

Funding source: The statistical analysis performed in this project was supported by the National Institutes of Health through grant UL1TR000005.

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