UPDATE   3.4.2020

Novel Coronavirus (COVID 19) has rapidly spread across the globe overwhelming health systems of many countries and is a cause of significant morbidity and increasing number of deaths in the affected countries. On March 11, 2020 the World Health Organisation (WHO) declared COVID 19 a global Pandemic.

This guidance is written to help British Society of Head and Neck Imaging (BSHNI) members and Head & Neck Radiologists in UK with local decision making. The situation is changing rapidly so the latest version of the statement should be accessed from the BSHNI website. The information in this document is a reflection of best available information and evidence and may need to be adapted to local guidance. This guidance is likely to change as more information becomes available.


COVID 19 is highly contagious and readily spread by pre-symptomatic and asymptomatic carriers. Performing non-urgent imaging puts patients and healthcare staff at risk and increases the likelihood of onward transmission of infection. In light of this BSHNI recommends that only urgent imaging should be undertaken at this time. This is particularly important for neck ultrasound and biopsy due to close proximity between the patient and the healthcare worker.

Imaging Guidance:

Patients meeting criteria below should have urgent imaging despite the current COVID 19 situation.

For Ultrasound imaging we propose urgent imaging for:

  • Definite neck lumps (excluding thyroid)
  • Enlarging neck lumps over a short period of few weeks (including thyroid)
  • Parotid masses (greater than 1cm)
  • Thyroid masses if associated with breathing or swallowing difficulty or palpable metastatic lymph nodes.

For Cross-sectional imaging we propose:

  • Any of above indications may also need cross-sectional
  • Stridor
  • Strong clinical suspicion of upper aerodigestive tract tumour
  • Peritonsillar/ retropharyngeal/ deep neck space abscess not responding to conservative management
  • Strong clinical suspicion of sinonasal or skull base tumour
  • Orbital or frontal sinus abscess

Personal Protection Equipment Guidance:

This guidance applies to radiologists undertaking neck ultrasound and biopsy lists.

Maintaining distance between individuals is important as asymptomatic spread of the virus is well recognised. When neck ultrasound or biopsy is performed the radiologist or sonographer would be in close proximity to the patient’s face/head and often for more than 15 minutes.

Patients undergoing neck ultrasound and biopsy during the pandemic may be vulnerable or cancer patients. At this time there is no documented evidence of spread of COVID-19 from a healthcare worker to a patient. However, there is a potential risk of infection of the patient by sonographer and vice versa.

After review of the WHO and NHS England PPE guidance BSHNI recommends that any healthcare worker undertaking neck ultrasound and/or biopsy list should wear the appropriate PPE.

The appropriate PPE would consist of:

  • Surgical mask as a minimum. Fit tested FFP3 (Equivalent to N99) masks are desirable when performing FNA or biopsy but this may be in short supply. Fit tested FFP2 mask may be used at an alternative if FFP3 masks not available. Same mask can be worn for whole list.
    • Note: FFP2 masks are generally no longer recommended in UK following recent PHE guidance dated 27.3.20. However, according to the joint letter from Academy of Royal colleges, NHS and PHE dated 28.3.20 an FFP2 fit tested mask may be used as a safe alternative if FFP3 mask is not available. WHO recommends FFP2 masks for Aerosol generating procedures (AGP).
  • Gloves and apron should be changed between patients. For Biopsy or FNA full sleeve apron recommended.
  • Eye protection. Goggles or Visor recommended if performing FNA or biopsy. Visors are in short supply at many organisations and can be reused if local doffing guidance and cleaning guidance followed.

COVID 19 positive patients are unlikely to require neck ultrasound. If COVID 19 positive patients require ultrasound imaging or aspiration then all standard local guidance should be followed including cleaning of the rooms and equipment after the procedure.

Core biopsy is felt to be less likely to generate aerosol than FNA. Some centres are avoiding use of slides and resorting to primarily use of cytorich / cytolyte for FNA samples. This needs risk assessment and local discussion with pathology.



Dr Jagrit Shah
BSHNI President

(On behalf of the BSHNI committee)