Stromal features are predictive of disease mortality in oral cancer patients.

Worldwide, approximately 405 000 cases of oral cancer (OSCC) are diagnosed each year, with a rising incidence in many countries. Despite advances in surgery and radiotherapy, which remain the standard treatment options, the mortality rate has remained largely unchanged for decades, with a 5-year survival rate of around 50%. OSCC is a heterogeneous disease, staged currently using the TNM classification, supplemented with pathological information from the primary tumour and loco-regional lymph nodes. Although patients with advanced disease show reduced survival, there is no single pathological or molecular feature that identifies aggressive, early-stage tumours. We retrospectively analysed 282 OSCC patients for disease mortality, related to clinical, pathological, and molecular features based on our previous functional studies [EGFR, αvß6 integrin, smooth muscle actin (SMA), p53, p16, EP4]. We found that the strongest independent risk factor of early OSCC death was a feature of stroma rather than tumour cells. After adjusting for all factors, high stromal SMA expression, indicating myofibroblast transdifferentiation, produced the highest hazard ratio (3.06, 95% CI 1.65-5.66) and likelihood ratio (3.6; detection rate: false positive rate) of any feature examined, and was strongly associated with mortality, regardless of disease stage. Functional assays showed that OSCC cells can modulate myofibroblast transdifferentiation through αvß6-dependent TGF-ß1 activation and that myofibroblasts promote OSCC invasion. Finally, we developed a prognostic model using Cox regression with backward elimination; only SMA expression, metastasis, cohesion, and age were significant. This model was independently validated on a patient subset (detection rate 70%; false positive rate 20%; ROC analysis 77%, p < 0.001). Our study highlights the limited prognostic value of TNM staging and suggests that an SMA-positive, myofibroblastic stroma is the strongest predictor of OSCC mortality. Whether used independently or as part of a prognostic model, SMA identifies a significant group of patients with aggressive tumours, regardless of disease stage.

CO2 laser of oral dysplasia: clinicopathological features of recurrence and malignant transformation.

The use of the CO(2) laser in the management of oral dysplastic lesions has become a more common practice. Very few studies have evaluated recurrence, residual disease malignant transformation, and overall outcome in patients undergoing such a procedure. In this prospective study, a total of 123 oral dysplastic lesions from 77 consecutive patients were treated with the CO(2) laser (resection and/or ablation). The average age was 58 ± 4.8 years. The patients' recovery was uneventful and no complications were reported. Comparisons with the clinical and histopathological features and rate of recurrence as well as malignant transformation were made. The patients were followed-up for a mean of 6.4 years, and biopsies taken in case of changes suggestive of malignant development. Homogenous leukoplakias were identified in 31 patients, non-homogenous leukoplakias in 34 patients, whereas 12 patients had erythroplakias. Ex- and life-long smokers formed 88.3% of the recruited patients. While people who currently smoke and drink formed 55.8% of the cohort. Erythroplakias were solely identified in heavy life-long smokers. The most common identified primary anatomical locations were the lateral border of tongue, floor of mouth, and buccal mucosa. Moderate dysplasia was identified in 42 patients while 18 patients had severe dysplasia. Laser resection margins in selected cases (68 patients) were clear in 53 and showed mild-moderate dysplasia in the involved margins. The rate of recurrence had no significant association with the location but the severity of epithelial dysplasia. The rate of first recurrence after laser surgery was approximately 19.5%. Malignant transformation was observed in eight patients (10.4%), in the tongue and the floor of mouth. Recurrence and malignant transformation was mainly identified in erythroplakias and non-homogenous leukoplakias. Laser resection/ablation is recommended for oral dysplasia to prevent not only recurrence and malignant transformation but also postoperative oral dysfunction encountered by other conventional modalities.

Photodynamic therapy outcome for T1/T2 N0 oral squamous cell carcinoma.

INTRODUCTION: This new prospective clinical study assessed the oncological outcomes following surface illumination mTHPC-photodynamic therapy of T1/T2 N0 oral squamous cell carcinoma (OSCC) patients. MATERIAL/METHODS: Thirty-eight patients participated in this study. Their mean age at the first diagnosis of OSCC was 58.0 years. Common clinical presentation was an ulcer mainly identified in the tongue, floor of mouth (FOM), or buccal mucosa. Current and ex-smokers represented 89.5% of the cohort; while current and ex-drinkers were 86.8%. Clinically nine patients had T1 disease while 29 had T2 disease. RESULTS: Pathological analysis revealed that 12 patients had well differentiated SCC, 16 moderately differentiated and 10 had poorly-differentiated cancer. All patients were discussed in a multidisciplinary meeting and, subsequently, underwent mTHPC-PDT. PDT was repeated in 6- to 7-month period following the first round when residual tumor was identified in the treated site. At last clinic review post-PDT, 26/38 patients showed complete normal clinical appearance of their oral mucosa in the primary tumor site. Recent surgical biopsies from the study cohort showed that 17 had normal mucosa, five with hyperkeratinization, 10 with dysplastic changes and six showed recurrent SCC. The overall recurrence was 15.8% and the 5-year survival was 84.2%. Death from loco-regional and distant disease spread was identified in three patients. The recurrence group comprised six patients. Most common presentation was an ulcer involving the buccal mucosa or retromolar area, identified in current or ex-smokers and current drinkers. The surgical margins in this group were also evaluated following laser or surgical excision and reconstruction. CONCLUSIONS: mTHPC-photodynamic therapy (up to three rounds) is a comparable modality to other traditional interventions in the management of low-risk tumors of the oral cavity. Although, sometimes, multiple rounds of the treatment is required, morbidity following PDT is far less when compared to the three conventional modalities: surgery, radiotherapy, and chemotherapy.

Photodynamic therapy outcome for oral dysplasia.

INTRODUCTION: Photodynamic therapy (PDT) is a minimally invasive surgical intervention used in the management of tissue disorders. It can be applied before, or after, any of the conventional modalities, without compromising these treatments or being compromised itself. MATERIALS AND METHODS: In this prospective study, a total of 147 consecutive patients with oral potentially malignant disorders were treated with surface illumination PDT, using 5-ALA or mTHPC as the photosensitizer. The average age was 53 ± 8.9 years. The patients' recovery was uneventful and no complications reported. Comparisons with the clinical and histopathological features and rate of recurrence as well as malignant transformation were made. The patients were followed-up for a mean of 7.3 years. ANALYSIS AND RESULTS: Homogenous leukoplakias were identified in 55 patients, non-homogenous leukoplakias in 73 patients, whereas 19 patients had erythroplakias. Ex- and current lifelong smokers formed 84.4% of the recruited patients. While people who currently smoke and drink formed 38.1% (56 patients) of the cohort. Erythroplakias were mainly identified in heavy lifelong smokers. The most common identified primary anatomical locations were the lateral border of tongue, floor of mouth and retromolar area. Moderate dysplasia was identified in 33 patients while 63 patients had severe dysplasias; and 32 patients had a histopathological diagnosis of carcinoma in situ. The rate of recurrence in laser surgery was approximately 11.6%. Malignant transformation was observed in 11 patients (7.5%), in the tongue, floor of mouth and retromolar area. Recurrence and malignant transformation was mainly identified in erythroplakias and non-homogenous leukoplakias. The final outcome of the cohort showed that 11 (7.5%) suffered from progressive disease, 5 (3.4%) had stable disease, 12 (8.2%) were considered partially responsive to the therapy. Complete response was identified in 119/147 patients (81%). CONCLUSION: 5-ALA-PDT and/or mTHPC-PDT offer an effective alternative treatment for oral potentially malignant disorders.

Interstitial PDT for vascular anomalies.

INTRODUCTION: Photodynamic therapy is a proven therapeutic modality in the management of variety of pathologies involving the human body. Our aim in this clinical study is to prospectively evaluate the outcome following interstitial photodynamic therapy for patients with vascular anomalies. Patients' reports on quality of life with clinical and radiological evaluation were the main end point parameters used to assess the outcome. MATERIALS AND METHODS: Forty-three patients were referred to the UCLH Head and Neck Centre for treatment of vascular anomalies of the head and neck, including: infantile and congenital haemangiomas, venous, lymphatic and arteriovenous malformations. After multidisciplinary discussion, all patients underwent interstitial photodynamic therapy under general anaesthesia, using 0.15 mg/kg mTHPC as the photosensitising agent. Following treatment, patients were followed-up for a mean of 21 months. RESULTS: Fifteen out of nineteen patients who presented with long-term pain reported improvement after treatment. Also, 7/8 reported significant reduction of bleeding related to their vascular anomaly. Improvement of swelling was reported by 28/35 patients; while reduction of infection episodes was evident in 8/11 patients and 31/36 reported reduction in the disfigurement caused by their pathology. Significant reduction of swallowing problems was reported in 9/12 patients, and breathing problems in 7/9 patients. Clinical assessment showed that half of the patients had 'good response' to the treatment. Moderate clinical response was reported by 13 (30.2%) patients. Radiological assessment comparing imaging 6-week post-PDT to the baseline showed moderate response in 11 (25.6%) patients and significant response in 15 (34.9%) patients. CONCLUSION: This study on 43 patients with vascular anomalies undergoing interstitial photodynamic therapy provided evidence that PDT is a successful modality in the management of these pathologies that are resistant to conventional modalities, with minimal side effects.

Photodynamic therapy: The minimally invasive surgical intervention for advanced and/or recurrent tongue base carcinoma.

INTRODUCTION: The management of tongue base carcinoma continues to be a major challenge in head and neck oncology. Our aim in this prospective study was to evaluate the outcome following ultrasound-guided interstitial photodynamic therapy (US-iPDT) of stage IV tongue base carcinoma patients. Patients' reports on quality of life with clinical and radiological evaluation were the main end point parameters used to assess the outcome. MATERIAL AND METHODS: Twenty-one consecutive patients referred to the UCLH Head and Neck Centre for treatment of advanced and/or recurrent tongue base cancer were included in this study. Two-thirds of the referred patients had not been offered further conventional therapeutic options apart from palliative treatment. It was decided, by the multidisciplinary team, that the only available option was to offer US-iPDT under general anesthesia, using mTHPC (Foscan®) as the photosensitizing agent. Following treatment, patients were followed-up for a mean of 36 months (min. 21, max. 45). RESULTS: Nine of the 11 patients who presented with breathing problems reported improvement after treatment. Also, 19 of the 21 patients reported improvement of swallowing. Improvement of speech was reported by 11 of 13 patients. Clinical assessment showed that more than half of the patients had "good response" to the treatment and about a third reported "moderate response." Radiological assessment comparing imaging 6-week post-PDT to the baseline showed stable pathology with no change in size in four patients, minimal response in seven patients, moderate response in six patients, and significant response in two patients. Eight patients died; four of which due to loco-regional disease; and two from distant tumor spread. Kaplan-Meir survival curve was generated from the survival and follow-up data. CONCLUSIONS: Photodynamic therapy is a successful palliative modality in the treatment of advanced and/or recurrent tongue base carcinoma.

An explanation for the worsened prognosis in some cancer patients of perioperative transfusion: the time-dependent release of biologically active growth factors from stored blood products.

Over 25 years ago Francis reported an association between blood transfusion and worsened cancer prognosis. Subsequently there has been much debate over whether there is in fact such an association, and if so, what is its underlying mechanism. Allogeneic blood transfusion is the most frequent allo-transplantation procedure performed on a routine basis with no prior HLA-typing. 50% of the recipients of unprocessed red cells and platelets become allo-immunised. It is our proposition that as result of normal physiological ageing and metabolic processes (with depletion of ATP and reduction of active membrane processes), there is leaching of biologically active substances from the cells into stored blood products. These leached bioactive substances have immuno-modulatory effects, which may in part explain the increased likelihood of postoperative sepsis and adult respiratory distress syndrome in transfusion recipients. They also promote cell growth and angiogenesis and may therefore have a direct effect on tumour growth. We provide evidence to support a possible hypothesis which could explain much of the conflicting clinical and experimental evidence.

Further anatomical approaches to parotid surgery.

The rhytidectomy incision has recently been used to approach the parotid gland and has gained increasing popularity, particularly amongst facial-plastic surgeons. However, as the skin incision is placed further back with this approach than with the traditional incision, many surgeons remain concerned with reference to the adequacy of exposure. We report a further anatomical study to compare the surgical access provided by the two incisions that helps address these concerns. We also discuss our modifications to the incision should it become oncologically necessary. Dissections were performed on formaldehyde-fixed cadavers. A standard cervico-mastoid-facial incision was performed on one side and a rhytidectomy approach on the other. The border of the parotid gland was defined in all cases and the distances from the border of the gland to the edge of the flaps, retracted with two standard Langenbeck retractors were measured and compared between the two incisions. The comparison of the exposure gained with traditional incision and the rhytidectomy approach for parotidectomy showed that the Wilcoxon-signed rank test paired nonparametric t test, P value was 0.3749. This suggests that there was no significant difference in exposure for the two surgical approaches. In conclusion, we would advocate its more widespread consideration for patients undergoing parotid surgery. However, we do not suggest the approach would be appropriate for all patients or pathological entities and the choice of incision should be dependent on circumstances. However, we do advocate a flexibility of surgical thinking in the light of developing anatomicopathological knowledge.

Mucogingival overgrowth in a geriatric patient.

Epulis fissuratum is a pathological condition caused by an ill-fitting denture. The mucogingival hyperplasia may be considered as a reactive condition of the oral mucosa to excessive mechanical pressure on the mucosa. Epulis fissuratum excision is a procedure usually done for prosthodontic reasons. The treatment of this benign entity is essential mainly for masticatory reasons. The use of diode laser for epulis removal without infiltrated anesthesia in a conscious geriatric patient is currently under investigation.

Ultrasound-guided photodynamic therapy for deep seated pathologies: prospective study.

INTRODUCTION: Interstitial photodynamic therapy remains an attractive remedial option in minimally invasive surgery. Our aim in this prospective study was to evaluate the outcome following ultrasound-guided iPDT of deep-seated pathologies. Patients' reports on quality of life with clinical and radiological evaluation were the main end point parameters used to assess the outcome. MATERIALS AND METHODS: Sixty-eight patients were referred to the UCLH Head and Neck Centre for treatment of various deep-seated pathologies involving the head and neck region, upper and lower limbs. All patients underwent interstitial photodynamic therapy under general anaesthesia, using 0.15 mg/kg mTHPC as the photosensitising agent. Following treatment, patients were followed-up for a mean of 7 months. RESULTS: All three patients who presented with visual problems reported improvement after treatment. Also, 14/17 patients reported improvement of breathing. Improvement of swallowing was reported by 25/30 patients; while speaking improvement was evident in 16/22 patients and 33/40 reported reduction in the disfigurement caused by their pathology. All five patients with impeded limb function reported some degree of improvement. Clinical assessment showed that half of the patients had 'good response' to the treatment and a third reported 'moderate response' with two patients being free of disease. Radiological assessment comparing imaging 6-week post-PDT to the baseline showed stable pathology with no change in size in 13 patients, minimal response in 18 patients, moderate response in 23 patients and significant response in 11 patients. CONCLUSION: This study on 68 patients with deep-seated pathologies undergoing interstitial photodynamic therapy provided evidence that PDT can be the fourth modality in the management of tissue disease.

The stylomastoid artery as an anatomical landmark to the facial nerve during parotid surgery: a clinico-anatomic study.

BACKGROUND: The identification of the facial nerve can be difficult in a bloody operative field or by an incision that limits exposure; hence anatomical landmarks and adequate operative exposure can aid such identification and preservation. In this clinico-anatomic study, we examined the stylomastoid artery (SMA) and its relation to the facial nerve trunk; the origin of the artery was identified on cadavers and its nature was confirmed histologically. METHODS: The clinical component of the study included prospective reviewing of 100 consecutive routine parotidectomies; while, the anatomical component of the study involved dissecting 50 cadaveric hemifaces. RESULTS: We could consistently identify a supplying vessel, stylomastoid artery, which tends to vary less in position than the facial nerve. Following this vessel, a few millimetres inferiorly and medially, we have gone on to identify the facial nerve trunk, which it supplies, with relative ease. The origin of the stylomastoid artery, in our study, was either from the occipital artery or the posterior auricular artery. CONCLUSION: This anatomical aid, the stylomastoid artery, when supplemented by the other more commonly known anatomical landmarks and intra-operative facial nerve monitoring further reduces the risk of iatrogenic facial nerve damage and operative time.

Management of deep-seated malformations with photodynamic therapy: a new guiding imaging modality.

Photodynamic therapy is an emerging technology and results from the interactions between a photosensitiser, oxygen and light. The delivery of light may either be by surface illumination or by interstitial application. We describe the first clinical application of ultrasound-guided interstitial photodynamic therapy (US-iPDT). A total of 23 treatments with meta-tetra-hydroxyphenyl chlorine (mTHPC) and ultrasound-guided interstitial photodynamic therapy were performed on 21 patients with various conditions at the Head & Neck Centre, University College London Hospital. The needles could be clearly identified during insertion in all 23 treatments, and it was possible to guide parallel needle insertions using ultrasound. Although the resolution of ultrasound is not as high as that of other imaging modalities [i.e. computed tomography (CT) and magnetic resonance imaging (MRI)] it was satisfactory in identifying the centre and the peripheries of the pathological lesions. Ultrasound is very easy to perform, non-invasive, relatively inexpensive, quick, convenient, non-ionising, suited to the imaging of soft tissues and does not cause any discomfort. Ultrasound can be used to guide 'real-time' photodynamic therapy in deep-seated tumours and other malformations and can augment the information from other imaging modalities without affecting the patient's treatment outcome.

Disease Phobia in Patients with Temporomandibular Joint Pain Assessed by the Illness Attitude Scale.

Disease phobia refers to a psychological state when the person continuously thinks that he/she is sick and improvement from the condition is impossible. Disease phobia in patients suffering from pain, secondary to temporomandibular disorders (TMDs), is usually the consequence of long-term problems; diagnosis and treatment of this group is a real challenge for healthcare professionals. AIM: The purpose of this prospective study was to objectively evaluate the role of Illness Attitude Scale (Kellner or IAS) in measuring cancerophobia and heart disease phobia in patients suffering from pain, as a consequence of TMDs. SUBJECTS AND METHODS: The cohort included 22 patients with TMDs who underwent evaluation of these phobias; pain was acute in 7 and chronic in 15. The patients were asked to complete the "Kellner" questionnaire, and this was followed by full clinical examination of the temporomandibular region. RESULTS: When measuring the correlation between the cancerophobia and heart disease phobia patients, the outcome was found significant in the total cohort, p<0.01. Comparisons were carried out in the chronic group (n=15) and was significant (p=0.034 and r=0.549); while in the acute group no significance was identified. CONCLUSION: Cancerophobia and heart disease phobia in TMD patients are factors that need to be taken in consideration when managing chronic pain in this group.

Disease phobia in patients with temporomandibular joint pain assessed by the Illness Attitude Scale.

UNLABELLED: Disease phobia refers to a psychological state when the person continuously thinks that he/she is sick and improvement from the condition is impossible. Disease phobia in patients suffering from pain, secondary to temporomandibular disorders (TMDs), is usually the consequence of long-term problems; diagnosis and treatment of this group is a real challenge for healthcare professionals. AIM: The purpose of this prospective study was to objectively evaluate the role of Illness Attitude Scale (Kellner or IAS) in measuring cancerophobia and heart disease phobia in patients suffering from pain, as a consequence of TMDs. SUBJECTS AND METHODS: The cohort included 22 patients with TMDs who underwent evaluation of these phobias; pain was acute in 7 and chronic in 15. The patients were asked to complete the "Kellner" questionnaire, and this was followed by full clinical examination of the temporomandibular region. RESULTS: When measuring the correlation between the cancerophobia and heart disease phobia patients, the outcome was found significant in the total cohort, p < 0.01. Comparisons were carried out in the chronic group (n = 15) and was significant (p = 0.034 and r = 0.549); while in the acute group no significance was identified. CONCLUSION: Cancerophobia and heart disease phobia in TMD patients are factors that need to be taken in consideration when managing chronic pain in this group.

Role of planned postchemoradiotherapy selective neck dissection in the multimodality management of head and neck cancer.

OBJECTIVE/HYPOTHESIS: To assess the oncologic efficacy and functional outcome of selective postchemoradiotherapy neck dissection for stage IV head and neck squamous cell carcinoma. METHODS: Retrospective review of patients with N2-3 cervical metastases at presentation who underwent planned neck dissection after complete biopsy-proven clearance of primary site mucosal disease with chemoradiotherapy between 2000 and 2006. RESULTS: There were 31 males and 10 females. The average age at presentation was 57 +/- 9 years. The oropharynx was the most common primary site (n = 23; 56%). Forty-nine hemineck dissections were performed, including six bilateral and two revision procedures. Sixteen (39%) patients had residual viable postchemoradiotherapy neck disease. Patient weight did not deteriorate after neck dissection (P > .4). Two patients had persistently worsened postoperative swallowing. Ten patients required shoulder physiotherapy, of whom eight were treated with conservative measures. Five-year hemineck disease control and disease-specific survival rates were 92% and 64%, respectively. Presence of viable postchemoradiotherapy neck disease was the only independent predictor of regional control (P < .001; hazard ratio 0.00; 0.00-0.40) and disease-specific survival (P < .02; hazard ratio 0.23; 0.04-0.55). Surgery was twice more likely to confer therapeutic benefit than to cause a significant, albeit in most cases, transitory, complication. CONCLUSIONS: Neck dissection is a safe and effective procedure and a necessary component of the multimodality management of all head and neck cancer patients with N2-3 disease. It should be performed soon after satisfactory demonstration of primary site disease clearance. Universal deployment of radical surgery appears unnecessary and should, when possible, be abandoned in favor of more selective procedures to lessen morbidity.

The direct effects of stored blood products may worsen prognosis of cancer patients; shall we transfuse or not? An explanation of the adverse oncological consequences of blood product transfusion with a testable hypothesis driven experimental research protocol.

Francis and colleagues reported an association between blood transfusion and worsened cancer prognosis. Since then there has been much debate over whether there is in fact such an association. We propose a possible mechanism which could explain much of the conflicting clinical and experimental evidence, and which can be readily tested experimentally. It is suggested that the extracellular accumulation of bioactive factors in blood transfusion products can directly and indirectly cause tumour growth and hence a worsening of prognosis. This theory can be applied both in vitro and in vivo. Two separate UK studies have shown that perioperative blood transfusion is associated with worsened prognosis in head and neck squamous cell cancer patients. Furthermore, pilot experiments have shown that as blood ages, endothelial growth factors are leached from the metabolically compromised red cell. We believe that we have provided a rationale to explain the conflicting findings of research to date in this area. That red cells should store endothelial reparative growth factors would seem logical, as would the release of any factors as the metabolic processes of the anucleate red cell decline over time. As a result, leuco-depletion should be promoted and blood transfusion should be avoided if possible.

Psycho-education programme for temporomandibular disorders: a pilot study.

BACKGROUND: Temporomandibular disorders (TMDs) are by far the most predominant condition affecting the temporomandibular joint (TMJ), however many patients have mild self-limiting symptoms and should not be referred for specialist care. The aim of this pilot study was to develop a simple, cost-effective management programme for TMDs using CD-ROM. 41 patients (age 18-70) participated in this study, patients were divided into three groups: the 1st group were involved in an attention placebo CD-ROM (contain anatomical information about the temporomandibular system), the 2nd group received information on CD-ROM designed to increase their control and self efficacy, while the 3rd group received the same programme of the 2nd group added to it an introduction to self-relaxing techniques followed by audio tape of progressive muscle relaxation exercises. Each of the groups was asked to complete a number of questionnaires on the day of initial consultation and six weeks afterwards. RESULTS: The two experimental groups (2nd & 3rd) were equally effective in reducing pain, disability and distress, and both were more effective than the attention placebo group (1st), however the experimental groups appeared to have improved at follow-up relative to the placebo-group in terms of disability, pain and depressed mood. CONCLUSION: This pilot study demonstrates the feasibility and acceptability of the design. A full, randomized, controlled trial is required to confirm the efficacy of the interventions developed here.

The acute effects of alcohol on auditory thresholds.

BACKGROUND: There is very little knowledge about alcohol-induced hearing loss. Alcohol consumption and tolerance to loud noise is a well observed phenomenon as seen in the Western world where parties get noisier by the hour as the evening matures. This leads to increase in the referrals to the "hearing aid clinic" and the diagnosis of "cocktail party deafness" which may not necessarily be only due to presbyacusis or noise-induced hearing loss. METHODS: 30 healthy volunteers were recruited for this trial which took place in a controlled acoustic environment. Each of the individuals was required to consume a pre-set amount of alcohol and the hearing was tested (using full pure tone audiogram) pre- and post- alcohol consumption over a broad range of 6 frequencies. Volunteers who achieve a minimum breath alcohol threshold level of 30 u/l had to have second audiogram testing. All the volunteers underwent timed psychometric and visuo-spatial skills tests to detect the effect of alcohol on the decision-making and psychomotor co-ordination. RESULTS: Our results showed that there was a positive association between increasing breath alcohol concentration and the magnitude of the increase in hearing threshold for most hearing frequencies. This was calculated by using the Pearson Regression Coefficient Ratio which was up to 0.6 for hearing at 1000 Hz. Over 90% of subjects had raised auditory thresholds in three or more frequencies; this was more marked in the lower frequencies. CONCLUSION: Alcohol specifically blunts lower frequencies affecting the mostly 1000 Hz, which is the most crucial frequency for speech discrimination. In conclusion alcohol does appear to affect auditory thresholds with some frequencies being more affected than others.

How we do it: a method of neck dissection for histopathological analysis.

BACKGROUND: Dissection of the lymphatic structures in the neck is an integral part of the management of many head and neck cancers. We describe a technique of surgical dissection, preparing the tissue for more precise histological analysis while also reducing operative time and complexity. METHODS: When dissected, each level is excised between lymph nodes groups and put into a separate pot of formalin taking care to avoid rupture of any obvious pathological nodes. RESULTS: This makes for a simpler dissection as the surgeon progresses, as a larger more cumbersome specimen is avoided and manipulation of involved nodes is actually reduced with a reduced risk of tumour spillage. CONCLUSION: We feel that our technique provides several advantages for the histopathologist as well as the surgeon. As the dissection of the specimen into the relevant levels has already been performed, time is saved in orientating and then dissecting the specimen. Accuracy of dissection is also improved and each piece of tissue is a more manageable size for processing and analysis.This technique may also have several surgical advantages when compared with the commonly practiced techniques e.g. with reducing in-vivo specimen manipulation, hence reducing the risk of inadvertent injury to important structures and tumour spillage.