Frequent novel DNA copy number increase in squamous cell head and neck tumors.

We have undertaken a study of DNA copy number changes in head and neck squamous cell carcinomas to identify novel DNA copy number changes and to determine the significance of previous findings of cytogenetic alterations in cultured cells. Comparative genomic hybridization was performed on genomic DNA extracted from ten tumors. A novel copy number gain on chromosome 3q26-27 and a loss of chromosome 3p were found at high frequency (> or = 50% of tumors). Many other novel chromosomal copy number changes were identified but occurred at a lower frequency. In addition, our data confirm that DNA copy number changes that frequently occur in cultured cells, such as loss of chromosome 3p, also occur in tumors. Frequently altered loci may encode oncogenes or tumor suppressor genes involved in head and neck squamous cell carcinoma tumorigenesis.

Contributors to violent behavior among elementary and middle school children.

OBJECTIVE: To examine the relative contributions of exposure to violence, parental monitoring, and television-viewing habits to children's self-reported violent behaviors. The study hypothesized that: 1) children's exposure to violence would be associated positively with self-reported violent behaviors; 2) parental monitoring would be associated negatively with children's violent behaviors; and 3) the number of daily television-viewing hours and a preference for watching violent television shows would be associated positively with children's violent behaviors. METHODS: The study used a survey design with an anonymous self-report questionnaire administered to students (grades 3-8) in 11 public schools. A total of 2245 students participated in the study, representing 80% of the students attending the participating schools during the survey. The subjects were from 7 to 15 years of age; 51% were male, 57% were white, 33% percent were black, and 5% were Hispanic. RESULTS: Hierarchical multiple regression analysis of the total sample revealed that the combination of demographic variables, parental monitoring, television-viewing habits, and exposure to violence explained 45% of students' self-reported violent behaviors. Violence exposure and parental monitoring were the most influential contributors in explaining children's violent behaviors, accounting for 24% and 5% of the variance in violent behaviors, respectively. CONCLUSIONS: All three hypotheses were supported. A significant association was demonstrated linking violence exposure, lack of parental monitoring, and television-viewing habits with children's self-reported violent behaviors within a diverse sample of elementary and middle school students. Our findings support the importance of parental monitoring of children and emphasize the need to identify and to provide services to youth who are exposed to violence.

The relationship between children's threats of violence and violent behaviors.

BACKGROUND: We sought to examine the relationship between students' threats of interpersonal violence and self-reported violent behaviors. METHODS: Anonymous self-report questionnaires were administered to students in grades 3 through 12 in schools located in Colorado, Arizona, and Ohio. A survey of 9487 students from 33 public schools was performed. Ages ranged from 7 to 19 years. Across the 3 samples, the percentage of African Americans ranged from 6% to 35%, whites from 31% to 57%, and Hispanics from 5% to 51%. RESULTS: Multivariate logistic regression analyses revealed that threatening others infrequently or frequently (compared with not threatening others) was significantly associated with violent behaviors. Students who infrequently threatened were about 3 to 4 times more likely to report exhibiting each of the violent behaviors than students who did not threaten others (odds ratio [OR] = 4.08-5.86). The relationship between frequently threatening others and violent behaviors was especially strong (OR = 7.19-24.30) and highest for the most severe forms of violence, knife attacks (OR = 15.39-24.30) and shootings (OR = 18.42). CONCLUSIONS: Findings suggest that students' threats of harm toward others should be taken seriously, and that policies and procedures should be developed to ensure that children who threaten others receive proper assessment and management. Arch Pediatr Adolesc Med. 2000;154:785-790

Violence exposure and emotional trauma as contributors to adolescents' violent behaviors.

OBJECTIVE: To investigate the degree to which violence exposure and symptoms of psychological trauma are related to adolescents' own violent behaviors. DESIGN AND SETTING: Anonymous self-report questionnaire administered to students in 6 public high schools (grades 9-12). PARTICIPANTS: Sixty-eight percent of the students attending the participating schools during the survey participated in the study (N=3735). Ages ranged from 14 to 19 years; 52% were female; and 35% were African American, 33% white, and 23% Hispanic. RESULTS: Multiple regression analysis determined that violence exposure and symptoms of psychological trauma together explained more than 50% of the variance in both male and female self-reported violent behavior. The independent effects of exposure to violence explained about one quarter of the variance in both male and female adolescents' violent behaviors. Anger was found to be the leading trauma symptom. CONCLUSION: Our findings suggest that health clinicians and other professionals who encounter adolescents should routinely screen them for both exposure to violence and symptoms of anger.

Microsurgical reconstruction of the midface.

OBJECTIVE: To establish a treatment algorithm for reconstructing complex midfacial defects. DESIGN: Retrospective case series. SETTING: University-based teaching hospital. PATIENTS: Thirty-one consecutive patients were treated from 1991 through 1995. The 18 males and 13 females were aged 15 to 90 years (mean age, 58 years). The cause of the defect included neoplasm (n = 27) and trauma (n = 4). Reconstruction consisted of 1 of 4 free flaps: rectus abdominis, radial forearm, fibula, or latissimus dorsi. Aesthetic and functional results were determined by patient questionnaires and physical examinations. MAIN OUTCOME MEASURES: Length of stay, postoperative morbidity and mortality, degree of aesthetic and functional restoration, and detection of tumor recurrence. RESULTS: Twenty-seven (87%) of the 31 patients underwent reconstruction with a single major procedure. All of the flaps survived. Postoperative hospital stays averaged 14 days. Late tumor recurrence occurred in 7 (23%) of the 31 patients and was promptly detected. Aesthetic and functional results were rated good or excellent in 77% (24/31) and 87% (27/31) of patients, respectively. Of the 20 patients who underwent alveolar ridge resection, 16 (80%) received dental rehabilitation, 44% of whom received osseointegrated implants into either a bone flap or remaining native bone. Osseointegrated implants were inset during the initial reconstruction 57% (4/7 patients) of the time. CONCLUSIONS: For complex midfacial defects, free-flap transfer can be performed with a high degree of success, restoring both appearance and function in most patients. The only instance in which bone is necessary to reconstruct the midface involves those areas in which osseointegrated implants are needed, ie, alveolar ridge (dental implant) and/or orbit (ocular prosthesis). In such cases, the fibula osteocutaneous free flap is the flap of choice. Otherwise, soft-tissue flaps are selected based on wound size.

Violence exposure, psychological trauma, and suicide risk in a community sample of dangerously violent adolescents.

OBJECTIVE: To examine violence exposure, violent behaviors, psychological trauma, and suicide risk in a community sample of dangerously violent adolescents by comparison with a matched community sample of nonviolent adolescents. METHOD: Anonymous self-report questionnaires were administered in the 1992-1993 school year to students in grades 9 through 12, in six public high schools located in Ohio and Colorado (N = 3,735). From this sample, 484 adolescents (349 males, 135 females) who reported attacking someone with a knife or shooting at someone within the past year (i.e., dangerously violent adolescents) were drawn. Four hundred eighty-four controls were also selected and matched on gender, age in years, ethnicity, area of residence, and family structure. RESULTS: Dangerously violent adolescents reported higher levels of exposure to violence and victimization than did matched controls. Dangerously violent females were more likely to score in the clinical range of depression, anxiety, posttraumatic stress, anger, and dissociation than were control females and violent males; they also had significantly higher levels of suicide potential. CONCLUSIONS: Students who have been known to commit violent acts should be adequately assessed for violence exposure and symptoms of psychological trauma, with special attention given to the suicide potential of violent females.

Viewing preferences, symptoms of psychological trauma, and violent behaviors among children who watch television.

OBJECTIVE: To examine the extent to which children's television-viewing practices are associated with symptoms of psychological trauma and aggressive behaviors. The following three hypotheses were tested: (1) children who report watching greater amounts of television per day will report higher levels of trauma symptoms than children who report lesser amounts of television viewing; (2) children who report watching greater amounts of television per day will report higher levels of violent behaviors than children who report watching lesser amounts of television per day; and (3) children who report a preference for action and fighting programs will report higher levels of violent behaviors than children who report a preference for other types of television programs. METHOD: The study used a survey design in which an anonymous self-report questionnaire was administered to students in grades 3 through 8 in 11 Ohio public schools during the 1995-1996 school year (N = 2,245). RESULTS: All three hypotheses were supported. CONCLUSION: Heavy television viewing by children may indicate the presence of problems such as depression, anxiety, and violent behaviors; such viewing should be screened for by psychiatrists and other mental health professionals working with children.

Clinical utility of positron emission tomography with 18F-fluorodeoxyglucose in detecting residual/recurrent squamous cell carcinoma of the head and neck.

PURPOSE: The use of positron emission tomography with 18F-fluorodeoxyglucose (FDG-PET) to detect residual/recurrent squamous cell carcinoma of the head and neck has been tested only in small groups of patients. Our purpose, therefore, was to evaluate the ability of this technique to detect the presence of tumor at both primary and nodal sites in a large cohort of patients. METHODS: All patients referred for PET scanning over a 2.5-year period with a question of residual or recurrent squamous cell carcinoma of the head and neck were identified. Thirty-five of 44 patients had sufficient follow-up to be meaningful to our analysis (range, 6-33 months). PET scans were interpreted visually with knowledge of the clinical history and correlative anatomic imaging findings. Detection of disease involving primary and nodal sites was assessed independently. Additionally, because each patient had been referred in an attempt to resolve a specific clinical problem, the usefulness of PET in accurately addressing these questions was assessed. RESULTS: At the primary site, sensitivity and specificity for residual/recurrent disease were 100% and 64%, respectively; for nodal disease, sensitivity and specificity were 93% and 77%, respectively. In helping to resolve the clinical question being asked, the positive predictive value of the test result was 65% and the negative predictive value was 91%. CONCLUSION: The high sensitivity and negative predictive value of PET scanning in our cohort of patients suggest an important role for this technique in the care of patients with suspected residual/recurrent head and neck carcinoma. The lower figures obtained for specificity and positive predictive value reflect the fact that increased FDG uptake may be due to either tumor or inflammation.

Long-term functional results after pharyngoesophageal reconstruction with the radial forearm free flap.

For recovery to be deemed adequate, the laryngectomized patient requires restoration of both the ability to swallow and to speak. Immediate results and long-term functional recovery after pharyngoesophageal (PE) reconstruction with the radial forearm free flap were studied in 22 consecutive patients who had undergone primary (n = 3) or secondary (n = 19) reconstructions after total laryngectomy. Circumferential reconstructions were done in 13 patients (mean length 10 cm, range 6 to 16) and patch reconstructions in 9 patients (defect size range 4 x 4 cm to 8 x 7 cm). Flap leakage was evaluated for all patients, and postoperative diet and ability to swallow were evaluated for 16 patients with an intact tongue base. Voice was evaluated for 6 patients with circumferential reconstructions who had later undergone tracheoesophageal puncture with placement of a Blom-Singer voice prosthesis, and the results compared with those of a control group of 5 voice-restored patients who had undergone laryngectomy with primary closure of the pharyngoesophagus. All 22 flaps survived and none of the patients died. Although 7 (32%) reconstructions leaked, all but 1 closed spontaneously. Fourteen (88%) of the patients with an intact tongue base have no dysphagia and are on a regular diet, and 2 remain on an oral liquid diet. Compared with controls, patients with a radial free-flap reconstruction had similar loudness with soft speech (43 dB for controls versus 52 dB for radial patients) and loud speech (61 dB versus 63 dB), comparable fundamental frequencies (136 Hz versus 125 Hz), and increased jitter (2% versus 5%). Speech intelligibility was judged by untrained listeners as excellent for 4 of the patients with radial flaps and good for the other 2. The radial free flap offers the advantages of rapid harvest, high flap reliability, and minimal donor-site and patient morbidity. Leakage rate and deglutition restoration were similar to those of other reconstructions, including the free jejunal flap. Speech rehabilitation in patients secondarily reconstructed with the radial free flap was nearly equivalent to that of total laryngectomy patients who have primary closure of the pharynx and was superior to that reported with other popular PE reconstructions, including the gastric pull-up and the free jejunal flap.

Tracheoesophageal speech: vocal rehabilitation after total laryngectomy.

Treatment of laryngeal cancer has evolved over nearly 100 years and includes many methods to conserve the function of speech. It was understood from the inception of total laryngectomy that diversion of exhaled pulmonary air into the pharynx or esophagus would produce satisfactory speech. The effect on safe deglutition of the phonatory fistulae limited the wide applicability of these techniques. The introduction of a silicone bivalve device for use in a tracheoesophageal tunnel permits large numbers of laryngectomees to use tracheoesophageal speech. Acoustic, intelligibility, and aerodynamic studies are described for four laryngectomees and reveal that this method more nearly approximates normal laryngeal speech than conventional esophageal speech. The criteria for contemporary treatment of laryngeal carcinoma are not altered by this rehabilitative method, and expected survival rates are not likely to be affected. The findings and analysis of this method of alaryngeal speech rehabilitation may have important implications for future therapy of laryngeal carcinoma.

Enhanced reliability and renewed applications of the deltopectoral flap in head and neck reconstruction.

Bakamjian introduced the deltopectoral skin flap in 1965, and thereafter it was used extensively for reconstructive surgery of the head and neck. Flap failure rates of 10% to 25% were reported, necessitating the development of alternative methods of reconstruction and eventually relegating the flap to historical references. Since 1991, we have used the deltopectoral flap in 24 patients for reconstruction after head and neck tumor surgery. Simple technical modifications have been used to enhance the reliability of this flap, with no observed failures or even partial flap loss. The deltopectoral flap remains a versatile and reliable tissue source that can be used simultaneously with the pectoralis major myocutaneous flap for a variety of complex head and neck reconstructions.

Experience with segmental reconstruction of the radiated mandible with alloplastic prostheses.

Reconstruction of the mandible after radiation therapy and segmental resection is often complicated by wound breakdown, osteoradionecrosis, and crippling of the oral cavity. These complications make patient salvage after radiated oral carcinoma a high-risk endeavor. Although head and neck surgeons have improved the reliability of mandibular reconstruction with microvascular free tissue transfer, medical and oncologic issues may prohibit their application. This report presents 12 selected cases undergoing alloplastic reconstruction of the mandible and soft tissue reconstruction of the oral cavity. Although not as reliable as some reports of free tissue transfers, the results were reproducible and satisfactory in these cases, with time-efficient hospitalization and functional rehabilitation. Ten of 12 prosthetic reconstructions have been durable in this study population for as long as 36 months.

Restoration of the airway following bilateral recurrent laryngeal nerve paralysis.

Bilateral recurrent laryngeal nerve paralysis has been treated by a number of ingenious techniques that include arytenoidectomies, vocal cord lateralizations, cordectomies, and, recently, reinnervation procedures and laser arytenoidectomies. An arytenoidectomy is recommended by a thyrotomy approach without lateralization of the vocal cord. The resulting airway is adequate for decannulation by expansion of the posterior glottic aperture, with preservation of the anterior glottis for phonation.

Heterotopic salivary tissue in the neck.

Six cases of heterotopic salivary gland tissue in the anterolateral neck are presented with a review of their clinical and histopathologic characteristics. Neoplastic transformation, fistulization, and isolated rests represent a spectrum of these uncommon lesions. The embryologic derivation of salivary tissue and close association with the branchial apparatus are discussed. The significance of salivary carcinoma presenting in the neck is reinterpreted in light of the embryogenesis of these heterotopias.

Congenital fibrosarcoma in the oral cavity. First reported case.

Fibrosarcoma is uncommon in the head and neck and constitutes less than 1% of malignancies and approximately 6% of the soft tissue sarcomas. Congenital fibrosarcomas are characterized by rapid proliferation and frequent local recurrence following excision. Unlike other sarcomas, metastasis is a rare event. The literature contains less than 50 cases of congenital, solitary fibrosarcoma, with none occurring in the oral cavity. This paper describes a unique case of fibrosarcoma in the oral cavity of a neonate. A 12 month follow-up is provided with an analysis of the histopathology including electron microscopy. The spectrum of fibroproliferative lesions in the pediatric patient is reviewed, and the evaluation and treatment modalities applicable to this age group are outlined.

Pharyngeal plexus neurectomy for alaryngeal speech rehabilitation.

Pharyngeal constrictor and cricopharyngeal spasm have been implicated as deterrants to esophageal speech acquisition as well as tracheoesophageal phonation. Recent efforts to reduce the resultant hypertonicity include pharyngeal constrictor myotomies and modifications of pharyngeal reconstruction during laryngectomy. Investigation of the innervation of the muscular wall of the pharynx led to the development of a pharyngeal plexus neurectomy technique to alter the tonicity of the pharynx without myotomy. The resultant alaryngeal speech is fluent, and acoustic parameters compare favorably to esophageal speech.

Sternocleidomastoid myocutaneous flap.

The sternocleidomastoid myocutaneous flap has several applications for reconstruction of defects about the head and neck. It is used for augmentation of facial defects, carotid artery protection, and repair of oral cavity defects. Additional reconstructive efforts suggest the sternocleidomastoid myocutaneous flap can be used for facial reanimation and as an osteomyocutaneous flap incorporating the clavicle for mandibular reconstruction. Reports of unreliable viability and resection of the sternocleidomastoid muscle during neck dissection decreases the applicability of the flap. Twenty-seven sternocleidomastoid flaps were used in 26 patients for head and neck reconstruction. In contrast to the reported 40% to 50% incidence of superficial slough or total flap necrosis, three (11%) flaps developed superficial (cutaneous) slough while two patients developed inclusion cysts. The technique includes elevation of the sternocleidomastoid muscle with the overlying platysma and skin originally described by Owens. The procedure is modified by removing the epithelium on the tunneled portion of the flap. This allows the flap to be used as a one-stage method of reconstruction without sacrificing the additional blood supply from the platysma and overlying dermis.

Transmucosal fine-needle aspiration diagnosis of intraoral and intrapharyngeal lesions.

OBJECTIVES: The effectiveness of fine-needle aspiration biopsy (FNAB) for the diagnosis of neck, thyroid, and salivary gland masses is well documented. Very few reports explore the potential of an intraoral FNAB approach for the diagnosis of submucosal lesions. We describe our technique and present case examples of pertinent differential diagnostic entities. We recommend an expanded role for FNAB of the oral cavity and oropharynx. STUDY DESIGN: Retrospective review. METHODS: A uniform technique was employed for transmucosal FNAB of 76 patients with intraoral masses. In applicable cases, cytology results were compared with traditional biopsy methods and permanent histopathologic specimens for accuracy. RESULTS: Our experience demonstrates the high sensitivity (93%) and specificity (86%) of intraoral FNAB when compared with biopsy by conventional means. FNAB provides distinct advantages for the cytologic diagnosis of submucosal lesions, which may be difficult to reach and adequately sample through conventional biopsy. FNAB of the tonsil and tonsillar fossa provides a safe and effective means of diagnosing both lymphoma and squamous cell cancer. Transmucosal FNAB via the mouth led to rapid diagnosis of a number of benign and malignant lesions. Applying this uniform FNAB technique, we had no significant complications. CONCLUSION: We recommend transmucosal FNAB as an effective means for highly accurate diagnosis of submucosal lesions of the oral cavity and oropharynx. CLINICAL RELEVANCE: Traditional biopsy techniques in the oral cavity may require anesthesia and may have diagnostic difficulties, particularly for submucosal lesions. Transmucosal FNAB overcomes these shortcomings by providing a minimally invasive means to rapid diagnosis of intraoral lesions.

Alloplastic and microvascular restoration of the mandible: a comparison study.

The evolution of mandibular reconstruction following composite resection is advanced by improved alloplastic prosthesis and reliable microvascular free tissue transfers. A 42-case, 6-year experience is presented using both methods at the University of California, San Francisco. The advantages and complications of both are discussed. The authors conclude that the success rate for lateral defect restoration is equivalent with either technique, and that the anterior defects are more reliably reconstructed with free tissue transfer. The advantage of microvascular flaps in the anterior defect must be gauged against the physical status of the patient, disease extent, and likelihood of dental rehabilitation by interosseous fixation.

Total laryngectomy and reconstruction of a pseudoglottis: problems and complications.

A modified procedure for the reconstruction of a pseudoglottis after total laryngectomy is examined. The history of this technique, including our experience, is reviewed with emphasis on problems and complications. Indications and justifications for surgery are discussed. Though we can only speculate on the basis of a few cases, we believe that a good voice can be obtained when a pseudoglottis is either primarily or secondarily constructed after laryngectomy. We acknowledge that perhaps the risk of liability tempers our approach and restricts our case selection which, no doubt, in part accounts for our modification of the procedure that was initially performed in Europe. We believe that continued careful application of this technique and its variations will improve the results of modern laryngeal surgery.