Radiology Coding Alert

CT-Guided Biopsy of a Left Neck Mass

History: Left-sided cervical lymphadenopathy

Procedure: Informed consent was obtained from the patient prior to the procedure. The risks discussed include hemorrhage and infection. The patient's superior left neck was prepped and cleaned in sterile fashion. 1% lidocaine was used for local anesthesia.

Under CT guidance, a 21-gauge needle was inserted into the enlarged left internal jugular lymph node just deep to the left sternocleidomastoid muscle. Two aspirates were obtained and the samples deemed sufficient by the pathology service. There were no immediate complications.

Impression: CT-guided aspiration of an enlarged left internal jugular lymph node.

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