Spatial filtering of a six-wavelength DBR-RW laser in a MOPA system

Lasing emission at multiple wavelengths can be used in different sensing applications and in optical telecommunication. In this work, we report a six-wavelength distributed Bragg reflector (DBR) laser, emitting around 976 nm with six ridge waveguide (RW) structures, where individual DBR gratings are combined into a common front section. These six elements are individually addressable and biased one at a time for individual wavelength selection. The drawback of this RW combination is observable in spatial characteristics where higher-order modes are supported. We addressed this issue by using a master oscillator power amplifier (MOPA) system that combines the six-wavelength MO laser with a tapered PA. Through this configuration, the PA acts as a spatial filter of the MO beam, providing a nearly diffraction-limited beam with M1/e²2<1.5. In addition, the described MOPA system provides output powers around 4 W with spectral single-mode operation, with up to 9.36 nm of thermal wavelength tuning. We believe that the described MOPA configuration can be used in different applications, such as absorption spectroscopy.

[Acute renal failure in a healthy 19-year-old woman after intake of 7 g of paracetamol]

In this case report, a 19-year-old woman was admitted with delayed acute renal failure due to a paracetamol intake of 7 g. No liver damage was present, and the renal function recovered spontaneously after a few weeks. Paracetamol is the most common cause of medical induced overdose or death. It is well known, that poisoning from paracetamol may cause liver damage, but the risk of renal toxicity is known to a lesser extent. Acute renal failure due to paracetamol overdose may easily be missed due to the delayed manifestation.

Pulmonary arteriovenous malformations: a radiological and clinical investigation of 136 patients with long-term follow-up

AIM

To assess the clinical outcome of patients with and without hereditary haemorrhagic telangiectasia (HHT) after embolisation of pulmonary arteriovenous malformations (PAVM) from a single national centre.

MATERIALS AND METHODS

The present register-based observational study including all patients with PAVM treated with embolisation at a reference centre for HHT and PAVM was undertaken over a 20-year period. Demographic data, HHT genotyping, clinical presentation, and outcome were registered. Patients with HHT were compared to the patients without HHT. Clinical examination, contrast-enhanced echocardiography, and computed tomography (CT) were used to assess the clinical outcome at follow-up.

RESULTS

One hundred and thirty-six patients with 339 PAVM underwent embolisation during the study period: 22 did not have HHT; 62% had HHT1, 10% had HHT2, 4% had JP-HHT, 8% had clinical HHT without identified genetic mutations. Solitary PAVM were more common among patients without HHT than with HHT. Mean follow-up after the first embolisation was 58 months. Mean age at first embolisation was 46.5 years, and at last follow-up 51.8 years. The clinical success without shunt at follow-up was 87%. The 30-day mortality related to the embolisation was 0%. Twenty patients died during follow-up (mean age 69 years). Most patients could be treated during one session, but many will need a long follow-up with repeated clinical examinations and embolisation.

CONCLUSION

The majority of patients referred for embolisation of PAVM had HHT. Multiple PAVM is associated with HHT. Patients with PAVM should be screened for HHT and patients with HHT for PAVM. Embolisation is a safe procedure with high clinical success.

MR spectroscopy of hepatic fat and adiponectin and leptin levels during testosterone therapy in type 2 diabetes: a randomized, double-blinded, placebo-controlled trial

BACKGROUND

Men with type 2 diabetes mellitus (T2D) often have lowered testosterone levels and an increased risk of cardiovascular disease (CVD). Ectopic fat increases the risk of CVD, whereas subcutaneous gluteofemoral fat protects against CVD and has a beneficial adipokine-secreting profile.

HYPOTHESIS

Testosterone replacement therapy (TRT) may reduce the content of ectopic fat and improve the adipokine profile in men with T2D.

DESIGN AND METHODS

A randomized, double-blinded, placebo-controlled study in 39 men aged 50-70 years with T2D and bioavailable testosterone levels <7.3 nmol/L. Patients were randomized to TRT (n = 20) or placebo gel (n = 19) for 24 weeks. Thigh subcutaneous fat area (TFA, %fat of total thigh volume), subcutaneous abdominal adipose tissue (SAT, % fat of total abdominal volume) and visceral adipose tissue (VAT, % fat of total abdominal volume) were measured by magnetic resonance (MR) imaging. Hepatic fat content was estimated by single-voxel MR spectroscopy. Adiponectin and leptin levels were measured by in-house immunofluorometric assay. Coefficients (b) represent the placebo-controlled mean effect of intervention.

RESULTS

TFA (b = -3.3 percentage points (pp), P = 0.009), SAT (b = -3.0 pp, P = 0.006), levels of adiponectin (b = -0.4 mg/L, P = 0.045), leptin (b = -4.3 µg/mL, P < 0.001), leptin:adiponectin ratio (b = -0.53, P = 0.001) and HDL cholesterol (b = -0.11 mmol/L, P = 0.009) decreased during TRT compared with placebo. Hepatic fat content and VAT were unchanged.

CONCLUSIONS

The effects of TRT on cardiovascular risk markers were ambiguous. We observed potentially harmful changes in cardiovascular risk parameters, markedly reduced subcutaneous fat and unchanged ectopic fat during TRT and a reduction in adiponectin levels. On the other hand, the decrease in leptin and leptin:adiponectin ratio assessments could reflect an amelioration of the cardiovascular risk profile linked to hyperleptinaemia in ageing men with T2D.

Anorexia nervosa with massive pulmonary air leak and extraordinary propagation

A rare case combining pneumothorax, pneumomediastinum, pneumopericardium, pneumoperitoneum, pneumorrhachis, air in retroperitoneum and extensive subcutaneous emphysema simultaneously in a severely anorectic male with BMI 9.2 (22.8 kg) and multiple vomitings is presented. This unusual condition was treated successfully with conservative medical approach in a specialized somatic unit for anorexia nervosa.

Concept for power scaling second harmonic generation using a cascade of nonlinear crystals

Within the field of high-power second harmonic generation (SHG), power scaling is often hindered by adverse crystal effects such as thermal dephasing arising from the second harmonic (SH) light, which imposes limits on the power that can be generated in many crystals. Here we demonstrate a concept for efficient power scaling of single-pass SHG beyond such limits using a cascade of nonlinear crystals, in which the first crystal is chosen for high nonlinear efficiency and the subsequent crystal(s) are chosen for power handling ability. Using this highly efficient single-pass concept, we generate 3.7 W of continuous-wave diffraction-limited (M(2)=1.25) light at 532 nm from 9.5 W of non-diffraction-limited (M(2)=7.7) light from a tapered laser diode, while avoiding significant thermal effects. Besides constituting the highest SH power yet achieved using a laser diode, this demonstrates that the concept successfully combines the high efficiency of the first stage with the good power handling properties of the subsequent stages. The concept is generally applicable and can be expanded with more stages to obtain even higher efficiency, and extends also to other combinations of nonlinear media suitable for other wavelengths.

Endovascular repair of postoperative vascular graft related complications after aorto-iliac surgery

AIM

Para-anastomotic aneurysms, leakage due to anastomotic failure, aorto- and arterioenteric fistulas are some of the serious complications after aorto-iliac surgical reconstructions. Treatment of these complications is challenging and is either done by open surgery or by endovascular therapy. The mortality and morbidity is higher compared to the initial treatment. We present twelve patients with these complications which were treated by an endovascular approach.

METHODS

From January 2008 through January 2013 our radiological records were searched for cases with post surgical vascular complications treated with endovascular intervention. These comprised of anastomotic pseudoaneurysm, suture leakage and arterial enteric fistulas. Patients with limb occlusions were not included in this study.

RESULTS

Twelve patients with graft related complications treated with endovascular intervention were recorded. There were four women and eight men with a mean age 75,3 years (range 48-80). At the time of diagnosis, 9 patients (75%) had symptoms and three (25%) was incidentally discovered. Six patients had leakage due to suture failure. All infective parameters were within normal limits. Four patients presented with anastomotic pseudoaneurysms without leak, of which three had proximal anastomotic pseudoaneurysms and one had distal iliac anastomotic pseudoaneurysm. Implanted stent graft were Endurant (Medtronic) bifurcated endoprostheses in three patients and Excluder (Gore) prosthesis in a two cases. Tubular Medtronic endoprosthesis was implanted in one case and in two cases aortic cuff was used. Fluency periphery stent grafts were used in four cases. There was a 100% technical success. Intervention related early mortality was 8%. One patient with pseudoaneurysm died 28 months after endovascular treatment because of cardiac infarct and one patient with previously infected arterio-enteric fistula and advanced malignancy died 7 months after second endovascular treatment. Overall the mortality was 25%. There was no procedure related morbidity or complications during hospitalization and follow-up of mean 12, 3 months (range 1-36 months) in the other 9 patients. There were no complications like endoleaks or limb occlusions.

CONCLUSION

Endovascular treatment of vascular graft related postsurgical complications is a valuable therapeutic option followed by lower mortality and morbidity rates compared with re-operation. Short and midterm follow-up is without severe complications and if it occurs most of them can be treated by endovascular means again.

Simultaneous dual wavelength eye-tracked ultrahigh resolution retinal and choroidal optical coherence tomography

We demonstrate an optical coherence tomography device that simultaneously combines different novel ultrabroad bandwidth light sources centered in the 800 and 1060 nm regions, operating at 66 kHz depth scan rate, and a confocal laser scanning ophthalmoscope-based eye tracker to permit motion-artifact-free, ultrahigh resolution and high contrast retinal and choroidal imaging. The two wavelengths of the device provide the complementary information needed for diagnosis of subtle retinal changes, while also increasing visibility of deeper-lying layers to image pathologies that include opaque media in the anterior eye segment or eyes with increased choroidal thickness.

Occlusion of pulmonary arteriovenous malformations by use of vascular plug

Pulmonary arteriovenous malformations are commonly treated by embolization with coils or balloons to prevent cerebral complications and to raise the oxygenation of the blood. The Amplatzer vascular plug is a new occlusive device made of a self-expanding cylindrical nitinol mesh. It is fast and safe to position, and can be repositioned before final delivery. It is especially suited for embolization of large high-flow vessels as in pulmonary arteriovenous malformations with big feeding arteries. Two cases of successful use of the new device for treatment of large pulmonary arteriovenous malformations are described.

Imaging and interventional radiological treatment of hemoptysis

Hemoptysis is coughing up blood originating from the lower respiratory tract. There are multiple causes of hemoptysis, from airway diseases, parenchymal diseases, cardiovascular diseases, and other causes. Hemoptysis may cease temporarily, but a possible life-threatening condition may still be present, requiring complete evaluation and probably treatment. Massive hemoptysis (>300 ml blood in 24 hours) seldom occurs but has high mortality. Diagnostic examinations include patient history, physical examination, bronchoscopy, laboratory tests, chest X-ray, computed tomography (CT) of the chest, pulmonary angiography, aortography, and angiography of the bronchials and other thoracic systemic arteries. Bronchoscopy together with clinical and radiological examinations indicates from which part of the lung the bleeding is occurring, yet the cause of hemoptysis cannot be determined in 20-30% of cases. One of the therapeutic measurements may be embolization of the bleeding vessel such as in pulmonary arteriovenous malformations or in bronchial or other systemic arterial branches supplying the bleeding lung segment. Systemic bronchial and non-bronchial collateral artery anatomy is very complex and variable, and it may be difficult to recognize how the systemic arteries or pulmonary arteries may be involved as a source of bleeding. Interventional treatments are effective and safe therapeutic methods which reduce the need for acute thoracic surgery. Embolization may be life saving, or it may postpone surgery and, in some situations, should be the treatment of choice.

Infrared thermography and ultrasonography to indirectly monitor the influence of liner type and overmilking on teat tissue recovery

Eight Danish Holstein cows were milked with a 1-mm thick specially designed soft liner on their right rear teat and a standard liner mounted under extra high tension on their left rear teat. Four of the animals were overmilked for 5 min. Rear teats were subjected to ultrasound examination on the first day and to infrared thermography on the second day. Teats were submersed in ethanol 20 min post-milking on the second day. Ultrasonography measurements showed that teat canal length increased by 30–41% during milking. Twenty minutes after milking, teats milked with modified standard liners still had elongated teat canals while teats milked with the soft liner were normalized. Overmilking tended to increase teat wall thickness. Approximately 80% of variability in teat canal length, from before teat preparation to after milking, could be explained by changes during teat preparation. Thermography indicated a general drop in teat temperature during teat preparation. Teat temperature increased during milking and continued to increase until the ethanol challenge induced a significant drop. Temperatures approached pre-challenge rather than pre-milking temperatures within 10 minutes after challenge. Teat temperatures were dependent on type of liner. Mid-teat temperatures post-challenge relative to pre-teat preparation were dependent on overmilking. Thermography and ultrasound were considered useful methods to indirectly and non invasively evaluate teat tissue integrity.

Clinical symptoms according to genotype amongst patients with hereditary haemorrhagic telangiectasia

BACKGROUND

Hereditary haemorrhagic telangiectasia (HHT) is a dominantly inherited disease, characterized by a wide variety of clinical manifestations, including epistaxis, gastrointestinal (GI) bleeding, pulmonary arteriovenous malformations (PAVMs) and neurological symptoms. HHT is a genetically heterogeneous disorder involving at least two loci; HHT 1 mapping to chromosome 9 q 34.1 (ENG) and HHT 2 mapping to chromosome 12 q 31 (ALK-1).

OBJECTIVE

To evaluate and describe the diversity of clinical manifestations in a Danish population of HHT patients with known HHT 1 or HHT 2 subtype.

DESIGN

Prospective clinical examination with genetic evaluation and follow-up.

SETTING

Investigation centre was Odense University Hospital. All HHT patients in the County of Fyn were included.

METHODS

HHT family members were invited to a clinical examination including registration of HHT manifestations, screening for PAVM and neurological evaluation. Blood tests were performed for analysis of disease-causing mutation, and clinical manifestations in the HHT subtypes were compared. The survival of the patients was studied in the follow-up period.

RESULTS

Included in the study were 73 HHT patients representing 18 families. In 14 of the families we identified a disease-causing mutation. Thirty-nine patients (from 10 families) had HHT1 and 16 HHT patients from four families had HHT2.

CONCLUSION

Amongst patients with HHT1 genotype the prevalence of PAVM was higher than amongst HHT patients with HHT2 genotype. HHT1 patients had experienced more severe GI bleeding than HHT2 patients. There was no significant difference in severity of epistaxis or age at debut. Finally the mortality over a 90-month observation period was not significantly increased.

MRI detection of cervical metastasis from differentiated thyroid carcinoma

BACKGROUND

With the advent of the use of serum thyroglobulin as a marker for the recurrence of well-differentiated thyroid cancer (WDTC) after total thyroidectomy, clinicians are increasingly faced with the diagnostic dilemma of detecting the site of recurrence in thyroglobulin-positive patients with normal clinical examinations. The high protein content of this thyroglobulin may make it specifically detectable by magnetic resonance (MR) imaging.

OBJECTIVE

To determine the ability of MR imaging to detect the presence of metastatic WDTC in cervical lymph nodes.

STUDY DESIGN

Retrospective cohort.

METHODS

Blinded review by two independent head and neck radiologists of 34 head and neck MR scans obtained from 26 patients with thyroid cancer (12 with primary disease and 14 with recurrent disease) all of whom subsequently underwent surgical removal of the lymph nodes considered at risk by imaging.

RESULTS

The average overall percent sensitivity, specificity, positive predictive value (PPV), negative predictive value (NPV), and accuracy of MR imaging were 95%, 51%, 84%, 78%, and 83%, respectively. The concordance between the two radiologists was 69%. There was no overall difference in the ability of the MR scan to detect the presence of disease in the upper jugular, lower jugular, or paratracheal nodal stations. However, it was more useful for papillary carcinoma (PPV 86%, accuracy 85%) than for follicular carcinoma or the follicular variant of papillary carcinoma (PPV 63%, accuracy 67%).

CONCLUSION

MR imaging is a sensitive and accurate technique for the detection of WDTC, particularly papillary carcinoma, metastatic to cervical lymph nodes. However, the lower specificity of this modality precludes its use as a screening tool.

Endovascular treatment of severe symptomatic stenosis of the internal carotid artery: early and late outcome

OBJECTIVES

To report a 6 year experience with carotid percutaneous transluminal angioplasty (CPTA) in a selected group of patients.

MATERIAL AND METHOD

We retrospectively reviewed our experience after performing 54 CPTAs, with (n=18) or without (n=36) stent deployment, over a period of 6 years from 1993 to 1999. All patients, except one, suffered from focal hemispheric neurologic symptoms. During the same time period 284 patients underwent carotid endarterectomy. The selection of the 54 patients (16%) for CPTA was based on the carotid angiogram and the sole inclusion criterion for endovascular treatment was a short, concentric, and smooth stenosis of more than 70% without ulceration or severe calcification. All patients who had a patent internal carotid artery after the last control were invited for a clinical duplex examination and all duplex examinations were carried out by a single experienced observer.

RESULTS

Early outcome (<30 days): CPTA was judged technically successful in 50 cases (93%). Ten patients (18%) experienced a neurological event in relation to the procedure and one patient (2%) suffered a major stroke. One stent occluded within 30 days.

LATE OUTCOME

Forty-six patients (85%) entered the follow-up study after a median of 34 months (range 1-80 months). Six patients (13%) had recurrent symptoms. The colour-duplex examination (n=45) showed internal carotid artery occlusion in 2 patients (5%), and restenosis (>70%) in 10 patients (22%). We found no significant difference in the reoccurrence of neurological symptoms or the rate of restenosis between patients treated with and without stent (Log Rank 0.28, p=0,59). ICA was patent without restenosis in 60% after 48 months in patients treated with CPTA alone, and in 76% after 3 months in patients treated with a stent (N.S.).

CONCLUSION

CPTA in a selected group of patients has a mortality and major stroke rate comparable to that of carotid endarterectomy. However, the risk of transient neurological events was high, as well as the incidence of restenosis (>70%) after 3 years. We still consider CPTA an experimental procedure. The indications for this treatment must be clarified if CPTA should be an alternative to surgery with a comparable neurological complication rate.

[Pulmonary arteriovenous malformations. Current therapeutic principles]

Pulmonary arteriovenous malformations are congenital vascular malformations in the lungs, which act as shunts so that the blood is not oxygenated or filtered. These patients are typically hypoxaemic with exercise intolerance and are at high risk of paradoxical emboli to the brain. About 25% of patients with the Rendu-Osler-Weber syndrome (hereditary haemorrhagic telangiectasia) have these pulmonary malformations. A modern treatment strategy is embolisation with balloon or coils of the afferent arteries to the arteriovenous malformations. It is a minimally invasive procedure with a very high technical success and few complications. Embolisation prevents cerebral stroke and abscess and pulmonary haemorrhage and further raises the functional level. Screening for pulmonary arteriovenous malformations in patients at risk is recommended.

[Endovascular treatment of uterine fibromas]

Uterine artery embolisation represents a promising new method of treating fibroid-related menorrhagia and pelvic pain. The procedure is performed under local analgesia and intravenous sedation. Both uterine arteries are selectively catheterised under fluoroscopic control. Microparticles suspended in contrast medium are used to embolise the uterine vascular bed. Ischaemic pain during the first day is treated with intravenous morphine. Patients treated with embolisation can expect excellent results with respect to menorrhagia, pelvic pain, and reduction in the fibroid tumour volume. Women undergoing uterine embolisation retain their potential for future pregnancies. The procedure is well tolerated by patients, and possesses the advantages of shorter hospitalisation and recovery time, as compared to hysterectomy.

Tracheoesophageal puncture in the office setting with local anesthesia

Tracheoesophageal puncture (TEP) with voice prosthesis placement is currently the method of choice for vocal rehabilitation of patients who have undergone total laryngectomy. Occasionally, secondary TEP needs to be performed. We have used a TEP technique that is performed in the clinic setting with local anesthesia and no sedation. The purpose of this study was to review our technique and experience and to evaluate results, complications, and patients' acceptance of the procedure. We performed a retrospective chart review of the records of 14 patients who had undergone total laryngectomy and secondary TEP placement in the clinic setting. The procedure was well tolerated. The voice results were fair to good in 11 of 12 patients. There was 1 complication, a false passage between the trachea and the esophagus. Voicing was immediate in 12 of the 14 cases. We conclude that TEP can be performed in the office setting with local anesthesia. The voice results are excellent, and the procedure is well tolerated by the patient. Proper patient selection and regular follow-up by a speech-language pathologist are important.

A Prospective Comparison of Scalpel Versus Bipolar Scissors in the Elevation of Radial Forearm Fasciocutaneous Free Flaps

OBJECTIVES/HYPOTHESIS

The radial forearm fasciocutaneous free flap has become the workhorse for reconstruction of head and neck ablative defects. A location distal to the head and neck allows this flap to be elevated concurrent with the ablation. Most commonly, the flap is elevated under tourniquet control. This involves a primary ischemic insult with a certain amount of hemorrhage after the tourniquet is released. Bipolar scissors are a new method of dissection. They may allow for a speedier dissection with a concomitant decrease in ischemic time. Their hemostatic properties may control hemorrhage after use of the tourniquet.

STUDY DESIGN

A prospective study of patients undergoing radial forearm free flaps over a 12-month period at a tertiary care referral center was undertaken.

RESULTS

Forty patients were entered into the study, flaps were elevated with scalpel (20) and with bipolar scissors (20). Mean time under tourniquet was 39 minutes (range, 30-56 min) with scalpel compared with 27 minutes (range, 21-31 min) with bipolar scissors (P <.001). Total mean time of elevation (including control of hemostasis and pedicle dissection) for scalpel elevation was 50 minutes (range, 35-61 min) compared with 32 minutes (range, 20-41 min) for bipolar scissors elevation (P <.001). Mean blood loss was 46 mL (range, 15-110 mL) in the scalpel elevation group compared with 14 mL (range, 0-50 mL) in the bipolar scissors elevation group (P <.001). Complications at the donor site were equal between groups.

CONCLUSIONS

Bipolar scissors are a safe, efficient method for elevating radial forearm free flaps.

Reversibility of cortical hyperostosis following long-term prostaglandin E1 therapy in infants with ductus-dependent congenital heart disease

Two neonates with complex cyanotic congenital heart disease, receiving long-term prostaglandin E1 infusion, for 59 and 78 days respectively, demonstrated significant radiographic changes of symmetric cortical hyperostosis of the long bones. Bone biopsies from one of the patients elucidated the histological changes and serial X-rays revealed regression of the hyperostosis. Long-term follow-up after 13 months did not reveal any late bony changes or growth disturbance.

Uterine artery embolization of symptomatic uterine fibroida . Initial success and short-term results

PURPOSE

To evaluate reduction in fibroid volume, the effect on clinical symptoms, adverse events and complications after percutaneous uterine artery embolization (UAE) as primary invasive treatment for symptomatic uterine fibroids.

MATERIAL AND METHODS

Sixty-two patients entered the study. Indications for treatment were fibroid-induced menorrhagia, bulk symptoms, pain, and/or large fibroid size. The first 50 patients were evaluated by clinical examination and ultrasonography with measurement of fibroid volume before treament and 1, 6 and 12 months after UAE. The remaining 12 patients were followed 3 and 12 months after treatment. Embolization with microparticles was performed percutaneously in local analgesia by selective catheterization of both uterine arteries.

RESULTS

A primary technical success with bilateral UAE was achieved in 60/62 (97%) of the patients. They were treated for postprocedural pain lasting up to 24 h. In 30 of the 62 patients with 6 months follow-up, the mean fibroid volume was reduced 68% 6 months after treatment. Twenty-nine (96%) of the patients experienced reduced bleeding, 21 (70%) reduced pain, and 18 (61%) reduced bulk symptoms at follow-up.

CONCLUSION

UAE is a method with a high technical success rate. The treatment has good effect on fibroid volume reduction and clinical symptoms. Severe post-procedural pain occurs generally in successful bilateral embolizations, but complications and adverse events are otherwise few and minor. UAE represents a promising new method for treating uterine fibroid-related symptoms.

[Percutaneous transluminal embolization of pulmonary arteriovenous malformations]

OBJECTIVE

The aim was to evaluate the effect of embolisation of pulmonary arteriovenous malformations (PAVM), as estimated by contrast echocardiography, arterial blood-gas analyses and functional level, and further to evaluate procedure-related and late complications.

PATIENTS AND METHODS

Seventeen patients were treated on 25 occasions for a total of 48 PAVM. Fifteen patients had hereditary haemorrhagic telangiectasia (HHT). Chest X-ray, pulmonary angiography, contrast echocardiography, arterial blood-gas analyses, and functional level were analysed before and after embolisation of PAVM. The mean follow-up period was 22 months.

RESULTS

Contrast intensity at contrast echocardiography decreased from median 4.0 (range 2-4) before embolisation to 1.5 after embolisation. PaO2 breathing 100% oxygen increased from mean 271 mm Hg before embolisation to 480 mm Hg after embolisation. The shunt was reduced from mean 24% before to 12% after embolisation. Most of the patients experienced an increased functional level after embolisation, and the median functional level (NYHA) increased from NYHA 2.5 to 1.2. No primary or secondary device migration, no cerebral insults, and no mortality was noted.

CONCLUSION

Embolisation is a well-established method of treating PAVM, with a significant effect on oxygenation of the blood. It is a minimally invasive, lung-preserving treatment with high affectiveness and low morbidity and mortality. Patients with HHT should be screened for PAVM as a high percentage of these have PAVM.

Accuracy of computed tomography in determining the presence or absence of metastatic retropharyngeal adenopathy

OBJECTIVE

To decide the accuracy of computed tomography in determining the presence or absence of metastatic retropharygeal adenopathy in patients with squamous cell carcinoma of the head and neck.

DESIGN

A comparison of the results of retrospective blinded review of preoperative computed tomographic scans with the histologic findings of retropharyngeal node dissection at the time of surgery.

SETTING

Academic tertiary care center.

PATIENTS

Twenty-six patients with advanced stage squamous cell carcinoma of the head and neck.

MAIN OUTCOME MEASURES

Computed tomographic findings and histologic results of retropharyngeal node dissection.

RESULTS

The retropharyngeal nodes were pathologically positive for metastasis in 6 (23%) of the 26 patients. The radiologist (J.M.T.) correctly read the scan in 3 of 6 patients with histologically proved metastasis, and in 14 of 20 patients with histologic features negative for metastasis. The sensitivity of the radiologist reading was 50%, and the specificity was 70%. The positive predictive value was 33%, and the negative predictive value was 82%.

CONCLUSION

The presence of retropharyngeal node metastasis cannot be determined by computed tomographic imaging alone. Arch Otolaryngol Head Neck Surg. 2000;126:1478-1481

Closed-form solution for the Wigner phase-space distribution function for diffuse reflection and small-angle scattering in a random medium

Within the paraxial approximation, a closed-form solution for the Wigner phase-space distribution function is derived for diffuse reflection and small-angle scattering in a random medium. This solution is based on the extended Huygens-Fresnel principle for the optical field, which is widely used in studies of wave propagation through random media. The results are general in that they apply to both an arbitrary small-angle volume scattering function, and arbitrary (real) ABCD optical systems. Furthermore, they are valid in both the single- and multiple-scattering regimes. Some general features of the Wigner phase-space distribution function are discussed, and analytic results are obtained for various types of scattering functions in the asymptotic limit s >> 1, where s is the optical depth. In particular, explicit results are presented for optical coherence tomography (OCT) systems. On this basis, a novel way of creating OCT images based on measurements of the momentum width of the Wigner phase-space distribution is suggested, and the advantage over conventional OCT images is discussed. Because all previous published studies regarding the Wigner function are carried out in the transmission geometry, it is important to note that the extended Huygens-Fresnel principle and the ABCD matrix formalism may be used successfully to describe this geometry (within the paraxial approximation). Therefore for completeness we present in an appendix the general closed-form solution for the Wigner phase-space distribution function in ABCD paraxial optical systems for direct propagation through random media, and in a second appendix absorption effects are included.

The relative value of fine-needle aspiration and imaging in the preoperative evaluation of parotid masses

BACKGROUND

To establish the sensitivity, specificity, and accuracy of imaging and fine-needle aspiration (FNA), alone or in combination, in distinguishing benign from malignant histologic findings for parotid lesions.

METHODS

Retrospective blinded review of preoperative imaging and FNA studies of parotid masses and comparison with histologic findings after excision.

RESULTS

Forty-eight patients were identified (13 with CT, 35 with MRI); 23 (48%) of the lesions were malignant, 25 (52%) were benign. MRI, CT, and FNA misclassified 17%, 46%, and 21% of the lesions, respectively. The sensitivity/specificity/accuracy of these tests for detecting malignant lesions were as follows: MRI (88%,77%,83%), CT (100%,42%, 69%), and FNA (83%,86%,85%) and were not significantly different. Combinations of imaging and FNA were not significantly better in detecting malignancy.

CONCLUSIONS

Imaging and FNA are comparable in their ability to correctly identify malignant parotid lesions preoperatively. Combining these two modalities yields no advantage in terms of specificity, sensitivity, or accuracy of a malignant diagnosis.

External beam radiation followed by planned neck dissection and brachytherapy for base of tongue squamous cell carcinoma

BACKGROUND

Surgical resection of tongue base cancer can leave the patient with significant functional deficits. Other therapies, such as external beam radiation followed by neck dissection and radiation implants, have shown equal tumor control with good functional outcome.

METHODS

Between March 1991 and July 1999, 12 patients at Oregon Health Sciences University, the Portland Veterans Administration Medical Center and West Virginia University School of Medicine Hospital were treated with external beam radiation followed by neck dissection and Ir192 implants. Two patients had T1 disease, two had T2, five patients had T3 tumors, and three had T4 tumors. Six had N2a necks, three had N2b necks, and three had N2c. Follow-up ranged from 13 months to 8 years.

RESULTS

After external beam radiation, five patients had complete response and seven had partial response in the neck without complications. One patient underwent a unilateral radical neck dissection, eight had unilateral selective neck dissections involving levels I to IV, and three had dissections involving levels I to III. One of the five patients who had a complete clinical response in the neck had pathologically positive nodes. One patient had a pulmonary embolus that was treated and had no permanent sequelae. There were three complications from brachytherapy. Two patients had soft tissue necrosis at the primary site and one patient had radionecrosis of the mandible. All healed without further therapy. One patient had persistent disease and underwent a partial glossectomy but died of local disease. Distant metastasis developed in two patients. All others show no evidence of disease and are able to eat a normal diet by mouth.

CONCLUSION

This combination of therapies should be considered when treating tongue base cancer.

Genetic polymorphisms in head and neck cancer risk

OBJECTIVE

To assess whether genetic polymorphisms implicated as risk factors for other tobacco-associated malignancies are associated with altered risk of head and neck squamous cell carcinoma.

DESIGN

Case-control study.

SUBJECTS

One hundred sixty patients with head and neck squamous cell carcinoma recruited from a university-based head and neck oncology clinic and 149 population-based controls.

METHODS

Genotyping of the CYP1A1 (Ile462Val), GSTM1 (null), GSTP1 (Ile105Val), GSTT1 (null), and P53 (Arg72Pro) genes was performed by polymerase chain reaction-based techniques on DNA prepared from peripheral blood. In addition, a questionnaire was used to collect demographic information from each subject.

RESULTS

Cases were significantly older (p <.0001) and had significantly greater tobacco use (p <.0001) and were more likely to be male (p <.0001) than were control subjects, thus confirming known risk factors for this disease. When cases and controls were compared by simple chi-square analysis, only the frequency of CYP1A1 (Ile462Val) polymorphism was significantly different between cases and controls (OR =.42; 95% CI =.18-.99; p <.04). However, with a logistic regression model to control for known risk factors, we were unable to demonstrate a significant association with head and neck cancer for any of the polymorphisms tested, including CYP1A1.

CONCLUSIONS

This population fails to identify a relationship between the above-mentioned polymorphisms and head and neck cancer.

Prevalence of pulmonary arteriovenous malformations (PAVMs) and occurrence of neurological symptoms in patients with hereditary haemorrhagic telangiectasia (HHT)

BACKGROUND

Hereditary haemorrhagic telangiectasia (HHT) is a dominantly inherited disease. HHT is characterized by a wide variety of clinical manifestations, including pulmonary arteriovenous malformations (PAVMs) and neurological symptoms.

OBJECTIVE

To estimate (i) the prevalence of PAVM, and (ii) the occurrence of neurological symptoms in a geographical well-defined population of HHT patients.

METHODS

HHT family members were invited to a clinical examination including registration of HHT manifestations, screening for pulmonary arteriovenous malformations and neurological evaluation. Two groups served as controls: (i) first-degree relatives without any signs of HHT; and (ii) age- and gender-matched controls.

SETTING

Odense University Hospital.

SUBJECTS

HHT patients identified in a cross-sectional family survey carried out in the County of Fyn, Denmark.

RESULTS

Included in the study were 169 HHT family members representing 24 families. They included both HHT patients and their first-degree relatives. The criteria of HHT were fulfilled in 75 participants; of these, 59 had a screening procedure performed, and PAVMs were demonstrated at pulmonary angiography (PA) in 18. Seven of the HHT patients had a history of cerebral stroke, compared with none of their healthy first-degree relatives.

CONCLUSION

The prevalence of PAVM was 24% amongst HHT patients. The study confirmed an increased prevalence of neurological symptoms amongst HHT patients; the odds ratio was estimated to be 7.6. In order to enable prevention of these complications, screening for PAVM should become an integral part of the medical care for HHT patients.

Mutagen sensitivity and environmental exposures as contributing causes of chromosome 3p losses in head and neck cancers

The interaction between environmental exposures and host susceptibility may lead to specific mutational events within head and neck squamous cell carcinoma (HNSCC). Furthermore, this interplay may determine not only the probability of cancer development but also the biologic characteristics of the tumor once it occurs. To better understand the relationship of mutagen sensitivity and tobacco and/or alcohol consumption on HNSCC carcinogenesis, we examined loss of heterozygosity on chromosome 3p in 58 HNSCCs using 10 microsatellite markers. Mutagen sensitivity was determined in vitro by quantitating bleomycin-induced chromatid breaks utilizing peripheral blood lympocytes from respective patients. Forty-six of the 58 invasive cancers showed allelic loss at one or more loci. Consistent with previous investigations, three discrete regions of deletions were identified: 3p13-14.2, 3p21.1-21. 2, and 3p25.1-26.1. The frequency and types of deletions were dependent upon tobacco and alcohol exposures. The distal region of 3p but not the remaining two regions was most frequently influenced by tobacco exposure. In contrast, heavy alcohol use when combined with tobacco use was associated with whole-arm loss of 3p rather than identifiable site-specific damage. Furthermore, this combined influence of alcohol and tobacco exposures on whole-arm loss was most apparent in those patients who expressed mutagen-sensitivity; the odds ratio of whole-arm loss increasing from 2.67 (95% CI 0. 21-33.49) in those individuals who were mutagen resistant to 13.5 (95% CI 1.3-136.0; P = 0.02 by Fisher's exact test) in those who were mutagen sensitive. An assessment of clinical parameters in this population demonstrated that patients with whole-arm loss were more likely to present with cervical lymph node metastases and advanced stage disease than patients with partial losses. Results indicate that various environmental exposures as well as the expression of mutagen sensitivity will influence the types of chromosome 3p allelic losses in head and neck cancers as well as the behavior of disease once it develops.

Sensory changes associated with selective neck dissection

OBJECTIVE

To evaluate sensory changes in the head and neck region associated with selective neck dissection with or without preservation of cervical root branches.

DESIGN

Retrospective cohort study.

SETTING

University tertiary referral hospital and a Veterans Affairs hospital.

PATIENTS

Fifty-seven patients who had undergone 84 neck dissections with or without preservation of the sensory cervical root branches 3 or more months before evaluation.

INTERVENTIONS

Questionnaire combined with head and neck sensory examination.

MAIN OUTCOME MEASURES

Neck and facial sensory function.

RESULTS

Neck dissections with preservation of the cervical rootlets were most likely to be associated with a small area of anesthesia in the upper neck below the body of the mandible and anterior to the mid-body of the mandible (P=.03). Neck dissections without rootlet-preserving technique increased the area of anesthesia to include all other areas of the neck (P= .02).

CONCLUSIONS

Preservation of the cervical root branches resulted in a small, limited, and uniform area of the neck rendered permanently anesthetic. Conversely, sacrifice of the nerve branches led to a pattern of anesthesia involving the entire neck.

Analysis of optical coherence tomography systems based on the extended Huygens-Fresnel principle

We have developed a new theoretical description of the optical coherence tomography (OCT) technique for imaging in highly scattering tissue. The description is based on the extended Huygens-Fresnel principle, valid in both the single- and multiple-scattering regimes. The so-called shower curtain effect, which manifests itself in a standard OCT system, is an inherent property of the present theory. We demonstrate that the shower curtain effect leads to a strong increase in the heterodyne signal in a standard OCT system. This is in contrast to previous OCT models, where the shower curtain effect was not taken into account. The theoretical analysis is verified by measurements on samples consisting of aqueous suspensions of microspheres. Finally, we discuss the use of our new theoretical model for optimization of the OCT system.

[Percutaneous transluminal embolization in arterial retroperitoneal traumatic hemorrhage]

This study presents three cases of uncontrollable retroperitoneal arterial haemorrhage diagnosed by angiography and treated by transluminal embolization with coils. The haemorrhage originated in one patient from a branch of the internal iliac artery and in the other two patients from a renal artery. The circulation was stabilized in all three patients after transluminal coil embolization proximal to the arterial lesions. One patient died of multiorgan failure due to prolonged uncontrolled haemorrhage before embolization and one patient died as a consequence of low haemoglobin due to religiously based rejection of blood transfusion. Trauma patients with uncontrollable haemorrhage and retroperitoneal haematoma should be suspected of an arterial lesion and as early as possible be transferred to a center with experience in catheterisation and transluminal embolization.

Pulmonary arteriovenous malformations: screening procedures and pulmonary angiography in patients with hereditary hemorrhagic telangiectasia

BACKGROUND

Hereditary hemorrhagic telangiectasia (HHT) is a dominantly inherited disease with a high prevalence of pulmonary arteriovenous malformations (PAVMs). The first symptom of HHT may be stroke or fatal hemoptysis associated with the presence of PAVM.

OBJECTIVE

To evaluate different screening methods applied for the identification of PAVMs.

SETTING

Odense University Hospital.

SUBJECTS

HHT patients with positive findings on contrast echocardiography (CE) who participated in a screening investigation and underwent pulmonary angiography (PA).

METHODS

Different screening methods were evaluated against the results of PA. In a group of patients with positive findings on CE, we compared results of PA with the following: severity of dyspnea; results of pulse oximetry arterial oxygen saturation (SaO2) supine and upright; supine PaO2 in room air and while breathing 100% oxygen; size of arteriovenous shunt in supine position; chest radiograph; and intensity of contrast at CE.

RESULTS

PA was performed in 25 HHT patients with positive findings on CE, 15 of whom had PAVM. Embolization therapy was recommended in 12 patients, and 3 patients had small PAVMs not accessible for therapy. In 10 patients, PAVM could not be demonstrated at PA. The sensitivity and specificity calculated for the screening procedures are as follows: 53% and 90%, respectively, for SaO2; 60% and 100%, respectively, for chest radiograph; 73% and 80%, respectively, for PaO2 in room air; 100% and 40%, respectively, for PaO2 breathing 100% oxygen; and 64% and 80%, respectively, for shunt measurement.

CONCLUSION

Initial screening with CE followed by measurement of PaO2 while breathing 100% oxygen seemed to be the best screening procedure for identification of patients with PAVM. Screening with chest radiograph and pulse oximetry was shown to be insufficient.

Chest roentgenogram in the evaluation of heart defects in asymptomatic infants and children with a cardiac murmur: reproducibility and accuracy

OBJECTIVES

To evaluate the reproducibility and the accuracy of pediatric radiologists' assessments of chest radiographs with respect to the presence or absence of heart defects in children with an asymptomatic heart murmur.

DESIGN

Ninety-eight children, ages 1 month to 15 years (median, 30.1 months), referred for evaluation of a heart murmur were consecutively included. They all had a standard chest radiograph and a color Doppler echocardiograph (CDE) performed. Six specialists in pediatric radiology evaluated the chest radiographs independently on two occasions 6 months apart. The radiologists were asked to classify each set of films into one of two categories: heart disease or no heart disease. The outcome of the CDE was considered the definite diagnosis. kappa statistics were used to analyze the reproducibility of the radiologic assessments. Sensitivity, specificity, and the predictive value of a positive and a negative test were used for evaluation of the accuracy of the radiologic assessments.

RESULTS

Mean intra- and interobserver kappa values were all <0.6, and the majority were <0.4. Mean sensitivity was 0.3 (range: 0.17-0.52), mean predictive value of a positive test was 0.4, implying that 60% of the positive assessments were falsely positive. Mean specificity was 0.86 (range: 0.75-0.93) and the mean predictive value of a negative test was 0.80 implying that 20% of the negative assessments were falsely negative.

CONCLUSION

We found a low reproducibility, as well as a low accuracy, of the radiologic assessments of the chest radiographs of children with an asymptomatic heart murmur with respect to the presence or absence of heart disease. A false-positive radiologic assessment of the chest radiograph with respect to heart defects causes unnecessary anxiety and further examinations, whereas a false-negative assessment might result in omission of relevant investigations and proper identification of the heart defect. We cannot recommend the use of chest radiographs in the initial evaluation of the asymptomatic child with a heart murmur. If a heart defect cannot be excluded by clinical examination a CDE must be performed.

Embolotherapy for pulmonary arteriovenous malformations in patients with hereditary hemorrhagic telangiectasia (Rendu-Osler-Weber syndrome)

PURPOSE

To evaluate the clinical results of embolization of pulmonary arteriovenous malformations (PAVMs) in patients with hereditary hemorrhagic telangiectasia (HHT), the Rendu-Osler-Weber syndrome.

MATERIAL AND METHODS

Twelve patients in the county of Fyn, Denmark, were treated with transcatheter embolization of 20 PAVMs using 12 detachable silicone balloons and 26 steel coils.

RESULTS

All PAVMs were completely occluded and we observed a significant rise in PaO2 after treatment and a significant decrease in right-to-left shunt estimated by contrast echocardiography. All patients experienced an improved functional level. One patient experienced severe pleurisy and another a rise in temperature following treatment, but otherwise no symptomatic complications were observed.

CONCLUSION

Embolotherapy is a definitive treatment for PAVMs: it is very effective with a high success rate and few complications. Patients with HHT are at risk of PAVM and should be screened and treated for PAVMs when these reach a size that is associated with complications. In the detection of PAVMs, contrast echocardiography is a very sensitive method, and follow-up of these patients can be done with contrast echocardiography.

Nodal disease in purely glottic carcinoma: is elective neck treatment worthwhile?

OBJECTIVE

Although there is a generalized understanding of the relatively low overall incidence of nodal disease from purely glottic carcinoma, the exact role for elective neck treatment in the management of this disease remains controversial. The purpose of this study was to identify the incidence of occult nodal disease (including paratracheal) in patients who have glottic carcinoma without significant extraglottic extension and to identify which patients are at risk for this. A retrospective chart review of 92 such patients who had either undergone neck dissection or been observed for a minimum of 2 years was performed.

RESULTS

For the 92 patients, neck treatment consisted of observation in 68 patients, paratracheal node dissection in four, unilateral neck dissection in four, unilateral neck dissection and excision of paratracheal nodes in 14, and bilateral neck dissection with paratracheal node excision in two. Of the 24 nodal dissections performed, four were positive for occult metastatic disease. No patient in the observation group developed nodal disease.

CONCLUSION

The incidence of occult nodal disease in NO glottic carcinoma is low, 0% in early stage disease (T1-T2) and 19% in late stage disease (T3-T4). Nodes at highest risk included only the paratracheal, level II, and level III. Elective neck treatment should only be undertaken for advanced (T3-T4) disease and even then is of questionable benefit. If undertaken, it should have a low potential morbidity, such as selective neck dissection or radiation. Computed tomography was not useful in staging the neck for this subset of patients.

The Barath Cutting Balloon versus conventional angioplasty. A randomized study comparing acute success rate and frequency of late restenosis

In a randomized multicenter study initial success rate and 6 months' follow-up were compared between coronary angioplasty performed with the Barath Cutting Balloon (group A, n = 32) and conventional balloons (group B, n = 32) in patients with type A or B lesions in native coronary arteries. The culprit lesion was not reached in one patient in group A. Initial success rates were similar with and without additional stenting (8 in group A and 10 in group B). Angiographic follow-up data (in 95%) revealed a non-significant improvement in minimal lumen diameter, diameter stenosis in group A. Restenosis developed in 16.7% of group A vs 25.8% of group B, (p = 0.57). A separate analysis of stented patients showed no restenosis in group A and restenosis in 4 out of 10 patients in group B (p = 0.10). A possible beneficial effect of the Cutting Balloon with respect to in-stent restenosis requires further studies.

Multiple anomalies, hypokalaemic paralysis and partial symptomatic relief by terbutaline

In this paper a follow-up is presented of a case report initially described by Andersen in 1971. The patient presented with a syndrome including elements of familial periodic paralysis with hypokalaemia, long QT syndrome, ventricular ectopy, myopathy with fibre-type disproportion and dysmorphic features resembling Treacher Collins' syndrome. The main symptom was hypokalaemic paralysis. The episodes were accompanied by a lowered intracellular potassium content and an increase in intracellular sodium. Treatment with terbutaline, a Na/K-ATPase-stimulating drug, resulted in attack-free periods of approximately 9 months, after which the attacks reoccurred. The patient suffered severe attacks whenever treatment with terbutaline was stopped. The patient experienced two attacks of respiratory arrest, the second being fatal.

[Percutaneous transluminal embolization of pulmonary arteriovenous malformations]

A series of nine patients with pulmonary arteriovenous malformations (PAVM) treated with embolotherapy at Odense University Hospital is presented. In all patients the arterial oxygen tension increased after embolisation. PAVM causes right-to-left shunting, which may result in severe hypoxaemia, and, due to lack of the normal filter function of the lung, paradoxical embolism. Women are particularly at risk during pregnancy. Among patients with Hereditary Haemorrhagic Telangiectasia 15-33% also have PAVM. Embolotherapy is a safe and efficacious treatment for occlusion of PAVM. Since serious complications to the disease can be prevented, all HHT patients should be offered screening for PAVM, and treated if required.

Determination of tissue optical properties from diffuse reflectance profiles by multivariate calibration

We describe a method for determining the reduced scattering and absorption coefficients of turbid biological media from the spatially resolved diffuse reflectance. A Sugeno Fuzzy Inference System in conjunction with data preprocessing techniques is employed to perform multivariate calibration and prediction on reflectance data generated by Monte Carlo simulations. The preprocessing consists of either a principal component analysis or a new, extended curve-fitting procedure originating from diffusion theory. Prediction tests on reflectance data with absorption coefficients between 0.04 and 0.06 mm(-1) and reduced scattering coefficients between 0.45 and 0.99 mm(-1) show the root-mean-square error of this method to be 0.25% for both coefficients. With reference to practical applications, we also describe how the prediction accuracy is affected by using relative instead of absolute reflectance data, by imposing measurement noise on the reflectance data, and by changing the number and the position of detectors.

[Internal carotid artery stent]

Stent implantation is a well established treatment of vascular stenoses if the result after percutaneous transluminal angioplasty (PTA) is suboptimal, or as a primary treatment to reduce the number of restenoses. Carotid artery stents have only been used in a relatively limited number of cases up till now. The first Scandinavian case of a successful internal carotid artery stent implantation after suboptimal PTA with five months follow-up is presented.

Midline mandibular osteotomy: an analysis of functional outcomes

Although the oncologic validity and perioperative complications of midline mandibular osteotomy are well described, little attention has been directed toward the long-term functional problems that may be associated with its use. Thirty-one patients who had undergone this procedure were examined to assess postoperative sensation, temporomandibular joint (TMJ) function, occlusion, and cosmesis. The majority (27 of 31) patients had some sequelae but these were minor in nature. Twenty of 31 patients had abnormal sensation, 24 of 31 noted a changed occlusion, and 15 of 31 had signs or symptoms of TMJ myofascial pain. Although patients should be advised of the potential for functional problems with this procedure, they can be reassured that these are likely to be relatively minor in significance. If technically feasible and if an exact restoration of occlusion is a priority, a prefabricated lingual splint should be used.

Endovascular management of hemorrhage in patients with head and neck cancer

OBJECTIVE

To present selective endovascular embolization as a therapeutic alternative to surgical ligation in the management of hemorrhage in patients with head and neck squamous cell carcinoma.

DESIGN

Retrospective chart review of patients with head and neck cancer and significant hemorrhage who were treated with selective endovascular embolization.

SETTING

A university medical center.

PATIENTS

A total of 12 patients, aged 26 to 72 years, with 13 episodes of hemorrhage were treated at Oregon Health Sciences University, Portland, between November 1991 and January 1996.

INTERVENTION

All patients underwent angiography with selective endovascular embolization at the interventional radiology suite using a combination of endovascular balloons, platinum coils, and microparticles.

OUTCOME MEASURES

All charts were reviewed for diagnosis, treatment, factors that may have contributed to hemorrhage, bleeding site, therapeutic measures, control of hemorrhage, postembolization course, complications, and number of hospital days.

RESULTS

The cause of the bleeding was tumor in 5 patients, pharyngocutaneous fistula in 4 patients, radiation necrosis in 3 patients, and postoperative complication in 1 patient. Bleeding arose from the common carotid artery in 4 patients, external carotid artery and its branches in 8 patients, and internal jugular vein in 1 patient. Hemorrhage was successfully controlled in all patients; a permanent left-sided hemiplegia and facial weakness developed in 1 patient. There were no recurrences of hemorrhage. All patients were discharged from the hospital.

CONCLUSION

Angiography with selective embolization is a safe and effective alternative to surgical ligation for control of hemorrhage in patients with squamous cell carcinoma of the head and neck.

The extent of neck disease after regional failure during observation of the N0 neck

BACKGROUND

The optimum management of the N0 neck remains controversial. When the neck is observed it is hoped that close follow-up will detect regional failure at an early stage. To test this hypothesis we examined patients undergoing therapeutic neck dissection for newly developed neck metastases during observation after treatment of the primary tumor.

METHODS

A retrospective chart review of 47 patients undergoing neck dissection for regional failure after surgical treatment of the primary tumor and observation of the neck from 1987 to 1992 was performed. The median time to failure in the neck was 13 months.

RESULTS

The clinical neck stage at the time of neck dissection was N1 in 37, N2A in 6, N2B in 1, and N3 in 3. However, pathologic staging revealed stages of N1 in 19, N2A in 5, N2B in 20, and N3 in 3. Extracapsular spread (ECS) was present in 23 patients (49%). Overall 36 patients (77%) had adverse pathologic findings (N greater than 1 or ECS).

CONCLUSIONS

These data indicate that when observation is used for the neck at risk for metastasis, patients tend to fail with high stage disease in the neck. This supports the philosophy of elective treatment of the neck but cannot show whether elective treatment will improve survival.