odontogenic keratocyst (OKC) is considered a benign cyst that can assume a locally aggressive and destructive behavior. Atypia of its lining is uncommon, and frank malignant degeneration is rare. Presence of these changes may remain clinically undetected and carry a significant influence on treatment and outcome. A patient with OKC of the maxilla containing both verrucous carcinoma and squamous cell carcinoma (SCC) is presented. Literature is reviewed pertaining to the malignant potential of an OKC. CASE REPORTA 46-year-old man was initially seen with fullness and discomfort in his right anterior maxilla in August 1991. He had been unable to wear his maxillary partial denture for the preceding 6 months. Examination disclosed the presence of a 2-by 2-cm mass in the right anterior maxilla, with no changes in the overlying mucosa. Dental radiographs demonstrated a well-circumscribed radiolucency surrounding the apexes of the maxillary central incisors (Fig. 1). Curettage of the lesion was performed by an oral surgeon. Histopathology of the curetted material was confirmed to contain verrucous carcinoma with coexistent synchronous SCC.At the time of referral to us (September 1991), the patient's physical examination revealed a well-healed mucosal scar without detectable residual mass. Computed tomographic scans showed a smooth cystic bony defect with a small amount of fluid within the maxillary sinus. A partial maxillectomy and a nasal septectomy were subsequently performed. Resected margins were considered free of tumor. Histologic examination of the material was reviewed by Dr. John Batsakis of M. D.

Competency to Stand Trial or Fitness to Stand Trial (FST) is the most frequent referral issue facing forensic mental health professionals (FMHPs) and consumes considerable scarce resources in the process. This article summarizes minimalist and expanded legal approaches to FST and briefly describes three instruments developed by FMHPs to structure FST assessments. We then present evidence supporting the validity of the Nussbaum Fitness Questionnaire for efficiently screening individuals for fitness and blatant or subtle malingering. The paper ends with a number of suggestions to optimize use of these instruments within the current set of forensic mental health practices. Specifically, it is suggested that use of the screening instrument could reliably eliminate up to 70% of current referrals for complete assessments while the more in-depth semistructured interviews be utilized to confirm unfitness, especially when the mental health professional has more than trivial doubt regarding an individual's FST. [Brief Treatment and Crisis Intervention 8:43-72 (2008)]

The odontogenic keratocyst (OKC) is a locally aggressive neoplasm with rates of recurrence reported as high as 60%. Correlation between histopathology and the likelihood of recurrence remains a subject of controversy. In this review of the authors' experience in treating 50 patients with OKC between 1977 and 1993, 58 specimens were studied to correlate the likelihood of recurrence with the presence of the following histologic features--parakeratosis, orthokeratosis, satellite cysts, epithelial rests, or epithelial proliferation. Orthokeratinized cysts were associated with a higher recurrence rate than in previously reported studies. Disruption of the epithelial lining in the resected specimen was found to be a primary determinant of recurrence.

Magnetic resonance (MR) imaging is commonly used in the followup of patients who have undergone surgical removal of tumors from the cranial base to assess the possibility of tumor recurrence, persistence, or surgical complications. Interpretations of this study must be cautious because postoperative enhanced signals are encountered frequently. Although technological improvements continue to enhance the usefulness of MR images for followup, problems remain in differentiating between fibrotic, reconstructive changes, and tumor recurrence. In this study, the hospital records and MR findings of 215 patients who had undergone skull base surgery were reviewed. The study was prompted by negative operative exploration in three patients in whom postoperative MR images strongly suggested tumor recurrence. One-year follow-up images were available in 174 patients. Of these, 94% showed signal enhancement on the 1-year follow-up study. Progressive changes were observed in 14% of patients. The correlation of preoperative MR findings and surgery, with regard to dural involvement, vascular involvement, cranial nerve infiltration, and extent of intracranial infiltration, was analyzed in 28 patients. Methods to facilitate the detection of tumor recurrence using MR images are reviewed.

Injuries from cocaine abuse are often seen and have been reported more often with the introduction of crack cocaine. Burns of the upper aerodigestive tract have been reported but no reports of esophageal obstruction have been located. We report ingestion of a foreign body from smoking crack cocaine and our management. A review of other possible aspiration and ingestion injuries is included.