Life threatening complication of fine needle aspiration of neck mass in a child: a case report

INTRODUCTION

Neck swellings in children may be due to various causes. Fine needle aspiration cytology (FNAC) has become an important first line of investigation in palpable neck masses. It was first described by Kunl.¹ It is simple, sensitive, inexpensive, rapid and safe investigation available in the assessment of patients with lateral neck swellings. Complications related to FNAC in neck are rare and insignificant. Common complication includes pain, minor hematoma and irritation at the site of aspiration.² Life threatening complications include hematoma, pseudoaneurysm, carotid artery hematoma, tracheal perforation, dysphagia, recurrent nerve paralysis, sinus along needle tract, vasovagal reaction, and secondary hemangioma.^2,3 Aim of this case report is create awareness about devastating consequence of simple procedure like FNAC- if not done cautiously.

CASE PRESENTATION

9 year old male child developed a painless swelling in the left lateral aspect of the neck since one and half months and had undergone diagnostic needle aspiration of the swelling at a local clinic 3 weeks ago following which there was a rapid increase in the size of the swelling associated with pain. Initially the neck mass (lymph node) was 2x2 centimeter. Other symptoms included hoarseness of voice, difficulty in swallowing. Child was comfortable in left lateral position as he had respiratory distress in supine position.

On examination, a large solitary, firm, non-pulsatile swelling was noticed in the left lateral aspect of the neck measuring about 12x8 cm (Figure 1). Trachea was displaced to the right. Child was admitted with the diagnosis of solid neck swelling with possibility of malignancy.

Routine blood investigations were normal. CT scan of the neck revealed highly vascular lesion with a differential diagnosis of ICA pseudo aneurysm, arterio venous malformation (Figure 2).

Child had to be shifted to pediatric intensive care unit (PICU) preoperatively in view of worsening of respiratory distress. In consultation with vascular surgeon child was taken up for neck exploration after counselling attenders regarding post-operative complication which included neurological deficits, seizures, mechanical ventilation.

Intra operatively intubation was difficult due to tracheal deviation. Neck exploration revealed pseudo aneurysm of left ICA with a thick fibrous capsule posterior to the left sternocleidomastoid muscle. Proximal and distal control of left ICA taken with application of slings. The muscle had to be released from its origin at the clavicle in order to take control of the proximal left common carotid artery. Once the capsule incised and swelling entered, blood clots to the extent of 800 ml to 1 litre was present (Figure 3). Following evacuation of the clots, site of injury to the left internal carotid artery (ICA) was identified. Closer examination revealed multiple puncture injuries to the left ICA for a length of 1 cm (Figure 4). Repair of the artery done using prolene 6’0. Distal pulsations were confirmed and the wound closed in layers after the placement of drain. Intra operatively child was hemodynamically stable, and required one packed cell transfusions. Post operatively child was monitored in PICU for 48 hours and was discharged after an uneventful recovery. The child is doing well on follow up after one year. Follow up Doppler shows good flow in the carotid artery.

DISCUSSION

Fine needle aspiration cytology (FNAC) is an important tool in diagnosing neck masses. It was first described by Kunl.¹ FNAC was introduced in USA 80 years later by a surgeon in Memorial Sloan Kettering hospital.

FNAC was first reported in children by Jereb et al in 1978.⁴ FNAC for paediatric neoplasms was first used by Shaller and colleagues in 1983.^5,6 Since then, FNAC has become a more acceptable diagnostic procedure in the paediatric age group and is well established in the adult population. Howell reported in his work the increasing application of fine needle aspiration cytology in superficial palpable lesions in the children.⁷ Doing FNAC avoids the need for open surgical biopsy in 40-75% of patients.^6-10

Neck masses in children can broadly be classified as congenital, inflammatory and malignant. Persistent or suspicious lymphadenopathy is the most common neck mass encountered in children and the common indication for FNAC.^6,8,10 Van de Schoot et al in is study found that FNAC is a useful initial diagnostic tool in children with persistent or suspicious peripheral lymphadenopathy to distinguish between benign and malignant disease ¹¹. Reactive lymphadenitis has to be differentiated from tuberculosis and lymphoma in developing country

FNAC is usually done using a 22-25 gauge needle fitted to a 10 millilitre (ml) or a 20 ml disposable syringe. The swelling is immobilized and multiple passes are done to get sufficient material. In the present child, the size of punctures indicates a wide bore needle was used. Multiple punctures co relates to the multiple passes done to get enough aspirates.

Reported complications of FNAC in neck mass include ecchymosis, hematoma, a draining sinus tract, tumor tracking, pseudo aneurysm and pneumothorax. These complications are rare. Cases of carotid artery hematoma following fine needle aspiration have been reported. Reason for hematoma is because of the close proximity of the vessels to the lymph nodes. This is especially true wherein aspiration is being done for lymph nodes which are not properly palpable. Hematoma results from seepage of blood into the carotid sheath or the neck tissue following damage to the carotid wall during Fine needle aspiration process. In few cases the hematoma can grow to alarming size causing respiratory distress. Carotid artery hematoma should be considered in case of pain, increasing swelling, mass effect post aspiration. Hematoma can push the trachea towards opposite side. In our case the trachea was pushed to the right side and patient had respiratory distress. In patients where hematoma does not cause respiratory distress close monitoring of the patient is required with ultrasonography. Most of the cases the hematoma is reabsorbed spontaneously.^2,3 In patients with respiratory distress hematoma drainage is required. With the use of ultrasound guided FNAC the accuracy and safety of the procedure has increased.

CONCLUSION

This case highlights the rare complication of FNAC. Though a simple procedure if not done properly may lead to devastating consequences. This case also emphasise the importance of ultrasound guided FNAC in deep seated neck swellings.

Funding: No funding sources

Conflict of interest: None declared

Ethical approval: Not required

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