Original Article

Fine needle aspiration cytology of oral and

oropharyngeal lesions with an emphasis on
the diagnostic utility and pitfalls
ABSTRACT Nalini Gupta,
Aim: This study was undertaken to evaluate the diagnostic utility and pitfalls of fine needle aspiration cytology (FNAC) in oral and Tarak Banik,
oropharyngeal lesions. Arvind Rajwan-
shi, Bishan D.
Materials and Methods: This was a retrospective audit of oral and oropharyngeal lesions diagnosed with FNAC over a period of six
Radotra1,
years (2005–2010).
Naresh Panda2,
Results: Oral/oropharyngeal lesions [n=157] comprised 0.35% of the total FNAC load. The age ranged 1–80 years with the male: Pranab Dey,
female ratio being 1.4:1. Aspirates were inadequate in 7% cases. Histopathology was available in 73/157 (46.5%) cases. Palate was Radhika
the most common site of involvement [n=66] followed by tongue [n=35], buccal mucosa [n=18], floor of the mouth [n=17], tonsil Srinivasan,
[n=10], alveolus [n=5], retromolar trigone [n=3], and posterior pharyngeal wall [n=3]. Cytodiagnoses were categorized into infective/ Raje Nijhawan
inflammatory lesions and benign cysts, and benign and malignant tumours. Uncommon lesions included ectopic lingual thyroid and
adult rhabdomyoma of tongue, and solitary fibrous tumor (SFT), and leiomyosarcoma in buccal mucosa. A single false-positive case Departments of
Cytology and
was dense inflammation with squamous cells misinterpreted as squamous cell carcinoma (SCC) on cytology. There were eight false- Gynaecologic
negative cases mainly due to sampling error. One false-negative case due to interpretation error was in a salivary gland tumor. The Pathology,
sensitivity of FNAC in diagnosing oral/oropharyngeal lesions was 71.4%; specificity was 97.8% with diagnostic accuracy of 87.7%. 1
Histopathology,
2
Otolaryngology,
Conclusions: Salivary gland tumors and squamous cell carcinoma (SCC) are the most common lesions seen in the oral cavity. FNAC
Postgraduate Institute
proves to be highly effective in diagnosing the spectrum of different lesions in this region. Sampling error is the main cause of false- of Medical Education
negative cases in this region. and Research,
Chandigarh, India

KEY WORDS: Fine needle aspiration cytology, oral cavity, oropharyngeal lesions
INTRODUCTION
Fine needle aspiration cytology (FNAC) is an
important diagnostic tool for the lesions of the head
and neck region especially for swellings in the thyroid
gland, salivary gland, and lymph nodes. It helps in
avoiding surgical procedures in conditions like non-
neoplastic or inflammatory lesions and metastatic
tumors.[1] However, its use is limited in the oral
and oropharyngeal lesions. Preoperative aspiration
cytology can be practiced on almost any anatomic
region evident visually, for example, skin or subcutis
of the face, pinna, external nose or the reachable
nasal cavity, floor of mouth, tongue, palate, tonsils,
and the posterior pharyngeal wall.[2-4] There have
been a few previous studies evaluating the role of
FNAC in the intraoral lesions with variable outcome.
The present study was undertaken to assess the
accuracy of FNAC in the intraoral lesions, as well as
to identify the common causes of misinterpretation
and fallacies of the technique.
For correspondence:
Dr. Nalini Gupta,
Department of
Cytology and
Gynecologic Pathol-
SUBJECTS AND METHODS ogy, Postgraduate
Institute of Medi-
An audit of all intraoral and oropharyngeal lesions cal Education and
Research,
diagnosed by FNAC was performed over a period
Chandigarh, India.
of six years (2005–2010). The cases were retrieved E-mail: nalini203@
from the records of the department of cytology and rediffmail.com
gynecological pathology in a tertiary care centre
in North India. Aspirations were performed by
consultant cytopathologists or trainee residents in
the department. The aspiration samples were taken
in supine or in sitting position with head support.
FNAC was performed without radiological guidance
Access this article online
using a 22–23 G needle and 20 cc disposable
Website: www.cancerjournal.net
syringe, fitted on Cameco’s handle. Air-dried smears DOI: 10.4103/0973-1482.106581
were stained with May-Grünwald Geimsa (MGG) PMID: ***
stain and smears fixed in 95% ethanol were stained Quick Response Code:
with hematoxylin and eosin (H& E)/ Papanicolaou
(PAP) stains. Special stains like Ziehl-Neelsen
and periodic acid-Schiff (PAS) were performed in
relevant cases. On-site assessment of the aspirates
was not done and ancillary techniques were

626 Journal of Cancer Research and Therapeutics - October-December 2012 - Volume 8 - Issue 4
 Gupta, et al.: FNAC in oral and oropharyngeal lesions

not used for cytological diagnosis. Procedure-related minor
complications in the form of prolonged bleeding were noted
in a few of the patients; however, no major complications were
seen. Cytological diagnosis was correlated with histological
diagnosis, wherever available.
RESULTS
Out of a total of 45,196 FNACs performed over a period of six
years, 157 (0.35%) cases of intraoral/oropharyngeal lesions
could be retrieved. Male: female ratio was 1.41: 1. The youngest
patient was a one-year-old female child with an inflammatory
swelling in the buccal mucosa and the oldest patient was
an 80-year-old male with a non-Hodgkin s lymphoma (NHL)
of the tonsil. There were 11/157 (7%) cases with inadequate
aspirates for a definitive opinion. Histopathology was available
in 73/157 (46.5%) cases. The most common site was the palate
comprising 66/157 cases (42%), followed by tongue 35 cases
(22.3%), buccal mucosa 18 cases (11.5%), the floor of the
mouth 17 cases (10.8%), tonsil 10 cases (6.4%), alveolus 5 cases
(3.2%), retromolar trigone three cases (1.9%), and posterior
pharyngeal wall three cases (1.9%).
plasmacytoma (2). A case of Langerhans cell histiocytosis (LCH)
was diagnosed from palatal swelling on FNAC in a one-year-old
female child [Figure 2c].
Lesions of tongue
Histopathology was available in 11/35 cases. Inflammatory
lesions of the tongue [n=11] included cysticercosis (3 cases)
and leprosy (1 case) [Figure 2d]. Another interesting case was
a 15-year-old girl with ectopic lingual thyroid. One false-
negative case was ACC reported as inflammation on cytology
[Table 1], due to inadequate sampling (ulcerated lesion
associated with inflammation). Benign neoplasms (7 cases)
included neurofibroma, schwannoma, and adult rhabdomyoma
[Figure 2e]. Two-third of the cases with inadequate aspirates
had follow-up biopsy and were confirmed to be SCC and
hemangioma.
Lesions of buccal mucosa
Histopathology was available in 10/18 cases. There were
inflammatory lesions/benign cysts (10 cases). A case of
sol = itary fibrous tumor (SFT) was reported as PA on cytology.
Collagenous eosinophilic matrix material and bland oval to

Cytological diagnoses were categorized into infective/

inflammatory lesions and benign cysts, benign neoplasms,
malignant neoplasms, and inadequate for opinion.

Lesions of the palate a b

Palatal lesions comprised infective/ inflammatory lesions
and benign cysts (24 cases), benign salivary gland tumors
(20 cases), malignant tumors (18 cases), and three cases had
inadequate aspirates. Histopathology was available in 32/66
cases (48.5%). One false-negative case was of polymorphous c d
low-grade adenocarcinoma (PLGA) reported as pleomorphic
adenoma (PA) on cytology [Table 1; Figures 1a and b]. One case
of adenoid cystic carcinoma (ACC) was reported as PLGA on
cytology [Figures 1c and d]. Two of three cases with inadequate
e f
aspirates had follow-up excision and were confirmed to be
ACC. One case was missed on aspiration due to the lesion Figure 1: Paired cytology-histopathology of intraoral (palatal) lesions;
(a) polymorphous low-grade adenocarcinoma (PLGA) reported as
being located in the distal portion of the soft palate [Figures 1e
pleomorphic adenoma on fine needle aspiration cytology (FNAC)
and f] and the other had cystic areas [Table 1]. The malignant
(MGG × 40X); (b) the corresponding histopathology of PLGA
palatal tumors included mucoepidermoid carcinoma (4), (H&E × 40X); (c) adenoid cystic carcinoma (ACC) reported as PLGA
adenocarcinoma (3), ACC (2), squamous cell carcinoma (SCC) on FNAC (MGG × 20X); (d) the corresponding histopathology of
(1), PLGA (1), nasopharyngeal carcinoma (NPC) (1) [Figure 2a], ACC (H&E × 40X); (e) ACC missed on FNAC due to sampling error
poorly differentiated carcinoma (1), NHL (3) [Figure 2b], and (MGG × 40X); 1(f) the corresponding histopathology of ACC (H&E × 40X)

Table 1: Summary of discrepant cases

Site Cytodiagnosis Histopathological diagnosis Explanation Interpretation
Palate PA PLGA Interpretation error False negative
Palate Blood only ACC Sampling error False negative
Palate Cystic lesion ACC Sampling error False negative
Tongue Inflammation ACC Sampling error False negative
Tongue Inadequate aspirate SCC Sampling error False negative
Floor of mouth Inflammation Pleomorphic sarcoma Sampling error False negative
Floor of mouth SCC Inflammation; no malignancy Interpretation error False positive
Tonsil Benign SCC Sampling error False negative
Tonsil Inadequate aspirate NHL Sampling error False negative

Journal of Cancer Research and Therapeutics - October-December 2012 - Volume 8 - Issue 4 627
 Gupta, et al.: FNAC in oral and oropharyngeal lesions
a b
c d
e f
Figure 2: A panel of microphotographs of intraoral lesions; (a)
nasopharyngeal carcinoma (MGG × 40X); (b) Non-Hodgkin’s lymphoma
(MGG × 40X); (c) Langerhans cell histiocytosis (MGG × 40X); (d)
epithelioid cell granuloma in leprosy (H&E × 40X); (e) adult rhabdomyoma
(H&E × 20X); (f) leiomyosarcoma of the buccal mucosa (MGG × 20X)
spindle cells of SFT were misinterpreted as chondromyxoid
material and myoepithelial cells of PA, respectively. Malignant
tumors included malignant melanoma and leiomyosarcoma
[Figure 2f ]. Three cases had inadequate aspirates.
Lesions in the floor of the mouth
Histopathology was available in 8/17 cases. One false-positive
case was inflammation with squamous cells misinterpreted
as SCC on cytology [Table 1]. This emphasises that a diagnosis
of SCC in the presence of inflammation should be offered
with extreme caution. Another false-negative case was an
inflammatory variant of malignant fibrous histiocytoma
(pleomorphic sarcoma) reported as inflammatory granulation
tissue on cytology [Table 1]. This was due to abundant
inflammation and scattered atypical spindle cells interpreted
as fibroblasts with reactive changes. In addition, inflammatory/
benign cystic lesions (9 cases), a case each of mucoepidermoid
carcinoma, SCC, and ACC were also seen.
Lesions of the tonsil
The tonsillar lesions included inflammatory lesions (3 cases)
and malignant tumors including SCC, poorly differentiated
carcinoma, and lymphoblastic lymphoma, and 7/10 cases had
follow-up histopathology. Two false-negative cases included
SCC and diffuse large B cell lymphoma (DLBCL) reported as
negative on cytology [Table 1]. This was due to difficulty in
sampling, highlighting the fact that deeply situated intraoral
lesions may be very difficult to approach, and improper
sampling leads to false-negative results.
Lesions of the alveolus/retromolar trigone/posterior
pharyngeal wall
These included inflammatory/benign cystic lesions (6 cases),
benign tumors (1 case), and malignant tumors including SCC
(2 cases), adenocarcinoma (1 case), and metastatic carcinoma
(1 case). Of these, 5/11 cases had follow-up histopathology.
628 Journal of Cancer Research and Therapeutics - October-December 2012 - Volume 8 - Issue 4
There were a total of eight false-negative and a single false-
positive case in the present series. Six of these eight cases
were due to sampling error, highlighting the fact that intraoral
sampling on FNAC poses problems and can lead to false-
negative results. The sensitivity of FNAC in diagnosing oral/
oropharyngeal lesions in our series was 71.4%, and specificity
97.8% with a diagnostic accuracy of 87.7%.
DISCUSSION
A variety of non-neoplastic and neoplastic lesions can involve
the oral and oropharyngeal cavity and these are common
lesions encountered in clinical practice. Although FNAC is
used increasingly in the evaluation of lesions of the neck and
head region,[1-3] experience remains limited in the aspiration
of intraoral masses.[4-8] FNAC can provide helpful information
about these lesions and may help in avoiding hasty or
unnecessary surgical biopsy. FNAC could avoid excision or
surgery in over 50% cases in the present study. FNAC in
intraoral lesions is less sensitive and specific than that of
superficial lesions.[9] This may be due to the small size and
deep location of the lesions as well as by the limited space for
maneuvering the needle, with difficulty in fixing the intraoral
lesion for adequate aspiration rather than to interpretation
or inherent limitations of the technique itself.[10] There are
previous studies in the literature exploring the potential of
FNAC in the diagnoses of oral and oropharyngeal lesions.[9-14]
The present study was an attempt to determine the efficacy
and reliability of FNAC in the diagnosis of these lesions.
Minor salivary gland tumors in the oral cavity account for
about 15% of all salivary gland tumors.[15-17] The majority of
palatal neoplasms in the present series were minor salivary
gland tumors, PAs, and ACCs being the common ones, which
corroborates with previous studies.[15,18] One case of PLGA was
misdiagnosed as PA on cytology. PLGA is seen almost exclusively
in the minor salivary glands.[19] Gibbons et al.[20] described
this tumor as having architectural diversity but cytological
uniformity. Two cases of PLGA were misdiagnosed as ACC and
PA in their study initially. It is important to differentiate PLGA
from more aggressive tumors like ACC. Differentiation of PA
from ACC may pose problems at times in cytology.
SCC is the most common malignancy followed by salivary gland
tumors and NHL represents the third common malignancy of
the oral cavity.[21,22] Oral manifestations are present in only
3–5% of the cases of NHL.[23] There were three cases of palatal
NHL including a mucosa-associated lymphoid tissue (MALT)
lymphoma in the present study. Two false-negative cases with
sampling error in the present study highlight the difficulties
in approaching the posterior soft palate lesions for FNAC.
Three cases of cysticercosis in the tongue were seen in the
present study. Oral cysticercosis is rare,[24-26] with the most
favorable sites being the tongue, lips, and buccal mucosa. This
needs to be distinguished from mucocele, benign mesenchymal
 Gupta, et al.: FNAC in oral and oropharyngeal lesions
tumors like, lipoma, fibroma, hemangioma, granular cell
tumor, or minor salivary gland tumors.[27] The tongue is a
common site for granular cell tumor.[28] Rhabdomyoma occurs
almost exclusively in the head and neck region.[29] Apart from
salivary gland tumors and SCC, a few uncommon lesions were
noted in the present series. These included ectopic lingual
thyroid, adult rhabdomyoma and schwannoma in tongue,
SFT, malignant melanoma, and LMS in buccal mucosa and
pleomorphic sarcoma in the floor of the mouth.
Diagnostic accuracy in the present series was 87.7% with eight
false-negative and one false-positive case. False-negative cases
were mainly sampling errors with a single case of interpretation
error in salivary gland tumor. Gunhan et al.[13] experienced high
accuracy in diagnosing oral cavity and jaw bone lesions by FNAC.
Scher et al.[8] had no false-positive diagnosis in malignant lesions.
FNAC was unsatisfactory in 16% cases[8] as compared to 7% in
the present series. They emphasized the need for repeating the
FNAC or recommending biopsies in negative and unsatisfactory
FNACs.[8] The diagnostic accuracy of FNAC in a study done by
Singh D et al. (2008)[12] was 93.75% with a sensitivity of 97.87%
and specificity of 88.35%. Shah et al. (1999)[11] had a sensitivity of
93.9% and specificity of 85.7% in their study. The sensitivity and
specificity of different studies vary because of selection bias of
the cases, whereas we have included all intraoral FNAC cases, and
therefore the main problem with our cases was sampling error.
CONCLUSION
The present study illustrates the role of FNAC in the diagnosis of
a variety of benign as well as malignant lesions of the oral cavity
and oropharynx. The deeply situated oral/oropharyngeal lesions
are sometimes difficult to aspirate. FNAC saved over 50% of
patients from surgery/excision biopsy in the present series. FNAC
is highly accurate for the malignant lesions which can be of great
help in early planning of the definitive course of management.
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Cite this article as: Gupta N, Banik T, Rajwanshi A, Radotra BD, Panda N, Dey
P, et al. Fine needle aspiration cytology of oral and oropharyngeal lesions with
an emphasis on the diagnostic utility and pitfalls. J Can Res Ther 2012;8:626-9.
Source of Support: Nil, Conflict of Interest: No.
629
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