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Cricopharyngeal spasm and Zenker's diverticulum represent disorders of the pharyngoesophageal junction for which a unifying theory of etiology has yet to be established. There is, however, a large body of evidence that supports an association with gastroesophageal reflux. Cricopharyngeal myotomy is the key to successful management of both disorders. Newer transoral endoscopic techniques of management have a lower overall morbidity than traditional open approaches in appropriately selected patients and are therefore gaining popularity as the preferred method of treatment., (Copyright 2003 Wiley Periodicals, Inc.)

Microinterferometric backscatter detection (MIBD) has previously been shown capable of measuring changes in the refractive index of liquids on the order of 10(-7). The MIBD technique is based on interference of laser light after it is reflected from different regions in a capillary. These reflections generate an interference pattern that moves upon changing refractive index of the liquid in the capillary. The small-angle interference pattern traditionally considered has a repetition frequency in the refractive index space that limits the ability to measure refractive index-to-refractive index changes causing such a repetition. Such refractive index changes are typically on the order of three decades. Recent modeling and experiments with the MIBD technique have shown that other intensity variations in the pattern are present for larger backscattered angles. By considering these variations, we have shown two methods by which it is possible to extend the dynamic measurement range to make an absolute refractive index measurement. One method utilizes variations in the Fresnel coefficients while the second approach is based on the refractive index-dependent onset of total internal reflection angles. With the second approach, we have been able to measure the absolute refractive index of a liquid with a precision of 2.5 x 10(-4).

Optical coherence tomography (OCT) is a novel technique for two and three-dimensional imaging of tissues at a histological level. The technique is based on optical technology and commercially available fiber-optic components that may be adapted for use in conventional endoscopes or intravascular catheters. OCT is a non-invasive technique, which does not utilize ionizing radiation, and it may within a few seconds provide in vivo images ("optical biopsies") of tissues in cases where excisional biopsy is hazardous or impossible, or when repeated examinations are required. OCT has numerous potential clinical applications, and the technique is currently used in ophthalmology, where it may improve diagnosis and therapeutic control of various eye diseases. Detection and characterization of skin tumors and other dermatological diseases is another area where OCT has tremendous clinical potential. In the field of cardiology, intravascular OCT may be capable to contribute to early diagnosis of vulnerable atherosclerotic lesions. The OCT technique is also being developed in other clinical areas and is expected to become integrated in a range of clinical situations in the future.

Objective: We examined staff utilization and procedure length for percutaneous and open bedside tracheostomies in an intensive care setting., Study Design: Prospective clinical outcomes study., Methods: Intensive care unit (ICU) tracheostomy consults meeting criteria for bedside procedures were randomized to open or percutaneous procedures. The Cook percutaneous kit and a prepackaged tracheostomy tray were used. ICU nursing and respiratory therapy staff was present for all procedures. The total resident time, staff time, and procedure length were recorded. Twelve patients underwent percutaneous tracheostomy, and 12 received an open tracheostomy., Results: An operating room nurse was present for 7 of the open procedures. Ancillary medical staff was present for 3 open tracheostomies: anesthesia for 2 and critical care for 1. Ancillary medical staff was present for 4 percutaneous tracheostomies: anesthesia staff for 1 and critical care for 3. The average resident presence, staff presence, and procedure length for open tracheostomies were 47, 30, and 12 minutes, respectively. For percutaneous tracheostomies, the times were 39, 29, and 12 minutes, respectively. One intraoperative complication occurred during a percutaneous procedure and 2 perioperative complications occurred: 1 in the open group and 1 in the percutaneous group., Conclusions: There was no significant difference in procedure length, resident time, or staff time between the 2 procedures. Ancillary staff was occasionally used but was not thought to be necessary for the majority of procedures. Both procedures can be safely and expediently performed in the ICU.

Objective: The radial forearm free flap has become the method of choice for reconstruction of head and neck defects following oncologic ablation. Harvesting of a radial forearm free flap leaves a donor site defect. This is most commonly closed with a split-thickness skin graft. Morbidity, most commonly owing to a lack of graft take over the tendons, can be quite high. Recently, an acellular matrix (Alloderm) has been advocated to decrease complications at the radial forearm donor site, as well as obviate taking a split-thickness skin graft from the thigh., Material and Methods: Tertiary referral academic centre. Retrospective chart review of 15 patients. Five patients received allogenic dermis, 10 patients received split-thickness skin grafting to the radial forearm donor site., Results: Patients with allogenic dermis took between 12 and 16 weeks to heal completely. Patients undergoing split-thickness skin graft were completely healed within 4 to 6 weeks. Cosmesis was judged to be marginally better in the allogenic dermis group. Allogenic dermis placement had a greater impact on hand function owing to prolonged healing, whereas patients with split-thickness skin graft required wound care at the thigh for a 2- to 3-week period owing to the harvesting of the skin graft., Conclusions: Allogenic dermis may be a viable alternative to split-thickness skin grafting and radial forearm free flap donor sites. Prolonged healing with subsequent increased health care services use needs to be addressed.

Objectives/hypothesis: The radial forearm fasciocutaneous free flap has become the reconstructive tissue of choice for the majority of soft tissue defects in the head and neck. The forearm skin has many of the ideal soft tissue characteristics that optimize reconstruction and rehabilitation in these patients. The tissue is malleable, supple, and moldable in three dimensions; has a reliable pedicle; and can be harvested with a two-team approach. In some patients, the radial forearm cannot be used. An alternative is to use the adjacent tissue, which shares identical tissue characteristics. This tissue gets its vascular supply from the ulnar artery. The purpose of the report was to describe the authors' experience with the ulnar fasciocutaneous free flap in head and neck reconstruction., Study Design: Prospective consecutive case series., Methods: Retrospective review of all patients undergoing ulnar fasciocutaneous free tissue transfer by a group of microvascular surgeons was performed. Thirty patients underwent free tissue transfer using the ulnar fasciocutaneous free flap. The male-to-female ratio was 3:1., Results: Defects were located in the oral cavity (14), oropharynx (12), neck skin (1), and soft tissue of the lateral skull (3). The average size of the skin paddle that was transferred was 7 x 10 cm (range, 3 x 5 to 9 x 12 cm). The mean area of tissue that was transferred was 70 cm2 (range, 15-108 cm2). Vessel sizes were somewhat smaller than the comparable radial forearm. One patient had complete loss of the skin graft on the donor site. There were no median nerve or other wound-healing problems. Two flaps were lost in the postoperative period. Indications for use of the ulnar fasciocutaneous free flap were failed Allen's test (23), use of a less hairy part of the forearm (3), and surgical preference (4)., Conclusions: The ulnar fasciocutaneous free flap has all of the tissue characteristics of the radial forearm flap. When a radial forearm flap cannot be used and forearm skin is desired, consideration of an ulnar fasciocutaneous free flap should be undertaken.

Introduction: First bite syndrome (FBS) is the development of pain in the parotid region after the first bite of each meal and can be seen after surgery of the parapharyngeal space. The cause is not clear but has been proposed to involve a loss of sympathetic nerve function to the parotid, causing a denervation supersensitivity of salivary gland myoepithelial cells. The purpose of this study was to review the records of 12 patients with FBS to determine any common features of the operations performed that would support this theory of parotid "sympathectomy" as an etiologic factor of FBS., Methods: Retrospective review of 12 patients with FBS managed at two tertiary care centers., Results: Twelve patients were diagnosed with FBS after surgery involving the parapharyngeal space. All patients had most of their parotid gland preserved. Six patients exhibited a postoperative Horner's syndrome, suggesting sympathetic chain interruption. The six patients without Horner's syndrome were found to have undergone external carotid artery ligation inferior to the parotid gland, suggesting an interruption of sympathetic innervation to the parotid gland itself., Conclusions: Preservation of parotid gland tissue and a loss of its sympathetic nerve supply, whether by disruption of the cervical sympathetic chain as evidenced by a Horner's syndrome or more selective denervation by ligation of the external carotid artery with its accompanying sympathetic nerve plexus, were common features of all patients. This series supports the concept of parotid "sympathectomy" as an etiologic factor in FBS., (Copyright 2002 Wiley Periodicals, Inc.)

A Monte Carlo (MC) method for modeling optical coherence tomography (OCT) measurements of a diffusely reflecting discontinuity embedded in a scattering medium is presented. For the first time to the authors' knowledge it is shown analytically that the applicability of an MC approach to this optical geometry is firmly justified, because, as we show, in the conjugate image plane the field reflected from the sample is delta-correlated from which it follows that the heterodyne signal is calculated from the intensity distribution only. This is not a trivial result because, in general, the light from the sample will have a finite spatial coherence that cannot be accounted for by MC simulation. To estimate this intensity distribution adequately we have developed a novel method for modeling a focused Gaussian beam in MC simulation. This approach is valid for a softly as well as for a strongly focused beam, and it is shown that in free space the full three-dimensional intensity distribution of a Gaussian beam is obtained. The OCT signal and the intensity distribution in a scattering medium have been obtained for several geometries with the suggested MC method; when this model and a recently published analytical model based on the extended Huygens-Fresnel principle are compared, excellent agreement is found.

Background: Although increasingly accepted in treatment of the N0 neck, use of selective neck dissection in patients with node-positive squamous cell carcinoma of the head and neck remains controversial., Objective: To determine the oncologic efficacy of selective node dissection in patients with node-positive squamous carcinoma of the head and neck., Setting: Three tertiary care academic/Veterans Affairs medical centers., Methods: Ten-year retrospective medical chart review of 106 previously untreated clinically and pathologically node-positive patients undergoing 129 selective neck dissections and followed for a minimum of 2 years or until patient death., Results: Regional metastasis was clinically staged as N1 in 58 patients (54.7%), N2a in 5 (4.7%), N2b in 28 (26.4%), N2c in 14 (13.2%), and N3 in 1 (0.9%). Extracapsular extension of tumor was present in 36 patients (34.0%), and postoperative radiation therapy was administered to 76 patients (71.7%). Overall, 9 patients experienced disease recurrence in the neck. Six of these recurrences were in the side of the neck that had undergone selective neck dissection, for a regional control rate of 94.3%., Conclusions: These results support the use of selective neck dissection in carefully selected patients with clinically node-positive squamous cell carcinoma of the head and neck region. Regional control rates comparable to those achieved with comprehensive operations can be achieved in appropriately selected patients.

The osteopetroses are a heterogeneous group of genetic conditions characterized by increased bone density due to impaired bone resorption by osteoclasts. Within the autosomal dominant form of osteopetrosis, the radiological type I (ADOI) is characterized by a generalized osteosclerosis, most pronounced at the cranial vault. The patients are often asymptomatic but some suffer from pain and hearing loss. ADOI is the only type of osteopetrosis not associated with an increased fracture rate. Linkage analysis in two families with ADOI from Danish origin enabled us to assign the disease-causing gene to chromosome 11q12-13. A summated maximum lod score of +6.54 was obtained with marker D11S1889 and key recombinants allowed delineation of a candidate region of 6.6 cM between markers D11S1765 and D11S4113. Previously, genes causing other conditions with abnormal bone density have been identified from this chromosomal region. The TCIRG1 gene was shown to underly autosomal recessive osteopetrosis (ARO), and, recently, mutations in the LRP5 gene were found both in the osteoporosis-pseudoglioma syndrome and the high bone mass trait. Because both genes map within the candidate region for ADOI, it can not be excluded that ADOI is caused by mutations in either the TCIRG1 or the LRP5 gene.

Background: Atelectasis is one of the most common postoperative complications encountered in head and neck surgery. Risk factors include preexisting pulmonary disease, the procedure performed, and the length of anesthetic. Regional flaps used to reconstruct defects in the head and neck predispose to radiographic atelectasis. The rectus abdominis myocutaneous flap is usually transferred as a free tissue transfer. Harvesting the flap results in abdominal wall pain and postoperative splinting that may contribute to an increased development of atelectasis. To our knowledge, this issue has not been previously examined., Design: Retrospective review., Results: Fifty-three patients underwent rectus abdominis myocutaneous free flap reconstruction following major ablative procedures for head and neck cancer. The flap size ranged from 5 x 7 to 25 x 27 cm. Most flaps were 8 x 15 cm. The cutaneous area transferred ranged from 35 to 600 cm(2) (mean, 120 cm(2)). These patients were compared with a group of 53 patients who were matched for age, sex, length of the procedure, and stage of disease. Postoperative atelectasis was radiographically detected in 37 (70%) of the patients who underwent rectus abdominis myocutaneous free flap reconstruction vs 41 (77%) of the controls. Major atelectasis was not encountered in any patient in either group. Patients with a larger cutaneous paddle (>120 cm(2)) had a higher atelectasis score than patients with smaller cutaneous paddles (< or =120 cm(2)) (P =.02)., Conclusions: The incidence of radiographic postoperative atelectasis in patients undergoing rectus abdominis myocutaneous free tissue transfer is high. The degree of atelectasis is small, and the clinical correlation and relevance are minimal.

Background: This work was done to determine whether the slope of change between preoperative and early postoperative (2 hr and 8 hr) ionized calcium levels (ciCa) could predict significant postoperative hypocalcemia., Methods: We did a retrospective chart review of 79 patients undergoing thyroid (n = 56) or parathyroid surgery (n = 23) where overall parathyroid function was felt to be at risk. Results/Conclusions A positive slope between the preoperative ciCa and any postoperative ciCa or the first two postoperative ciCa's predicted normocalcemia in 100% of patients. For the thyroid group, the difference in the slope of the change from preoperative ciCa to first (<2 hours) postoperative ciCa (-15.940%/hours vs -9.375%/hours, p =.082) did not differentiate patients who developed hypocalcemia (n = 11) and those who remained normocalcemic (n = 45). By contrast the slope of change from preoperative ciCa to the second postoperative (8 hr) ciCa (-1.671%/ hour vs -0.849%/hours, p =.006) and first to second postoperative ciCa (-1.022%/hour vs -0.473%/hour, p =.001) did. For the parathyroid group, none of the differences in similar comparisons between the normocalcemic (n = 20) and hypocalcemic patients (n = 3) approached statistical significance. The relatively small number of patients who became hypocalcemic in this study precluded definition of an absolute slope of calcium level change above which normocalcemia can be assured., (Copyright 2002 John Wiley & Sons, Inc.)

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 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.

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 (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.

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.

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.

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.

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

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.

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.

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.

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.

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.

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.

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.

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.

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.

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.

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.

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.

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.

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.

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.

Objective: To assess the oncologic effectiveness of the selective neck dissection (SND) in patients with both clinically and pathologically proven regional metastases., Methods: A 4-year retrospective medical chart review was conducted in an academic tertiary care referral center. Twenty-nine patients with a newly diagnosed upper aerodigestive tract squamous cell carcinoma, and both clinically and histologically proven cervical metastases who underwent 36 SND, had their records reviewed. Minimum follow-up was 2 years., Results: Regional metastasis were staged N1 in 13 patients, N2A in 1, N2B in 8, and N2C in 7. Seventeen supraomohyoid and 19 lateral neck dissections were performed. Extracapsular spread of tumor was present in 11 patients. Postoperative radiation therapy was administered to 20 patients. Actuarial disease-specific survival at 4 years was 47% overall, 67% in N1 patients, and 41% in N2 patients. Only 1 failure in the treated neck occurred for a 4-year actuarial regional failure rate of 4%. The actuarial local failure and distant metastasis rate were 36% each., Conclusions: In carefully selected patients with clinically and histologically apparent regional metastases, the selective neck dissection can be an oncologically effective procedure.

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.

A 47-year-old female patient underwent surgical correction of a recently diagnosed anomalous left coronary artery. The artery originated from the pulmonary artery, and the patient had suffered from pulmonary hypertension and congestive heart failure. The follow-up after 3 and 6 months showed only slight improvement in the patient's condition.

Various alternative conduits for aortocoronary bypass grafting have been suggested when the saphenous vein quality is inadequate. During a 10-year period we have used the cephalic vein in 39 patients. Eighteen entered an angiographic follow-up study. A total of 31 arm vein grafts were used with 43 distal anastomoses. When calculating patency by number of patent distal anastomoses, this was 46% (median follow-up was 31 months), but calculating by the number of patent grafts we found 52% patency (median follow-up 31 months). In conclusion, we discourage others from using arm veins in aortocoronary bypass operations.

Background: We have analyzed our experience with differentiated thyroid cancer patients with extrathyroidal extension (ETE) to investigate patterns of recurrence and define factors that predict failure., Patients and Methods: The records of 1,012 patients treated surgically from 1930 to 1985 were reviewed. A total of 79 patients (8%) had ETE. The median length of follow-up was 10 years., Results: Patients with ETE were more likely to fail treatment and to die of their disease than were patients without ETE (77% versus 34% and 71% versus 13%, respectively; P < 0.0001). Local, regional, and distant failures were more prominent among patients with ETE than among those without ETE (48% versus 9%, 41% versus 16%, and 37% versus 11% respectively; P < 0.0001). Survival of patients with ETE was adversely affected by nonpapillary histology, distant metastasis, age > 45, tumor size > 4 cm, and incomplete excision (P < or = 0.05). After stratification for age, survival in older patients was not affected by tumor size or incomplete excision, while in younger patients tumor size or the presence of distant metastasis did not adversely affect survival. Patients younger than 45 with negative margins had similar survival to patients without ETE (P = 0.46)., Conclusions: Patients with ETE are more likely to die of their disease and to fail at all sites. Survival in older patients was not affected by incomplete excision while it was in younger patients. The presence of distant metastasis did not affect survival in younger patients. Our results suggest that among patients under 45, the presence of ETE does not adversely impact upon survival when the primary tumor is completely resected.