marker

a drain

within

throughout

the length

should

extend

of the drain

and

should include the tubular external component. That this is not the case

would be unfortunate if these types of radiologic examinations were initiated without excluding the presence of a flat

with all drains is worthy of note to the radiologist evaluating a patient for the

silicone drain. Because they may not have access to the patient, reporting radiologists in particular should be

possible

aware

presence

of a retained

sponge.

of this potential

When patients are delayed in presenting with symptoms of retained sur-

References

gical

1.

sponge,

plain

radiographs

usually

may

be nonspecific.

It

2.

Jerome William

ofthe

W, Haynes

125:405-407. Buy JN, Hubert

A. Barakos, P. Dillon,

Foramen

of tumor along the mandibular division of the trigeminal nerve in four patients, the authors obtained cytologic specimens by means of a CT-guided transfacial fine-needle aspiration technique. Diagnoses were squamous cell carcinoma (n 3) and meningioma (n 1). The technique allows biopsy of deep leTo verify

perineural

spread

=

=

sions

that

open

surgical

would

otherwise

require

biopsy.

Index terms: Biopsies, technology, 124.126 Computed tomographic (CT) guidance, 124.1211 a Head and neck neoplasms, 124.33 Radiology

T

1992;

182:573-575

of the head and neck often by means of perineural extension. Dissemination along nerves allows tumors to gain access to noncontiguous areas, which alters the prognosis and treatment plan substantially. The mandibular division of the trigeminal nerve provides a common route for perineural metastasis, and in some cases, such a metastasis may be the only UMORS

spread

visible tumor at computed (CT) or magnetic resonance ing.

In this

From

the

setting,

treatment

Department

tomography (MR) imagcan pro-

of Neuroradiology,

University

of California, San Francisco Medical Center, 505 Parnassus Aye, Box 0628, San Francisco, CA 94143. Received April 3, 1991; revision requested May 8; revision received August 21; accepted September 6. Address reprint requests to JAB. C RSNA, 1992

Volume

182

#{149} Number

2

K.

The

C, Ghossain

JP, Ecoiffler

4.

retained

sursur1990;

after

J.

MA,

Computed

Malbec

pathologic

of retained

abdominal

Liessi

G, Semisa

iviero

B, Mann

sponges

Radiol 1989;

Gastrointest

M, Sandini

and

14:41-45.

F, Roma

R, Spal-

G. Retained surgical and chronic CT and US find-

gauzes: acute ings. EurJ Radiol 1989; 98:182-186. Choi BI, Kim SH, Yu ES, Chung HS, Han MC, Kim CW. Retained surgical sponge: diagnosis with CT and sonography. AJR 1988; 150:1047-1050. Kokubo T, Itai Y, Ohtomo K, Yoshikawa K, ho M, Atomi Y. Retained surgical sponges: CT and US appearance. Radiology 1987; 165: 415-418.

L,

tomog-

CT-guided

Ovale:

ceed only

MD MD

3.

5.

Rappaport

Bethoux

Lesions Aspiration’

towels.

#{149}

gical sponge following intra-abdominal gery: a continuing problem. Arch Surg

reveal no abnormalities, and findings with computed tomography or ultrasonography

pitfall.

raphy

Fine-Needle

verification

of

face,

in the

of the mandibu-

distribution

the lesion. Obtaining histologic material from this area can be difficult, and an open surgical approach may be re-

tar division of the tngeminal nerve. This slowly progressed to complete anesthe-

quired. We describe

to his face and back as treatment

relatively

a simple,

safe method

effective,

and

for fine-needle

aspiration of lesions that involve the third division of the trigeminal nerve the level

sia. As a child,

of the foramen ovale. consists of CT-guided

at

This transfa-

technique cial fine-needle aspiration, which may obviate the need for surgical biopsy.

Although techniques for inserting needles within the cavernous sinus under fluoroscopic guidance have been described in the surgical literature, CT guidance provides for greater accuracy in needle placement. Also, with the technique described, the needle is placed at the level of the foramen ovate without it actually entering the foramen, thus reducing the risks associated with entering the cavernous sinus. Materials

and

Patients-Four two women)

patients (two men, underwent CT-guided aspiration of lesions cen-

fine-needle tered at the foramen

ovate.

Evaluation

mi-

of these patients at our institution tially took place because of symptoms referable to the trigemmnal nerve. All patients underwent MR imaging (1.5-T Signa; GE Medical Systems, Milwaukee) with the use of gadopentetate dimeglumine. After identification of a foramen ovale lesion, fine-needle aspiration with

guidance (9800; GE Medical Systems) was performed as an outpatient procedure in the radiology department. Case example-A 63-year-old man presented with a 6-month history of dysesthesia involving the right side of his CT

acne. Over the past several dozen basal moved from his face months prior to the esthesia, a squamous been removed from

MR imaging

received

radiation

for

decade, he had had cell carcinomas reand back. Two onset of facial dyscell carcinoma had

his right upper demonstrated evidence

lip. of

enhancement extending the trigeminal nerve (Fig 1). Although there was suspicion of perineurat tumor spread, tissue specimens were perineural

along

needed planning. Anatomic

to ensure

proper

from

treatment

considerations-Trans of the

fine-needle aspiration ovale is feasible, since

facial foramen

a direct

approach

the submalar region crosses no structures. This approach passes

vital inferior

zygomatic eral wall

Methods

he had

to the malar

eminence

of the

bone just parallel to the latof the maxilla. Since the fora-

men ovale lies immediately posterior to the lateral pterygoid plate, the pterygoid provides a readily identifiable landmark (Fig 2). This serves to distinguish the foramen ovate from other skull base foramina such as the foramen lacerum. Thus, with CT guidance, a needle

may

maxillary without structures

be advanced

along

the lateral

wall to the foramen ovate risking damage to important of the face.

Fine-needle aspiration technique-The is placed supine on the CT scanner, with padding under the shoulders to allow the neck to be mildly extended. patient

The patient’s head is then rotated approximately 15#{176} away from the side of planned aspiration. This serves to open Ratin1nr--i

#{149} #{231}7

2.

1.

3.

1-3. (1) Coronal gadopentetate dimeglumine-enhanced fat-suppressed Ti-weighted MR image (repetition time, 600 msec/echo time, 20 msec) through the foramen ovale of a 63-year-old man (case example). Abnormal enhancement of the mandibular portion of the trigeminal nerve is demonstrated (arrows). (2) Anterior oblique view of a skull demonstrates the relationship of the foramen ovale (black open arrow) and mandibular division of the trigeminal nerve (white solid arrows) as it courses behind the pterygoid plate (*). The cervical portion of the inter-

Figures

nal carotid artery is seen entering the carotid canal posteriorly (arrow) in the patient of the case example. The foramen ovale approaching carcinoma.

the

the

foramen

ovale

before

it is advanced

inframaxillary

region and creates a the anterior face to the foramen ovale, perpendicular to the plane of the table. With the patient in this position, contiguous 3-mm axial images are obtained through the foramen ovale. The pterygoid plate is used as a landmark in the identification of the foramen ovate. The table is then moved to the section location of the axiat image that displays the foramen ovale, and a mark is made on the patient’s skin with the aid of the gantry location light. On the display console,

direct

line from

the distance from the skin surface foramen ovale is determined.

to the

of the overlying skin and administration of local anesthesia, a 22-gauge needle (spinal needle) is advanced into the submalar region (Fig 3). To assure accurate needle placement, several CT sections are obtamed as the needle is advanced to the foramen ovate. While the needle is advanced to the foramen ovate, it is perpendicular to the long axis of the nerve After

preparation

and thus does not traverse ovate or enter the cavernous

the foramen

sinus. the needle is in the region of the trigeminat nerve, aspiration is performed. This is accomplished by moving the needle back and forth with an excursion of about 5 mm during aspiration. Care must be taken to limit the aspiration to the extracranial foramen ovate, because the carotid artery and cavernous sinus lie just superior and posterior to the needle tip. A total of two to four passes may be required to

further.

ensure

(white

open

lies just Histologic

acquisition

arrow).

posterolateral examination

(3) Axial CT scan through to the pterygoid plate of aspirated material

of an adequate

logic specimen. We have also

employed

a coaxial

cyto-

is first placed just anterior to the foramen ovate. At this point, the stylet is removed, and passes are made through

cannula

needle.

is taken

curatety Chiba

Care

with a 22-gauge beforehand to ac-

measure how far the 22-gauge needle will extend beyond the tip

of the 19-gauge needle, to ensure that damage to adjacent structures does not occur. It is essential that the cytopathologist

be present to process the material and to confirm that sufficient representative tissue has been acquired. Because of the highly vascular nature of the pterygoid muscles and associated pterygoid venous plexus, aspiration of blood is not unusual but should be minimized to avoid complicating interpretation of the specimen. This problem can also be minimized by performing biopsy without using aspiration.

immediately

Once

574

#{149} Radioloiv

Results

these was meningioma

were performed Patients underwent

biopsy

with

local

tients

tolerated

complications

only

analgesia.

the case example) in one.

and

of

Discussion

Fine-needle aspiration cytology has been used with tremendous diagnostic success

including sufficient

vested,

on an

readily

palpable

wise

the procedure well, and did not develop. Patients to home after 3 hours of

were released observation. Aspirated cytologic matenat allowed diagnosis of squamous cell carcinoma in three patients (one of

and

that

would

other-

require

open surgical biopsy may be reached (1,2). For this reason, CTguided fine-needle aspiration is a powerful diagnostic toot in the evaluation of head and neck disease. A variety of head and neck neoplasms

have been reported to have a propensity for perineural spread. The most common tumors with such a characteristic are those of the skin and mucous membranes, such as squamous cell carcinoma and melanoma. Additionally, nasopharyngeal squamous cell and adecystic

pensity nat

All pa-

at sites throughout the body, the head and neck (1). When numbers of cells are hara diagnostic interpretation can

be made. In the hands of experienced cytopathotogists, the accuracy of diagnosis is high. When fine-needle aspiration is guided by means of CT, head and neck lesions that are deep and not

noid

All procedures outpatient basis.

ovale

19-

and 22-gauge needle system. With the coaxial technique, the 19-gauge cannula

the 19-gauge

the level of the foramen

(*). The needle is confirmed to be yielded a diagnosis of squamous cell

nerve

carcinomas

for perineural involvement

often

have

spread. should

a pro-

Trigemibe

suspected clinically when paresthesias and dysesthesias are evident in the distribution of the trigeminal nerve, as welt as when

there

of mastication. high soft-tissue multiptanar

is atrophy

of the muscles

MR imaging, contrast capability,

with

its

resolution and allows direct

February

1992

visualization volvement

of trigeminat nerve in(3). In subtle perineurat in-

ingeal artery, which is an inconstant branch, may pass through the foramen

volvement, hancement

thickening and of the trigeminat

ovate.

contrast nerve

enwill

In summary,

Hemorrhage

used to reach the gasserian ganglion through the foramen ovate for the treatment of trigemmnal neuralgia have been

has been reported to percutaneous biopsy of the gasserian ganglion during trigeminat neuralgia therapy. The reported rate of clinically important hemorrhage is well less than 1%, and this is despite the use of large-bore core needles that actually enter the foramen ovate during rhizotomy of the gasserian ganglion (5). In the

described.

procedure

be seen. In more advanced cases, tumor bulk filling the Meckel cave or bowing the lateral cavernous sinus can be visualized.

A variety

rily ance

of percutaneous

These

fluoroscopic

or involved

procedures (4-7). scribe is a simple

The principal nique is that

techniques

techniques use and radiographic CT triangulation

The

technique

CT-guided

advantage

prima-

guidwe de-

procedure.

of this tech-

needle placement may be performed with great accuracy. This technique is based upon the fact that by turning the head approximately 15#{176} away from the side of interest, a direct line that does not cross vital structures exists from the anterior face to the foramen ovate. When the patient’s head is tilted 15#{176}, the line of approach is perpendicular to the table top, and the nee-

dte can thus be advanced without need for any angulation. Hemorrhage from puncturing the carotid artery is a potential complication procedure. Also, several smaller that may be damaged are nearby. These include the middle meningeal artery as it passes through the foramen spinosum and emissary veins that pass anteromedially to the foramen ovale through the foramen of Vesalius. Additionally, the accessory middle menof this vessels

occur

with

182

#{149} Number

2

however, the to the long axis should not traor enter the cavern-

the foramen

verse ous

sinus.

Nevertheless,

a 22-gauge hemorrhage

with

the

use

of

needle, we believe the risk of or carotid dissection is very of MR images obtained

low. Review prior to the aspiration allows assessment of the relationship of the carotid artery to the tumor. Tumor seeding

the tract after fine-needle

along

tion

is another

several

onstrate

large

any

theoretical series

such

have

risk.

aspira-

concern, failed

Thus,

tions

of head

been described

and

neck

lesions

with

MR

material

gery.

1.

2.

3.

4.

tumor

that

involves

U

Abemayor E, Ljung BM, Ward PH, Larsson 5, Hanafee W. CT-directed fine needle aspiration biopsies of masses in the head and

neck. Laryngoscope Ljung BM, Larsson

1985;

95:1382-1386.

SG, Hanafee W. Computed tomography-guided aspiration cytologic examination in head and neck lesions. Arch Otolaryngol 1984; 110:604-607. Lame FJ, Braun IF, Jensen ME, Nadel L, Som PM. Perineural tumor extension through the foramen ovale: evaluation with MR imaging. Radiology 1990; 174:65-71. Krol G, Arbit E. Percutaneous electrocoagulation of the trigeminal nerve using CT guidance: technical note. J Neurosurg 1988; 68:972-973.

5.

Stechison MT. Bernstein

M. Percutaneous needle biopsy of a middle cranial fossa mass: case report and technical note. Neurosurgery 1989; 25:996-999. Tew JM Jr, Keller JT. The treatment of tntransfacial

6.

geminal frequency

at-

has the advan-

from

References

have

and less costly imaging.

experi-

of the foramen ovate. The is straightforward and diagnostically expeditious, and eliminates the morbidity and expense of sur-

to dem-

lows lesions that are not detectable with CT to be aspirated. A lesion involving the foramen ovale, however, detectable with CT or not, can be easily localized and aspirated with CT guidance, since the bony foramen is clearly depicted.

our

the region technique

fine-needle

(8). This technique

CT-guided aspiration tages of being faster

logic

but

aspiration has proved to be a very safe and effective means of sampling tissue for cytologic evaluation. Recently, MR imaging-guided aspira-

guidance

Volume

we describe,

needle is perpendicular of the nerve and thus

we describe

ence with a CT-guided transfaciat fineneedle aspiration technique in a limited number of patients. This method provides a simple means of obtaining cyto-

neuralgia technique.

by percutaneous Clin

radio-

Neurosurg

1977;

24:557-578.

7.

Dresel SHJ, Mackey JK, Lufkin Meckel cave lesions: percutaneous dle-aspiration biopsy cytology.

RB, et al. fine-nee-

Radiology

1991; 179:579-581.

8.

Duckwiler C, Lufkin RB, Teresi L, et al. Head and neck lesions: MR-guided aspiration biopsy. Radiology 1989; 170:519-522.

than

R-