Oral Surgery, Biopsies

Excerpt

Biopsies are essential procedures for any practitioner caring for patients with head and neck pathology. Before performing a biopsy, a comprehensive medical history must be obtained. The characteristics and timeline of the relevant symptoms, aggravating and alleviating factors, and presence of comorbidities help to establish a working diagnosis. Practical knowledge of oral pathology is paramount to determining which type of biopsy is best in any given circumstance.

Biopsies of the oral cavity sample two broad classes of tissue: soft tissue and hard tissue. Soft tissue biopsies are performed on the oral mucosa, gingiva, and tongue. Hard tissue biopsies collect samples from bony structures or access intraosseous areas to obtain tissue for histopathologic examination. Biopsies of deeper structures in the airway, such as the pharynx and hypopharynx, are beyond the scope of this activity.

A radiographic examination of any hard tissue lesions is recommended to evaluate the size of the lesion(s) and facilitate procedural planning. Generally, an initial office-based orthopantomogram or cone-beam computed tomography (CBCT) is sufficient. Noncontrast medical-grade computed tomography plays a role in evaluating more extensive or invasive hard tissue lesions, except in cases of suspected infection such as osteomyelitis.

The 3 biopsy procedures commonly performed in clinical practice are fine needle aspiration, core biopsy, and brush biopsy.

Fine needle aspiration (FNA) is commonly performed to evaluate lesions within deeper tissues where access is otherwise surgical, and a definitive diagnosis is required to plan the final extirpation of the lesion. FNA is commonly used for lesions in the salivary glands and lymph nodes in the head and neck. FNA is performed by passing a hollow needle in and out of the lesion several times and collecting the small tissue fragments within the needle for cytological examination. FNA can only reliably indicate if a lesion is benign or malignant; the obtained tissue is insufficient for a definitive diagnosis. However, the limited information obtained through FNA helps plan further treatments.

A core biopsy is similar to an FNA but obtains a tissue sample adequate for a definitive histological diagnosis of the lesion. At some institutions, the interventional radiology department offers this service.

Lastly, a brush biopsy involves sampling a soft tissue lesion with a specialized brush to harvest cells for examination. The technique could represent a predictable and less invasive biopsy method in the future; however, it is not yet recommended as the biopsy of choice due to a lack of supporting evidence.