Deep-seated head and neck lesions, which traditionally were evaluated by surgical means, are now accessible with less invasive computed tomography-guided percutaneous needle biopsy techniques. Major vessels, the trachea, and osseous structures like the maxilla, mandible, and vertebrae often preclude direct access to these lesions. It is important to understand the anatomy relevant to safe access route planning and the techniques, advantages, and limitations associated with various approaches used for percutaneous biopsy of head and neck lesions. For biopsy of suprahyoid head and neck lesions, including those of the skull base and upper cervical vertebrae, various approaches such as the subzygomatic, retromandibular, paramaxillary, submastoid, transoral, and posterior approaches can be used. Lesions in the infrahyoid portion of the neck and lower cervical vertebrae can be accessed with the anterolateral approach (between the airways and the carotid sheath), posterolateral approach (posterior to the carotid sheath), and direct posterior approach. The location and extent of the lesions and their relationship to adjacent structures influence the choice of the trajectory to use. Careful planning of the procedure and considerable familiarity with head and neck anatomy are necessary for a biopsy that is both precise and safe.

merica is captivated by the surgeon-perhaps more so than by any other servant in medicine. Channel surfing through daytime soap operas and prime-time television shows, for instance, inevitably displays the drama of the operating room, a domain otherwise foreign to the lay public. Surgery's allure likewise extends to most medical students; many are fascinated by their operating room experiences during the surgery clerkship and enjoy the combination of procedures, teamwork, and patient care. If medical students continue to be intrigued by surgery as a discipline, though, why do they not appear to be as interested in general surgery as a career?

Case Presentation and EvolutionA 55-year-old man with end-stage liver disease due to chronic hepatitis C and alcohol abuse underwent orthotopic liver transplantation (OLT). Six weeks later, he developed a sudden rise in liver enzyme level. He underwent a liver biopsy that revealed acute cellular rejection and was treated with anti-thymocyte globulin. Although his aminotransferase levels declined over the following weeks, total bilirubin remained elevated over 5 mg/dl. Hepatic sonography and color Doppler imaging were normal. Endoscopic retrograde cholangiopancreatography (ERCP) revealed a stricture at the biliary anastomosis ( Fig. 1), which was treated with balloon dilation and biliary stent placement.The patient presented four months later with fever, sweats, and enterococcal bacteremia. An abdominal computed tomography (CT) scan with intravenous contrast revealed a 6-cm right hepatic lobe fluid collection communicating with dilated intrahepatic bile ducts, consistent with a biloma. Altered hepatic perfusion was also seen, manifested by heterogeneous attenuation in the right hepatic lobe (Fig. 2a-b). Percutaneous transhepatic cholangiography (PTC) with biliary drainage was performed, followed by internal-external biliary drain placement over the next several weeks. Follow-up hepatic sonography showed interval development of low resistance within the hepatic artery and tardus-parvus waveforms, suggesting proximal occlusion. A CT angiogram demonstrated complete occlusion of the common hepatic artery ( Fig. 3a-b). Over the following weeks, the patient developed multifocal intrahepatic biliary strictures with recurrent bilomas requiring percutaneous drainage. Because of subsequent progressive graft failure, he ultimately underwent a second liver transplantation.