Before Your Surgery

Common Investigations

There are a number of investigations that may be required depending on your reason for your appointment with Dr. Manzie. Please see below an explanation of the common tests and investigations that may be requested in the course of your care. Should you have questions about any of these, please do not hesitate to ask during or after your appointment.

Imaging

Orthopantogram (OPG)

An OPG is a common dental x-ray. It may be performed by your dentist before your appointment or referred for after. It is an x-ray with a low dose of radiation. It is useful in reviewing your overall teeth (not as good at detecting small holes), defects within the bones or planning dentoalveolar surgery. It is commonly used for assessing wisdom teeth and their position from the inferior alveolar nerve (the nerve that supplies sensation to your bottom lip).

Cone beam computed tomography (CBCT)

A CBCT is a low-dose dental CT. It may be performed by your dentist or dental specialist before your appointment. It is an x-ray with a dose of radiation lower than a normal CT scan. It is useful in assessing the relationship of the teeth to structures such as the nerves, dental implant planning or to assess the shape of a tooth. It does not demonstrate pathology in as much detail as a normal CT.

Ultrasound scan (USS)

An USS has no radiation and uses sound waves to produce a live, black, white and grey image. As it does not need radiation, it is safe for use in pregnancy (and is used to look and examine the baby). It is useful in assessing superficial lumps of the parotid gland or neck or for surveillance. It can also be useful to look at vascular lesions such as venous or arterial malformations. It may also be used for image guided biopsies such as a fine needle aspirate or core biopsy.

Computed Tomography (CT)

A CT scan has a number of uses for before and after surgery. It has a dose of radiation greater than plain film x-rays. Often, an intravenous cannula (drip) will be needed to allow for intravenous contrast (drip) to be delivered as this helps to highlight the blood vessels in greater quality. These scans are important for pre-surgical planning, assess bone healing after and monitor for other complications such as hardware issues or osteoradionecrosis. Please let Dr. Manzie or the Radiology practice know if you have kidney related disease as you may require an updated blood test before your scan.

Magnetic Resonance Imaging (MRI)

A MRI requires the use of no radiation as it works on a sequences of magnets (and therefore safe in pregnancy). It is useful for looking at soft tissue structures such as nerves, fat compartments and lymph nodes (glands). An MRI may be used before or after surgery as part of staging or assessment and post-operatively for surveillance. Similarly to a CT, you may require the insertion of an intravenous cannula (drip) to allow an injection of a contrast dye. A downside to an MRI is it is often difficult for patients with claustrophobia. It requires you to lie still inside a small tunnel for 10-20 minutes with loud noises. The radiology practice will do their best to make you feel comfortable but people with severe claustrophobia may not be suitable.

Positron Emission Tomography (PET)

A PET scan is a nuclear medicine, whole body scan that uses the highest dose of radiation of any of the scans. These scans are useful for staging (seeing if a cancer has spread), measuring the response to treatment or helping in difficult or cases where a cancer may not be obvious. A PET scan requires insertion of an intravenous cannula (IV) for injection of a specialized contrast or dye, most commonly 18F-FDG, which is a radioactive form of glucose (sugar molecule. The scan is typically performed in the morning as it will require you to fast prior. You will receive advice in regards to any diabetic medications and are asked to limit exercise or activity in the days before your test. A PET scan is combined with a CT scan to demonstrate cells that are using more energy (almost like acting like a highlighter), this is typically any brain, liver, cancer or cell of inflammation. It cannot tell the difference between these different cells and so therefore the brain, liver, kidneys and liver will always appear bright. It cannot tell the difference between inflammation or cancer cells so could be used to investigate both. PET scans are not available in all locations and there are only a handful across NSW. If you require a PET scan, we will discuss with you your options of where you can have this done.

Lymphoscintigraphy

Lymphoscintigraphy is a nuclear medicine scan with a dose of radiation greater that of a normal CT. A lymphoscintigraphy is useful in monitoring the pattern of draining through the lymphatic system. It is used in sentinel lymph node (gland) biopsies to determine which are the ‘echelon’ nodes. This essentially means identifying the first one, two or three (sometimes even more) lymph nodes that may be draining the area of a tumour such as a melanoma or small mouth cancer. Similar to a PET scan, these scans highlight the lymph nodes of interest. The technician will mark the skin with a marking pen and a tattoo a small dot on the skin. Lymphoscintigraphy is not available in all locations and there are only a handful across NSW. If you require lymphoscintigraphy, we will discuss with you your options of where you can have this done.

Biopsies

Fine needle aspirate (FNA)

A fine needle aspirate is a form of incisional biopsy. It is typically performed under guidance with an ultrasound or CT scan. An FNA is a day procedure performed in a radiology practice. It involves a radiologist (medical specialist), placing a needle into the area being investigated (such as a lump in the neck or parotid gland) and suctioning out a sample of the cells. A pathologist (medical specialist) may also be in attended will often check the sampling before you leave to make sure there are enough cells to help with your diagnosis. This may be able to be performed with or without local anaesthetic. Compared with a core biopsy, the number and structure of the cells removed provides less information. It is more simple and often less painful (which is why we might prefer it).

How accurate is a FNA?

A FNA is accurate, but they are not perfect. It’s ability to detect whether a lesion is a cancer (malignant) or non-cancerous (benign) growth is very good. It’s ability to detect which type of malignant or benign lesion is less accurate and often the reason why you may still be advised to have benign growths removed (to allow proper assessment/diagnosis and treat the lump). A FNA may be ordered for any neck or salivary gland lump to help guide treatment. These are very readily available, generally less painful and the results can be available in only a couple of days.

What are the risks of an FNA?

There are a small number of risks to be aware of when having an FNA. These should be explained to you by the doctor performing this procedure (and ask them if you have questions before the procedure). They almost always done under image guidance (ultrasound or CT scan) to reduce the risk of bleeding or injury to other structures. There is a risk of bleeding (causing a haematoma or blood blister under the skin), infection or an inconclusive biopsy (there isn’t enough tissue to tell or the tissue doesn’t look representative of the lump). The procedure itself might be uncomfortable with some discomfort after, however would anticipate that this would be managed with simple pain killers such as paracetamol (Panadol, Herron Gold, etc.).

Core Biopsy

A core biopsy is very similar to a FNA, but it just samples more tissue. This may require numbing of the skin with local anaesthetic beforehand and occasionally a very small incision or nick in the skin. Similar to an apple core, it delivers a cylinder of tissue that allows the pathologists (medical specialists) to assess the arrangement within the lump and provide additional tissue for special tests. This is useful for any unusual lump or lesion of the salivary glands or neck when we might be worried about lymphoma. It can also be useful when a FNA comes back as inconclusive. The risk of bleeding is a little bit higher and it can be a little bit more uncomfortable than an FNA but often preferred due to the quality of the biopsy and ability for additional tests.

How accurate is a core biopsy?

A core biopsy is a more accurate than an FNA, but it is not perfect. It is up 99% accurate at determining if a lump is cancer or not (it is just little less accurate about telling us what type). This is better than an FNA but does come with a higher risk of complication.

What are the risks of a core biopsy?