|Year : 1978 | Volume
| Issue : 4 | Page : 13-17
Needle exploration and needle biopsy in orbital tumours
K Nath, R Gogi
A.M.U. Institute of Ophthalmology, Aligarh, India
A.M.U. Institute of Ophthalmology, Aligarh
Source of Support: None, Conflict of Interest: None
|How to cite this article:|
Nath K, Gogi R. Needle exploration and needle biopsy in orbital tumours. Indian J Ophthalmol 1978;26:13-7
Orbit is a closed cavity and the diagnosis of space occupying lesions can seldom be clinched entirely on clinical observations. Although various investigations can help in the localization of a lesion, but the exact nature of the disease remains concealed. In order to decide the appropriate line of treatment, it is important to know the exact nature of the orbital tumour before hand. To overcome this difficulty Reese (1956) suggested a deep exploratory biopsy even after exposure of the tumour on lateral orbitotomy. However, we have tried a simple and a valuable method of diagnosis in the form of needle exploration (in 43 cases) and needle biospy (in 31 cases) in space occupying lesions of the orbit. The procedure and results are detailed below.
| Material and methods|| |
The present work includes forty three cases of space occupying lessions of the orbit admitted in the in-patients section of A.M.U. Institute of Ophthalmology at Gandhi Eye Hospital, Aligarh. Every case was thoroughly examined and investigated. The procedure was explained to the patient and a mild sedative was given half an hour before the procedure. An initial exophthalmometric reading was taken in the supine position.
(A) Needle Exploration
Under sterile conditions, with a long 22 gauge hypodermic needle 2 c c of xylocaine was injected under the skin and deeper orbital tissues in the selected area. The area for exploration was selected according to the direction of proptosis, e.g., in downward proptosis, upper orbital quadrant, in down and outward proptosis upper inner quadrant and so on. In axial proptosis muscle cone area was explored. Needle was pushed into the orbital tissues till it touched the mass in the orbit and the following points were noted in the sequence given below:
1. Area of the tumour mass was defined by gently moving the tip of the needle in the adjacent areas.
2. Most prominent part of the tumour was located in order to decide the site for needle biopsy (vide infra).
3. Needle was pushed further into the tumour, the resistence so encountered gives a fair idea about the conistency of the tumour.
4. At the end, suction was applied to see the presence of blood or anyother fluid. In the end exophthalmometry was repeated to record the extent of proptosis subsided due to the suction of fluids or has increased due to retrobulbar haemorrhage, if any.
(B) Needle Biopsy
Vim-Silverman liver biopsy needle [Figure - 1] was used for biopsy of the tumour and the following procedure was carried out soon after the needle exploration.
(1) The outer needle (A) with stylet (B) in place was advanced upto the most prominent part of the growth [Figure - 2]. If the growth was not palpable, the desired area was defined with hypedermic needle (vide supra).
(2) The stylet was removed and the inner needle (C) was inserted to its full length through the outer needle so that it takes a bite into the tumour [Figure - 3]. At this point the patient may feel a slight discomfort.
(3) Now the outer needle (A) was advanced with slight rotation over the inner needle [Figure - 4].
(4) Both the needles were then withdrawn and the biopsy tissue was placed in 10% formosaline for histopathological processing [Figure - 5].
At the end of the procedure tincture benzoin was applied at the site of puncture and pressure bandage given for twenty four hours.
| Observations and comments|| |
(A) Needle Exploration
The needle exploration provided the following information:
(1) This proved to be a very successful method in defining the anterior, superior, inferior, medial and lateral limits of the tumour in all the cases specially when the tumour mass is not palpable [Table - 1].
(2) The most prominent part of the tumour, where subsequent needle biopsy was to be taken was also outlined by this method.
(3) One can get a fair idea aboutthe consistency of the tumour while pushing the needle into it. A gritty sensation is felt in orbital fibrous dysplasia (one case), a firm rubbery feeling in pseudo-tumour (4 cases) and fibroma (one case) and variable consistency in three cases of pleomorphic adenoma were noted [Table - 1].
(4) On pushing the needle into the orbital mass when suction was applied, pus came into the syringe in four cases and blood in eight cases.
i) Pus Aspiration
In four cases, the proptosis was present for the last 2-3 months when the needle was pushed into the swelling there was sudden release of resistence and on suction thick viscous pus came out. The pus cavity was washed with chloromycetin succinate 10% solution and pressure bandage was given. Clinically the course the disease simulated a benign growth except that there was history of eye soreness in words of the patient. We want to press upon this point that an exploratory needle in most of the space occupying lesions of the orbit must be tried before opening the case for surgery in order to avoid any subsequent disappointment.
ii) Blood aspiration
On pushing the needle into the tumour mass at different levels blood was aspirated in eight cases.
In two cases (case 1 & 2) the proptosis subsided following aspiration of the blood and that was dark red in colour. However, the proptosis re-appeared after twenty four hours. Aspirations were repeated, and subsequently it was a blood tinged serum which gradually decreased in amount after three to four aspirations. Pressure bandage was given following each aspiration and patient was kept on antibiotics to avoid any secondary infection. In both of these cases proptosis subsided completely with this line of treatment. These were the cases of orbital blood cysts due to retrobular haemorrhages of two to three weeks duration.
In the third case, blood did come into the syringe but proptosis did not subside. Therefore, needle biopsy was performed and the presumptive diagnosis of cavernous haemangioma was made. Three subsequent cases (case No. 4,5,8), were similar and we based our diagnosis of cavernous haemangioma upon aspiration of blood from the tumour showing no appreciable decrease in the degree of proptosis. No biopsy was taken and the diagnosis was confirmed only after postoperative histopathology. However, in two cases (Case No. 6 & 7) we were completely misled. There was blood in the syringe on exploration by needle indicating cavernous haemangioma whereas postoperative histopathology revealed rhabdomyosarcoma. These were the cases of two children aged two and three years with a highly vascular rapidly growing tumours which were infact clinically suspected to be rhabdomyosarcoma but our test came out to be fallacious.
Therefore, in all those cases where blood comes into the syringe without decrease in the size of proptosis may not be haemangiomas and diagnosis must be confirmed by needle biopsy, if the need be. Mild to moderate degree of retrobulbar haemorrhage was noticed in cases 3 to 7. Positive results of needle exploration are summarised in [Table - 1].
(B) Needle Biopsy
It was carried out in 31 cases. In twenty five (86.6%) out of thirty one the histopathological diagnosis was possible and was found to be correct when compared with the postoperative histopathological diagnosis of the tumour mass [Table - 2]. In six cases (19.4%) it was not possible to fix up any specific diagnosis because proper tumour tissue was not obtained with the needle [Table - 3].
While performing needle biopsy, care should be taken to avoid injury to the trochlear pulley when tumour is located in upper inner quadrant. One should try to approach the tumour in between the recti rather than entering through the muscle belly. This can be easily achieved simply by changing the direction of the needle. In small tumours within the muscle cone, biopsy should always be avoided because of the danger of injuring the vessels which may be displaced. Apart from this, procedure is very safe.
It is obvious from this study that needle exploration and needle biopsy are the simplest and yet highly informative procedures. Various sophisticated investigations in a space occupying lesion of the orbit aim at localization of the tumour in order to simplify the subsequent surgical approach. Whereas a simple needle exploration can provide valuable informations like the extent of the tumour inside the orbit, its consistency presence of encystid pus or blood which can not only be detected but can be treated as well.
Equally important is the prior knowledge before the surgery about the kind of orbital lesion one is going to face. A wedge biopsy can be done when the tumour is easily palbable, yet this is no answer to the problem when the lesion is deep seated. Reese (1956) has advised an exploratory biopsy even by opening the lateral orbital wall. We feel that it is by no means a simple procedure as compared to a needle biopsy which can be performed even in the out patient department at the time of admission. Further, a wedge biopsy is likely to bring in superficial inflammed tissues surrounding the tumour mass. Reese (1956) has stressed this point that superficial tissues should be avoided, as more often this is misleading specially in lacrimal gland tumours. To over come this pitfal there is no match for needle biopsy as the deeper tissue biopsy can always be obtained without any difficulty.
We feel convinced that these two procedures are simple and very informative diagnostic tools for every student of orbit whether a clinician or a pathologist.
| Summary|| |
Hypodermic needle exploration in 43 cases and Vim silverman liver biopsy needle in 31 cases of space occupying lesions of the orbit was tried. Needle exploration can define the margins of the tumour, can give fair idea about the consistency of the tumour and can help in the diagnosis and treatment of encysted pus or blood cyst of the orbit. Whereas needle biopsy can clinch the histopathological diagnosis of the tumour. Success rate was 80.6%. Importance of these procedures in localization and diagnosis of orbital lesions has been elaborated.
| References|| |
Reese, A.B., 1956, Amer. J. Ophthal., 41, 3.
[Figure - 1], [Figure - 2], [Figure - 3], [Figure - 4], [Figure - 5]
[Table - 1], [Table - 2], [Table - 3]