This 30-years old lady presented with fever and a large right paratracheal node. The working diagnosis was lymphoma, given its homogeneous appearance and size. While the nodal mass is easy to biopsy, I did not want to go through the lung.
In the prone position, I first inserted a 20G spinal needle obliquely into the space between the pleura and the vertebral body and then injected a combination of saline and local anesthetic. There was adequate separation. Then using an 18G coaxial biopsy gun, I went in straight and again injected a little more saline to complete the separation and managed to get into the node using an extra pleural approach.
The diagnosis was non-caseating granulomatous disease and in view of the lung lesion, she was treated for tuberculosis.