Conservative Management Options Research Articles

The effects of shared decision making in the conservative management of stable ankle fractures

IntroductionThe majority of ankle fractures seen in clinic are stable, will not displace and do not require plaster casting to achieve union in a good position. Nevertheless, many patients with stable ankle fractures are advised that they need a cast. In this study we counseled patients regarding the different options for conservative management of their stable ankle fracture. We then encouraged them to make an informed decision on which method of treatment they would like to pursue. Materials and methodsWe analyzed eight years of a single consultant's fracture clinic. 163 patients were offered a choice of: a weight bearing below knee cast; a functional ankle brace; or a regime of rest, ice, compression bandage and elevation (“RICE” regime). All patients were advised to mobilize on the injured ankle as their pain allowed. Results163 patients were suitable for all 3 treatment options. 82% (133/163) chose an ankle brace, 15% (25/163) opted for a RICE regime and 3% (5/163) chose a below knee cast. Of these only one returned to clinic complaining of increased pain, however after further discussion the patient opted to continue with his RICE regime as planned. DiscussionA conservative approach to these injuries is now common practice; however there is a wide variation in what type of conservative management is given. Recent studies suggest orthopedic surgeons are still treating the majority of these injuries with a weight-bearing cast despite risks of stiffness, skin damage and thromboembolism. This study showed when the patient is given opportunity to make an informed choice the vast majority opt not to have a cast. The study suggests management of these injuries should be decided via a two-way conversation between patient and practitioner. ConclusionsUsing a shared decision making approach to these injuries is a useful method of providing patients with the most suitable treatment for their personal treatment goals.

Mechanistic species distribution modelling as a link between physiology and conservation.

Climate change conservation planning relies heavily on correlative species distribution models that estimate future areas of occupancy based on environmental conditions encountered in present-day ranges. The approach benefits from rapid assessment of vulnerability over a large number of organisms, but can have poor predictive power when transposed to novel environments and reveals little in the way of causal mechanisms that define changes in species distribution or abundance. Having conservation planning rely largely on this single approach also increases the risk of policy failure. Mechanistic models that are parameterized with physiological information are expected to be more robust when extrapolating distributions to future environmental conditions and can identify physiological processes that set range boundaries. Implementation of mechanistic species distribution models requires knowledge of how environmental change influences physiological performance, and because this information is currently restricted to a comparatively small number of well-studied organisms, use of mechanistic modelling in the context of climate change conservation is limited. In this review, we propose that the need to develop mechanistic models that incorporate physiological data presents an opportunity for physiologists to contribute more directly to climate change conservation and advance the field of conservation physiology. We begin by describing the prevalence of species distribution modelling in climate change conservation, highlighting the benefits and drawbacks of both mechanistic and correlative approaches. Next, we emphasize the need to expand mechanistic models and discuss potential metrics of physiological performance suitable for integration into mechanistic models. We conclude by summarizing other factors, such as the need to consider demography, limiting broader application of mechanistic models in climate change conservation. Ideally, modellers, physiologists and conservation practitioners would work collaboratively to build models, interpret results and consider conservation management options, and articulating this need here may help to stimulate collaboration.

Treating Plantar Fasciitis Conservatively: Evidence-Based Case Report

A 44 year old obese female housewife had plantar fasciitis due to long-term standing and frequent high-heel use. Conservative management options for this condition are many but there is no strong evidence supporting effectiveness of any single option. This paper focused on evidence based physiotherapy treatment of a patient with plantar fasciitis. The treatment strategy included ultrasound at 1.5 watts/cm2 for 4 minutes, iontophoresis with acetic acid, taping, stretching of the plantar fascia and Achilles tendon, intrinsic foot muscle strengthening, manual therapy of myofascial chains and use of heel pads. Home exercises included myofascial release with tennis ball and tin, standing stretches to triceps surae and strengthening of intrinsic foot muscles on towel. Dietary consideration included vitamin C (1-3 g/day) and glucosamine sulphate (500mg three for times/day). The patient recovered after 6 weeks of evidence-based physiotherapy treatment.

Evaluating landscape options for corridor restoration between giant panda reserves.

The establishment of corridors can offset the negative effects of habitat fragmentation by connecting isolated habitat patches. However, the practical value of corridor planning is minimal if corridor identification is not based on reliable quantitative information about species-environment relationships. An example of this need for quantitative information is planning for giant panda conservation. Although the species has been the focus of intense conservation efforts for decades, most corridor projects remain hypothetical due to the lack of reliable quantitative researches at an appropriate spatial scale. In this paper, we evaluated a framework for giant panda forest corridor planning. We linked our field survey data with satellite imagery, and conducted species occupancy modelling to examine the habitat use of giant panda within the potential corridor area. We then conducted least-cost and circuit models to identify potential paths of dispersal across the landscape, and compared the predicted cost under current conditions and alternative conservation management options considered during corridor planning. We found that due to giant panda's association with areas of low elevation and flat terrain, human infrastructures in the same area have resulted in corridor fragmentation. We then identified areas with high potential to function as movement corridors, and our analysis of alternative conservation scenarios showed that both forest/bamboo restoration and automobile tunnel construction would significantly improve the effectiveness of corridor, while residence relocation would not significantly improve corridor effectiveness in comparison with the current condition. The framework has general value in any conservation activities that anticipate improving habitat connectivity in human modified landscapes. Specifically, our study suggested that, in this landscape, automobile tunnels are the best means to remove current barriers to giant panda movements caused by anthropogenic interferences.

The conservative (non‐pharmacological) management of female urinary incontinence

Key content Urinary incontinence (UI) affects up to 69% of the female population at some point in their lives but remains under‐reported. There are three main types of UI: stress, urgency and mixed. It is recommended to try conservative approaches as first‐line measures in the management of all types of UI. These include lifestyle interventions such as adjustment of fluid intake and weight loss, physical and behavioural therapies (pelvic floor muscle training, electrical stimulation, vaginal cones and bladder training programmes) and occasionally containment devices. Initial management of UI, in most cases, renders itself to primary care settings: this involves appropriate assessment of women's symptoms, including quality of life (QOL) assessment, appropriate simple investigations (such as urine analysis) and conservative treatment. Appropriate referral pathways to secondary and tertiary levels of care are necessary. Regular audit should take place to assess the efficacy of management options and referral pathways. UI has significant adverse affects on women's QOL. Hence patient reported outcome measures (PROMs) have been highlighted in recent NHS reports as a means of assessing effectiveness of care from the patient's perspective by gauging patient health status or health‐related QOL. Learning objectives To gain an understanding of the assessment and various conservative management options for common types of UI in women. To explore the existing evidence base for such conservative management modalities and to analyse the effect of the current economic climate and reorganisation of services on the conservative management approach. To recognise the important role of patient reported outcome measures as well as service and user involvement, in the assessment of clinical and cost‐effectiveness of various treatment options of UI in women. Ethical issues Should conservative measures such as weight loss and smoking cessation be a pre‐requisite for offering further management options? In the present climate of scarce health resources should more emphasis be placed on the active role of patients in their own management? Will reorganisation of the NHS pose any threat to the conservative measures for treating UI in women? Is it acceptable to take a ‘one size fits all’ approach to management of common types of UI?

Conservation management options and actions: Putative decline of coral cover at Palmyra Atoll, Northern Line Islands, as a case study

Localised loss of live coral cover at Palmyra Atoll (central Pacific Ocean) has been attributed to increased temperature and/or sedimentation arising from alterations made to the lagoon system. It has been hypothesised that a causeway spanning the lagoon hinders water circulation, resulting in warmer and/or more turbid water flowing towards a site of high coral cover and diversity (Coral Gardens). Analyses of a multi-site and multi-year data set revealed no differences in mean temperature or turbidity values on either side of the causeway and provided no evidence of significantly warmer or more turbid water at Coral Gardens. We conclude that the putative decline in live coral cover cannot be attributed to the presence of the causeway and that proposed management actions involving modification to the causeway cannot achieve the conservation outcomes suggested of them.

Use of Bakri Balloon Tamponade in the Treatment of Postpartum Hemorrhage

Objective. Massive postpartum hemorrhage (PPH) is one of the most serious complications during delivery. Hysterectomy is commonly performed when other conventional treatment attempts fail. Bakri balloon tamponade (BBT) is a novel conservative management option for PPH. Little is known of the effectiveness of this procedure. We report a large case series from a tertiary teaching hospital. Design. Retrospective case series (October 2008–June 2011). Setting. University teaching hospital. Population. Forty-four women with massive PPH (blood loss >1000 mL) and six other women with expected high risk of PPH (blood loss <1000 mL) managed by BBT. Methods. Chart review. Main outcome measures. Achievement of definitive hemostasis by BBT among the study population. Results. Among the women treated with BBT, the cause of PPH was uterine atony (16%), cervical rupture (14%), vaginal rupture and/or paravaginal hematoma (22%), placenta previa (18%) and placental retention (30%). The overall success rate was 86%. Seven of the 50 patients needed additional procedures. Of the seven failures, supravaginal uterine amputation or hysterectomy was required in four cases and embolization of the uterine arteries in three cases. Conclusions. BBT is a simple, readily available, effective and safe procedure for the management of PPH in selective cases. BBT does not exclude the use of other procedures if necessary. Even if BBT failed, it may provide temporary tamponade and time to prepare for other interventions or transportation from local hospital to tertiary centre. We suggest that BBT should be included in the PPH protocol. Abbreviations: BBT, Bakri balloon tamponade; CS, cesarean section; PPH, postpartum hemorrhage.

The experiences of close persons caring for people with chronic kidney disease stage 5 on conservative kidney management: Contested discourses of ageing

Chronic kidney disease stage 5 is a global health challenge in the context of population ageing across the world. The range of treatment options available to patients at all ages has increased and includes transplantation and dialysis. However, these options are often seen as inappropriate for older frailer patients who are now offered the option of conservative kidney management, which is presented as a non-invasive alternative to dialysis, involving symptom management and addressing psychosocial needs. In this study, we conducted qualitative interviews with 26 close persons caring for someone with chronic kidney disease stage 5 in the United Kingdom to investigate how conservative kidney management interacted with implicit ideas of ageing, in both the experience of conservative kidney management and the understanding of the prognosis and future care of the kidney disease. Our findings highlighted participant confusion about the nature of conservative kidney management, which stems from an initial lack of clarity about how conservative kidney management differed from conventional treatments for chronic kidney disease stage 5. In particular, some respondents were not aware of the implicit palliative nature of the intervention or indeed the inevitable end-of-life issues. Although these findings can be situated within the context of communication failure, we would further argue that they also bring to the surface tensions in the discourses surrounding ageing and old age, drawing on the use of a ‘natural’ and a ‘normal’ paradigm of ageing. In the context of chronic kidney disease stage 5, more patients are being dialysed at older ages, but conservative kidney management is being advanced as a better option than dialysis in terms of quality of life and experience. However, in doing so, conservative kidney management implicitly draws on a notion of older age that echoes natural ageing rather than advocate a more interventionist approach. The role of discourses of ageing in the provision of treatments for conservative kidney management has not previously been acknowledged, and this article addresses this gap.

The effect of cell cycle progression (CCP) score on treatment decisions in prostate cancer: Results of an ongoing registry trial.

277 Background: Improved prognostic markers that provide individual patient risk stratification are a pressing need in prostate cancer. The CCP signature test (Prolaris, Myriad Genetic Laboratories, Inc.) is a novel prognostic assay that has been validated in multiple cohorts and provides accurate risk of prostate cancer-specific disease progression and disease specific mortality risk when combined with standard clinicopathologic parameters. This study evaluated clinicians’ judgment regarding the clinical utility of the CCP test in a prospective registry. Methods: Clinicians ordering the CCP signature test commercially were asked to complete a survey regarding their treatment recommendations before and after they received the CCP test result. In addition, clinicians were asked how influential the CCP test result was in making therapeutic decisions on a 5 point scale (0=None, 5=Very High). Results: Currently, 368 patients have been enrolled and 47 clinicians have completed surveys on the influence of the CCP signature test in 58 cases. In five additional surveys, the therapeutic decision was undecided pre-test, post-test or both. In 77% of cases [95% CI: 65%-86%], there was a change recorded between the therapy initially planned and the therapy actually selected. The table shows the change in intended therapeutic burden from pre-CCP test to post-CCP test. In 30 of 58 cases [52%; 95% CI 39%-64%], clinicians indicated they would reduce the intended therapeutic burden post-CCP test. The CCP signature test influenced treatment selection to a ‘High’ or ‘Very High’ degree in 37 men (62%) and had “Low” or “No” influence in only 3% of cases. Conclusions: Based on the judgment of ordering physicians, the CCP score appears to add meaningful new information to risk assessment for localized prostate cancer patients. Test results led to major changes in treatment decisions with a significant increase in conservative management options, including active surveillance or watchful waiting. [Table: see text]

Osteopathic Manipulative Treatment in the Management of Biliary Dyskinesia

Biliary dyskinesia is a functional gastrointestinal disorder of the gallbladder and sphincter of Oddi. Diagnosis is made on the basis of symptoms of biliary colic in the absence of cholelithiasis and gallbladder inflammation. Palpatory findings of tissue texture changes at midthoracic levels (T6-T9) may correspond to visceral dysfunction related to the biliary system. Osteopathic manipulative treatment (OMT) of the T6-T9 segments can remove the feedback related to the somatic component, thereby affecting nociceptive facilitation at the spinal level and allowing the body to restore autonomic balance. Few reports in the current literature provide examples of treatment for patients with biliary dyskinesia using OMT. The author describes the case of a 51-year-old woman who presented with symptoms consistent with biliary dyskinesia. Her biliary colic completely resolved after OMT. Osteopathic evaluation and OMT should be considered a safe and effective option for conservative management of biliary dyskinesia.

未破裂脳動脈瘤術後の慢性硬膜下血腫

The incidence of postoperative chronic subdural hematoma (CSH) after clipping surgery for unruptured intracranial aneurysm (UIA) is reported to be in the range of 1.8–13.3%. Recent reports revealed that an increase in subdural fluid collection (SFC) during the first postoperative week is a significant risk factor for CSH after UIA surgery. Accumulating evidence from various studies indicates the potential benefit of arachnoid plasty in the prevention of SFC/CSH after surgery for intracranial aneurysms. In addition, Gorei-san, a Kampo medicine that exerts a hydragogue effect through aquaporins, has been suggested as a useful option for conservative management of CSH in which symptoms are either absent or minimal. Here, we retrospectively analyze the effects of arachnoid plasty and Gorei-san on the prevention and management of postoperative CSH after clipping surgery for UIA. Between January 2008 and December 2012, 42 patients underwent clipping surgery for UIA in anterior circulation using front-temporal craniotomy. Arachnoid plasty was performed immediately after UIA clipping. Four patients (9.5%) developed CSH after the surgery. In one case, a head injury during the postoperative period caused CSH. By excluding this case, the true incidence of postoperative CSH in our study was 7.1%, which was consistent with data shown in previous reports of case series without arachnoid plasty. The previous reports, however, included symptomatic cases and cases requiring surgical intervention. In contrast, all CSH cases in the present study were asymptomatic and improved without surgical treatment. Among the four CSH cases, three received Gorei-san during the postoperative period. Preventive administration of Gorei-san was started in 10 patients who showed increasing SFC in the postoperative period (1–2 weeks). In nine of the 10 cases, SFC diminished in one to two months. The remaining case developed CSH, which was eventually cured with conservative management. Symptomatic cases of CSH after UIA surgery often require surgical evacuation. Data in the present study suggested that intraoperative arachnoid plasty in combination with Gorei-san administration in cases that show increasing postoperative SFC or evidence of asymptomatic CSH might help prevent such detrimental complications. Further studies are required to clarify the precise effects of this therapeutic approach.

Are Results of Surgical Treatment for Calcaneal Fractures better than Nonoperative Treatment?

ABSTRACT The methods of treatment of displaced intra-articular calcaneal fractures (DIACFs) have always been surrounded by controversies, whether operative treatment is better or conservative. Some randomized controlled trials (RCTs) have been published comparing the operative vs conservative management options for DIACFs, but the conclusions are varied, with some of them supporting operative treatment while others showing equivocal results. To get some clarity on this subject, we reviewed 9 RCTs and 4 meta-analyses to evaluate the evidence that was present for both operative and nonoperative methods of management. Most studies report equivocal outcomes of operatively and nonoperatively managed DIACFs when looked at; however on stratification of groups, the evidence seemingly points towards better functional results in the operated patients who do not develop a complication, but poorer outcomes in patients with more severe injury patterns (higher Sanders’ Type). Complications were associated with both groups; no differentiation between closed and open fractures is made in most studies, leading to slightly higher rate of complications in the operated group (probably due to open cases inclusion); nevertheless the difference was not found significant. Despite a high level of interest in calcaneal fractures, the current evidence in published literature does not support a specific management protocol for DIACFs, although detailed analysis points to importance of patient selection, surgeon experience and soft tissue status. As of today, there is a need for larger randomized trials, which should also clarify the role of extensile approach vis a vis Minimally Invasive Surgery, to address this question and bring out a conclusive answer. How to cite this article Dhillon MS, Gahlot N. Are Results of Surgical Treatment for Calcaneal Fractures better than Nonoperative Treatment? J Foot Ankle Surg (Asia-Pacific) 2014; 1(1):17-23.

Genetic and Morphological Variation of Two Rare Species of Lepidium (Brassicaceae) on Mangere Island, Chatham Islands, and Implications for Their Conservation Management

The genus Lepidium in New Zealand comprises a number of threatened and endemic species. Two recently described species, Lepidium panniforme and L. oblitum, have a restricted distribution on the remote and difficult to access Mangere Island, Chatham Islands. We examined the genetic and morphological variation of L. panniforme and L. oblitum on Mangere Island to assess the best conservation management options. Amplified fragment length polymorphism (AFLP) data and morphological data were used to detect finer scale variation in L. panniforme and L. oblitum. Bayesian analysis of AFLP genotypes detected up to four genetic clusters on Mangere Island. The morphological data were also variable, although better reflected the taxonomic treatment of the Mangere Island plants. The conservation implications of such high genetic and morphological variation over such a small spatial scale are discussed, to propose the best method for ensuring the ongoing survival of these island endemics.

Cavernous Hemangioma of the Uterine Cervix Treated with Carbon Dioxide Laser Ablation

Abstract Background: Hemangiomas of the uterine cervix are extremely rare benign gynecologic tumors. Approximately 50 cases have been described worldwide. This article describes a unique case of a large cervical hemangioma treated surgically with carbon-dioxide laser ablation. Case: A 23-year-old, nulliparous Caucasian woman presented with complaints of postcoital bleeding and dyspareunia. On physical examination, a large expophytic purple mass extending from the anterior lip of the cervix to the posterior fornix was noted. The patient underwent an examination under anesthesia with cervical biopsies and laser ablation. Final pathology revealed a cervical cavernous hemangioma. Results: The patient's vaginal bleeding and dyspareunia were reduced postoperatively. Conclusions: Cervical hemangiomas may be asymptomatic or may present with postcoital or intermenstrual bleeding and should be considered as part of the differential diagnosis for abnormal uterine bleeding. Conservative management options include loc...

Incidence of complications following mandibular third molar extraction under day case general anaesthesia

Incidence of complications following mandibular third molar extraction under day case general anaesthesia

9:20 AM Abstract No. 80 - Balloon angioplasty vs wire disruption as therapy for dysfunctional hemodialysis catheters due to fibrin sheath

Purpose A common cause of tunneled hemodialysis catheter dysfunction is the formation of a fibrin sheath. Dysfunctional catheters unresponsive to conservative management options often require guidewire catheter exchange and fibrin sheath disruption. There are multiple reported techniques for fibrin sheath disruption however there is no reliable evidence to support whether one technique is superior over any another. The purpose of this study is to prospectively compare two different methods of catheter sheath disruption: balloon angioplasty versus wire disruption. Materials and Methods We designed a prospective randomized control study comparing two different methods of hemodialysis catheter fibrin sheath disruption. Subjects with dysfunctional hemodialysis catheters requiring guidewire catheter exchange from January 2009 to June 2012 were included in the study. Subjects with the presence of a fibrin sheath at the time of catheter exchange were randomized to have the sheath disrupted by one of two methods: balloon angioplasty or wire disruption. Subjects without evidence of a fibrin sheath at the time of catheter exchange were used as a control. Patients were followed for a minimum of six months to determine the time to repeat catheter dysfunction, time to repeat catheter exchange, mean blood flow during hemodialysis treatment, and adverse events. Results Pending (late-breaking abstract). Conclusion Pending (late-breaking abstract).

Management of Urolithiasis in Live-Related Kidney Donors

To analyze our experience in management of urolithiasis in renal donors. The stones were treated either pretransplant or posttransplant. The Amsterdam forum criteria for acceptance of living donors were used for donor selection. The donors underwent the following procedures: pretransplant extracorporeal shock wave lithotripsy (ESWL) (n=5), pretransplant retrograde intrarenal surgery (RIRS) (n=1), ex-vivo ureteroscopy (ex-vivo URS) (n=1), and ex-vivo pyelolithotomy (ex-vivo Pyl) (n=2); intraoperative Double-J stent; and observation (n=3). Data were analyzed for technical feasibility, intraoperative and postoperative complications, and stone clearance. The male and female ratio was 4:8 and average age was 52.3 years (38-71). In the pretransplant ESWL group, average of 740 shocks (600-1500) was given; the power was not ramped up beyond 12 kV. Ex-vivo URS was performed on bench with 6F pediatric cystoscope, while in the ex-vivo Pyl, a 12F nephroscope was introduced via a pyelotomy and stones were retrieved intact with a dormia basket. A postoperative ultrasound at one month revealed complete clearance of stones in all except one donor. At a mean follow-up of 36 months (10-58), there was no stone recurrence in donor or recipient. This report shows the feasibility and safety of ex-vivo URS and ex-vivo Pyl in living donors, in select cases with subcentimeter calculi, an option of conservative management with Double-J stent is safe. ESWL/RIRS can be performed safely in the pretransplant setting. Proper donor selection and follow-up are crucial to success. We propose a treatment selection algorithm for management of these donors.

The young osteoarthritic knee: dilemmas in management

As a result of increasing life expectancies, continuing physical careers, lifestyles into later life and rising obesity levels, the number of younger patients presenting with osteoarthritis (OA) of the knee is increasing. When conservative management options have been exhausted, the challenge for the orthopedic surgeon is to offer a procedure that will relieve symptoms and allow a return to a high level of function but not compromise future surgery that may be required as disease progresses or prostheses fail and require revision. We discuss the options available to this group of patients and the relative benefits and potential negative points of each. Total knee replacement (TKR) in the young patient is associated with high risk of early failure and the need for future revision surgery. After TKR, most surgeons advise limitation of sporting activities. If osteoarthritis is limited to only one compartment in the knee there may be surgical options other than TKR. Osteotomy above or below the knee may be considered and works by redirecting the load passing through the joint into the relatively unaffected compartment. A unicompartmental knee replacement (UKR) or patella-femoral joint (PFJ) replacement only replaces the articular surfaces in the affected compartment, leaving the unaffected compartments untouched with better preservation of the soft tissues. Which of these options is best for a particular patient depends upon the patient's symptoms, precise pathology, lifestyle, and expectations.

Venous Ulcer: Review Article

Venous ulceration is the most severe and debilitating outcome of chronic venous insufficiency in the lower limbs and accounts for 80 percent of lower extremity ulcerations. The morbidity caused by them has a serious impact on the quality of life. Sustained venous hypertension, caused by venous insufficiency leads to venous ulceration. The diagnosis is mainly clinical but needs to be differentiated from other causes of lower limb ulcers. Doppler ultrasound is the diagnostic investigation. Treatment options for venous ulcers include conservative management, mechanical treatment, medications, and surgical options. The goals of treatment are to reduce edema, improve ulcer healing, and prevent recurrence. The achievement of good long term results depends on continuous care, ulcer care clinics, home health nursing and regular evaluation by the doctor. They have a crucial role to play for the amelioration of this common and morbid condition.

Dentigerous Cyst of Mandible

ABSTRACT Dentigerous cyst of mandible is a rare entity in routine clinical practice. A dentigerous or follicular cyst is formed from the accumulation of fluid between the reduced enamel epithelium and the completely formed tooth crown or in the layers of the reduced enamel epithelium. Pulp necrosis is a commonly observed sequel in traumatized primary teeth and is one of the possible etiologic factors for the development of dentigerous teeth. The dentigerous cyst is found in children and adolescents; the highest incidence is in the second and third decades. This article reports the case of a dentigerous cyst associated with the germ of a permanent mandibular right lower canine. The therapeutic approach included endodontic treatment of the primary tooth and marsupialization of the lesion. In conclusion, with proper case selection, marsupialization might be a good treatment option for conservative management of dentigerous cysts. How to cite this article Aggarwal P, Sohal BS, Uppal KS. Dentigerous Cyst of Mandible. Int J Head Neck Surg 2013; 4(2):95-97.