Given the increased risk of cardiac toxicity with higher doses, cardiac sparing is crucial for left-sided breast cancer patients. Deep inspiration breath hold (DIBH) is one approach, but its reproducibility is questioned. This study evaluates the reproducibility of DIBH with an active breathing coordinator (ABC) device, focusing on its dosimetric impact in maintaining consistent cardiac sparing for patients undergoing partial breast irradiation (PBI).

Thirty-three patients undergoing PBI with a prescription dose of 30 Gy in five fractions were randomly selected. Each patient was treated with 6 MV photons using volumetric modulated arc therapy (VMAT) with DIBH using an ABC device. Prior to each fraction, kilo-voltage cone beam computed tomography (kV-CBCT) images were acquired to assess inter-fractional heart motion. Contours of the whole heart and left anterior descending artery (LAD) were transferred from the planning CT to CBCTs and back, using rigid alignment and isocentre shifts to represent treatment positions. Agreement between delivered and planned doses assessed DIBH reproducibility.

Throughout the entire treatment course, changes in mean and maximum cardiac doses were less than 16·4 cGy and 264·8 cGy, respectively. Changes in mean and maximum LAD doses were less than 54·0 cGy and 160·2 cGy, respectively. Overall, the mean cardiac dose increased by 2·4 ± 6·6 cGy, and the maximum by 23·3 ± 58·0 cGy. The mean LAD dose increased by 4·8 ± 18·5 cGy, and the maximum by 17·0 ± 51·0 cGy.

DIBH can be effectively reproduced with the ABC device, limiting inter-fractional cardiac dose changes.

End-of-life care poses significant ethical challenges for nurses, requiring a deep understanding of moral empathy and ethical decision-making. This study examines the impact of these factors on end-of-life decision-making among nurses in oncology and pain management units in Egypt.

A cross-sectional design was employed to gather data from participants at a single point in time, facilitating an analysis of the relationships among ethical principles, moral empathy, and nursing practice. The study involved 246 registered nurses with at least 6 months of experience, selected through stratified random sampling from oncology and pain management units in Damietta, Egypt. These settings were chosen due to their central role in palliative care, as Damietta serves as a regional healthcare hub with specialized units addressing chronic and end-of-life conditions. This selection allows for an in-depth exploration of the ethical dimensions involved in providing palliative care. Informed consent was acquired from all participants, ensuring confidentiality and the right to withdraw from the study at any time.

The findings indicated that 72% of participants reported high levels of moral empathy, which positively correlated with ethical decision-making scores (r = 0.65, p < 0.01). However, 58% of the nurses also reported experiencing moderate to high levels of moral distress in various clinical scenarios. Additionally, nurses in supportive ethical climates experienced significantly lower moral distress than those in less supportive settings (p < 0.05).

This study highlights the importance of integrating ethical training and moral empathy into nursing education and practice. The findings underscore the need for policy reforms to embed ethics and empathy training in nursing curricula and professional development programs, fostering ethical competence and enhancing patient care quality.

Nurses, as the largest group of frontline responders, play a crucial role in managing catastrophic incidents and addressing the health needs of affected populations. This study aims to identify and analyze the challenges faced by emergency nurses in Palestine who work in active conflict zones.

A quantitative, descriptive study design was employed. The research was conducted across emergency departments in 7 hospitals located in the West Bank. Data were collected from 171 nurses using a sociodemographic questionnaire and a challenge-specific questionnaire, developed and validated through literature review and expert consultations.

The study revealed that 70% of the nurses were aged between 25-29 years, with 51% being male and 60% married. Most respondents (95%) held a bachelor’s degree, 72% had received advanced cardiac life support (ACLS) training, and 68% had advanced trauma life support (ATLS) training. Additionally, 76% of the nurses were informed about critical cases before the patients arrived at the hospital. The main challenge during emergencies, as the results mention, are inadequate numbers of nurses and physicians (60%). There was a significant concern regarding whether the number of nurses was sufficient to manage the demands and pressures specific to active conflict environments, with 62% of those in nursing feeling unsafe.

The scope of emergency nurses’ challenges in managing several hospitals in areas of armed conflict was examined in this study. The resulting overview of their duties, difficulties, and experiences serves as a useful tool and presents crucial details for future emergency nursing workforce readiness. To perform effectively in armed conflict situations, emergency nurses complete a variety of preparatory courses; however, the necessary education and training should be carefully designed in accordance with their actual roles and responsibilities in these circumstances.

Chronic kidney disease (CKD) is a global health challenge that affects patients’ symptom burden and quality of life. Palliative care interventions show promise in addressing the multiple needs of CKD patients, focusing on symptom management, psychosocial support, and advance care planning. This study aimed to evaluate the effectiveness of palliative care interventions in improving symptom management in patients with CKD.

The study used a quasi-experimental research design with a sample size of 128 participants diagnosed with CKD. Participants were selected based on strict criteria to ensure consistency of palliative care interventions. Non-probability purposive sampling was used to select participants. Data were collected using validated instruments such as the Edmonton Symptom Assessment System, Kidney Disease Quality of Life-Short Form, Palliative Performance Scale, Dialysis Symptom Index and Functional Assessment of Chronic Illness Therapy-Fatigue. These instruments provided robust measures of symptom severity, quality of life, performance status, symptom burden, and fatigue. The intervention consisted of 4 sessions designed to address symptom management, psychosocial support, and advance care planning strategies.

Post-intervention, CKD patients showed significant improvements across multiple measures. Pain decreased from 6.2 to 4.8 (p = 0.002, 23% improvement), and fatigue decreased from 7.5 to 6.1 (p = 0.001, 19% reduction). Depression improved from 5.6 to 4.2 (p = 0.001, 25% reduction) and anxiety decreased from 4.9 to 3.8 (p = 0.004, 22% reduction). Physical functioning increased from 65.3 to 72.1 (p = 0.002, 10% improvement), cognitive function from 72.8 to 78.5 (p = 0.003, 8% increase), and emotional well-being from 60.2 to 65.7 (p = 0.004, 9% improvement). Ambulation improved from 75.2 to 81.5 (p = 0.001, 8% increase), activity from 68.7 to 74.3 (p = 0.004, 8% increase), and self-care from 82.4 to 88.1 (p = 0.003, 7% improvement). Nutritional status improved from 79.6 to 85.2 (p = 0.002, 7% increase) and level of consciousness from 70.3 to 75.8 (p = 0.005, 8% increase). Fatigue scores decreased significantly from 53.2 to 48.6 (p = 0.001, 9% decrease), activities of daily living from 50.1 to 45.8 (p = 0.001, 9% decrease), and well-being from 55.6 to 50.2 (p = 0.001, 10% improvement).

The results highlight the potential of palliative care interventions to improve outcomes and well-being for people with CKD. By addressing their complex needs, these interventions offer valuable lessons for nephrology and palliative care practice, emphasizing holistic approaches to patient care. The findings add to the evidence supporting the integration of palliative care into CKD management, highlighting its value in improving patient outcomes and quality of life.

Preoperative anxiety is a common phenomenon affecting 60–80% of surgical patients, with potential implications for surgical outcomes. Despite its prevalence, there remains a lack of consensus on its precise effects and optimal management strategies.

This meta-analysis aimed to synthesize current evidence on the impact of preoperative anxiety on various surgical outcomes, including anesthetic and analgesic requirements, delirium, recovery times, and pain.

We conducted a comprehensive literature search and meta-analysis of studies examining the relationship between preoperative anxiety and surgical outcomes. Standardized mean differences (SMD), correlation (COR), and odds ratios (OR) with 95% confidence intervals were calculated.

Our analysis revealed significant associations between preoperative anxiety and increased anesthetic requirements (SMD = 0.67, 95% CI: 0.32–1.01) and analgesic requirements (SMD = 0.89, 95% CI: 0.65–1.12). Preoperative anxiety was associated with postoperative delirium in adults (OR = 1.90, 95% CI: 1.11–3.26), unlike the pediatric population. Preoperative anxiety was associated with prolonged time to reach Modified Aldrete Score of 9 (SMD = 0.79, 95% CI: 0.50–1.07) and extubation time (SMD = 0.89, 95% CI: 0.58–1.21). Preoperative anxiety was positively correlated with propofol consumption (STAI-S COR = 0.35, 95%CI: 0.15–0.55). No significant association between preoperative anxiety and postoperative pain was found.

This meta-analysis provides evidence for the wide-ranging effects of preoperative anxiety on surgical outcomes. The findings emphasize the need for routine preoperative anxiety screening and the development of targeted interventions. Future research should focus on long-term impacts and the effectiveness of various anxiety management strategies.

This study aims to illuminate the prevalence of various behavioral addictions among health professions students and examine their negative effects on mental health.

In March 2023, a systematic literature search was conducted, encompassing randomized controlled trials, cohort, case-control, and cross-sectional studies from the past five years in PubMed and ScienceDirect. Adhering to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines, 19 papers underwent qualitative analysis, while 15 studies were subjected to quantitative analysis following a quality assessment review.

The study included 9,994 health professions students, primarily in the field of medicine, aged between 18 and 23 years. The majority of the students were unmarried, females, and most were in clinical years. The prevalence of behavioral addiction was 36% (95% CI: 20–51), with smartphone addiction being the highest at 46%, followed by internet addiction (42%), social media disorder (22%), and gaming disorder (4%). Substantial heterogeneity was observed among the studies. A funnel plot analysis assessed the potential for publication bias, revealing no significant indication of bias. A significant difference was observed between the groups.

This study identifies five distinct forms of behavioral addictions influencing the mental health and daily activities of health professions students. The findings underscore the need for longitudinal and interventional studies to address this technological threat.

Our aim was to see if the following have been done during medical reviews:

1. 1. For service users with a diagnosis of psychosis or schizophrenia; is there clear documentation of employment status in case notes?

2. 2. To see if supported employment/alternative education or occupational activity is being offered to unemployed service users in their Outpatient Clinic Appointments.

3. 3. Whether acceptance or refusal of offered support is being documented and followed up.

This is a re-audit and it was done to check the compliance of our service with recommended NICE guidelines following the first cycle audit.

The NICE Guidelines (CG178 – Psychosis and Schizophrenia in Adults: Prevention and Management and NG181 – Rehabilitation for adults with complex psychosis) recommend the following for all patients with diagnosis of psychosis or schizophrenia.

Standard 1:

Offer supported employment to people with psychosis or schizophrenia who wish to find or return to work (CG178 Psychosis and schizophrenia in adults: prevention and management – 1.5.8 – Employment, Education & Occupational Activities).

Standard 2:

Facilitate alternate educational or occupational activities for people who do not wish to pursue mainstream education or work (NG181 Rehabilitation for adults with complex psychosis – 1.8.9 Engagement in community activities, including leisure, education and work).

This re-audit was carried out in the Community Adult Mental Health Services at Taylor Centre, Southend.

A list of service users that attended Outpatient Services at the Taylor Centre during the months of August and September 2023 was obtained.

Case notes of service users with diagnosis of psychosis or schizophrenia that attended an Outpatient Clinic over the 2-month period as new appointment or follow up were reviewed retrospectively. The 2 months (August and September) were chosen at random to achieve a reasonable sample size.

Service users within age range of 18–68 years were selected as they fall into the working age group range in UK.

The following details were checked:

1. 1. Is the service user's employment status recorded in case notes?

2. 2. For those who are unemployed – is supported employment offered?

3. 3. Service User's acceptance or refusal and any alternative educational or occupational activity facilitated if they refuse mainstream work.

The data was collected on an Excel spreadsheet and analysed.

Findings:

• • In the case notes of our sample, Employment status was documents in 97% of the cases; 78% were not actively seeking work.

• • The type of appointment in which employment was most often discussed was in the follow up appointments = 87% of the cases.

• • Supported Employment was offered to 38% of the sample. It was noted that 64% of service users that were offered supported employment had declined the offer.

Based on individual service users’ circumstances alternative educational or employment options like prevocational training was offered to 47% of the sample. This is a notable improvement from 26% in first cycle.

There was good documentation of employment status in the case notes of 97% of the sample which shows that Employment history is being taken for almost all the service users that attend our Outpatient Service.

The type of appointment in which employment was most often discussed was in the follow up appointment (87% of the cases). This could be due to service users’ mental state at the time of their first appointment, with them being unwell; hence it may be unsuitable to discuss employment options at that time.

Supported Employment was offered to 38% of the sample. The initial audit showed that this was offered to 35% of the non-working sample; therefore, a small improvement in offering supported employment has been noted. However, it is worth noting that 64% of the people that were offered supported employment have declined the offer, which reiterates the attitude towards mainstream employment in people with serious mental illness.

Only 33% of the service users were followed up, but this could be due to the fact that some of the service users are still waiting to be seen in clinic.

Overall, there has been an improvement following the initial audit especially in offering other educational activities if supported employment is not appropriate or if the service user is not interested.

This review aims to evaluate the lasting advantages of cognitive behavioral therapy (CBT) in alleviating anxiety and depression and improving overall health outcomes post-CABG.

A comprehensive search across databases including Science Direct, PsycINFO, PubMed, Google Scholar, VHL, Cochrane, and Scopus was conducted up to October 2023. The study adhered to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) statement and Cochrane guidelines. Inclusion criteria involved randomized controlled trials reporting on CBT or CBT-based interventions tailored for CABG patients and control groups had usual care, with anxiety and depression symptoms, as well as quality of life, as primary outcomes. Outcome variations were analyzed through standard deviation, while efficacy was measured via confidence intervals. Evaluation of the intervention process included examining feasibility, adherence, acceptability, inclusion rates, safety, and tolerability.

Three randomized controlled trials including a pilot study in America and Denmark, encompassing a total of 286 patients, were reported in this review. The participants' pooled mean age was 63.19 years (intervention) and 63.9 years (control), the male-to-female ratio was approximately 2:1 [males n = 174 (intervention n = 101; control = 73) while females n = 91 (intervention n = 60; control n = 31)], and cardiac as well as non-cardiac comorbidities including psychiatric diagnosis have been reported. The array of therapies ranged from education on anxiety and depression management skills to a combination of CBT and supportive stress management (SSM), and psychoeducational interventions paired with physical therapy. Results indicated that both CBT and SSM led to improvements in anxiety and depression symptoms, accompanied by reduced hospital stays, decreased hopelessness, lower scores in dysmorphic mood and irritability, lowered perceived cognitive impairment and stress, and increased satisfaction with therapy. The cognitive behavioral therapy demonstrated commendable feasibility, acceptability, safety, and efficacy, with some concerns raised about potential issues of low adherence.

This systematic review emphasizes the positive impact of CBT on depression, anxiety, and quality of life in individuals post-CABG surgery. Future studies should adopt standardized CBT protocols, comprehensively evaluating CBT's influence on overall patient prognosis, considering cardiovascular outcomes across diverse ethnic groups, exploring cost-effectiveness, and specific patient cohorts that could benefit the most from CBT interventions.

Emphasizing the pivotal role of caregivers in the cancer care continuum, a program designed to educate caregivers of cancer patients undergoing chemotherapy underscores their significance. The palliative care education initiative strives to cultivate a compassionate and effective care environment, benefiting both patients and caregivers. By imparting education, fostering positive attitudes, offering support, encouraging appropriate behaviors, and providing essential resources, the program aims to enhance the overall caregiving experience and contribute to the well-being of those navigating the challenges of cancer treatment.

To evaluate the effectiveness of a palliative care education program for caregivers of cancer patients receiving chemotherapy.

The research employed a purposive sample comprising 155 caregivers who were actively present with their cancer patients throughout the pre- and post-test phases within a quasi-experimental research design. The study took place at the outpatient oncology center of Al-Shifa Medical Complex in Port Said City, Egypt. To gather comprehensive data, 4 instruments were utilized: a demographic questionnaire, a nurse knowledge questionnaire, a scale measuring attitudes toward palliative care, and an assessment of reported practices in palliative care. This methodological approach allowed for a thorough exploration of caregiver perspectives, knowledge, attitudes, and practices within the context of a palliative care education program.

Before the palliative care education program, only 1.3% of caregivers had a good overall level of knowledge about cancer and palliative care; this increased to 40.6% after the program. Similarly, before the palliative care education program, 32.9% of caregivers had a positive overall attitude, which increased to 72.3% after the program. Similarly, 27.1% of caregivers had an overall appropriate palliative care practice during the pre-test phase, which increased to 93.5% after the palliative care education program.

The palliative care education program significantly improved caregivers’ knowledge, attitudes, and practice scores. It is strongly recommended that caregivers of cancer patients receive continuing education in palliative care. In addition, it is crucial to conduct further research with a larger sample size in different situations in Egypt.

The prevalence of medical illnesses is high among patients with psychiatric disorders. The current study aimed to investigate multi-comorbidity in patients with psychiatric disorders in comparison to the general population. Secondary aims were to investigate factors associated with metabolic syndrome and treatment appropriateness of mental disorders.

The sample included 54,826 subjects (64.73% females; 34.15% males; 1.11% nonbinary gender) from 40 countries (COMET-G study). The analysis was based on the registration of previous history that could serve as a fair approximation for the lifetime prevalence of various medical conditions.

About 24.5% reported a history of somatic and 26.14% of mental disorders. Mental disorders were by far the most prevalent group of medical conditions. Comorbidity of any somatic with any mental disorder was reported by 8.21%. One-third to almost two-thirds of somatic patients were also suffering from a mental disorder depending on the severity and multicomorbidity. Bipolar and psychotic patients and to a lesser extent depressives, manifested an earlier (15–20 years) manifestation of somatic multicomorbidity, severe disability, and probably earlier death. The overwhelming majority of patients with mental disorders were not receiving treatment or were being treated in a way that was not recommended. Antipsychotics and antidepressants were not related to the development of metabolic syndrome.

The finding that one-third to almost two-thirds of somatic patients also suffered from a mental disorder strongly suggests that psychiatry is the field with the most trans-specialty and interdisciplinary value and application points to the importance of teaching psychiatry and mental health in medical schools and also to the need for more technocratically oriented training of psychiatric residents.

This study aimed to determine the prevalence and determinants of goitre among children aged 6–12 years at South Kordofan state.

This was a cross-sectional facility-based study.

The study was conducted in twenty villages of South Kordofan state during a medical mission.

All 575 school-age children (6–12 years) who attended the medical day were examined for clinical assessment of goitre.

The prevalence of goitre among children of South Kordofan was 42·8 % (grade 1: 15·7 %, grade 2: 27·1 %). Only 24·2 % of caregivers reported using iodised salt. Mothers working as farmers (OR: 3·209, CI 95 % 1·437, 7·167; P = 0·004) and children of Darforian tribes (OR: 21·799, CI 95 % 2·566, 185·226; P = 0·005) were found to be significantly associated with higher prevalence of goitre among children. This contrasts with children of African tribes, where they were found to have less goitre prevalence (OR: 0·432, CI 95 % 0·213, 0·875; P = 0·02). Iodised salt utilisation (OR = 0·523, CI 95 % 0·320, 0·854; P = 0·01) was found associated with a lower prevalence of goitre.

Even though National Iodine Deficiency Disorders control programs were initiated in Sudan more than 25 years ago, the prevalence of goitre among children in South Kordofan state was alarming (42·8 %). Efforts to improve access to iodised salt, increase utilisation and raise awareness are urgently needed.

To assess the efficacy of budesonide intrapolyp injection in chronic rhinosinusitis with nasal polyps.

Ninety patients were divided into three groups; group A was given oral prednisolone, group B was given budesonide intrapolyp injection weekly for five consecutive weeks and group C was given budesonide as nasal irrigation for one month. Patients were assessed using Sino-Nasal Outcome Test 22 score, total nasal polyp score, serum immunoglobulin E, absolute eosinophilic count, and morning cortisol level before treatment, one week and three months after completing their treatment.

Total nasal polyp score decreased significantly in all groups compared to those at baseline. Reduction in the oral and injection groups was greater than the wash group (p2 = 0.004), (p3 < 0.001), and the same trend concerning Sino-Nasal Outcome Test 22 score (p2 < 0.001), (p3 < 0.001).

Budesonide is an effective agent used in intrapolyp injection with no documented systemic or visual side effects that has comparable results with oral steroids.

To examine the prevalence of Generalized anxiety disorder (GAD), levels of anxiety and perceived stress in Sudanese medical students. Also measuring students’ academic performance, the satisfaction with the former, and lifestyle characteristics. Then investigating the different correlations between all these factors.

We conducted a cross-sectional study at University of Khartoum, among Sudanese medical students. A self-administered anonymous online questionnaire was filled by 340 medical students,which includes Generalized anxiety disorder-2 (GAD-2), and Perceived Stress Scale (PSS-10), beside academic performance and lifestyle characteristics questions.

The data obtained from 340 medical students revealed 3.8% (n = 13) had a previous GAD diagnosis and 29.1% scored ≥ 3 in GAD-2, indicating the possibility of having GAD, 7 of them have a previous GAD diagnosis. Among participants 9.7% use addictive substance, with 42% of them having a high GAD-2 score. Higher anxiety levels were associated with high stress scores (p = 0.000). High GAD-2 scores were significantly associated with those spending less than 10,000 SDG (18$)/week, increased hours of smart devices usage for entertainment (p-value = 0.004), and unhealthy diet (p-value = 0.004). Low anxiety scores were associated with improved quality of sleep (p-value = 0.00), satisfaction with religious practices (p-value = 0.00) and increased leisure /hobbies time (p-value = 0.018). Elevated stress levels were higher in females (p-value 0.035), students with lower academic performance satisfaction levels, and increased hours of smart devices usage for entertainment (p-value = 0.001). Reduced stress levels were associated with age > 23, increased time spent on leisure/hobbies (p-value = 0.002) and eating a healthier diet (p-value = 0.006). Mean academic score was positively associated with academic performance satisfaction (p-value = 0.00), making the mean academic score an indirect modulator for anxiety and perceived stress.

The study elaborates that GAD diagnosis is quite low; with almost third of participants having the probability of developing GAD, asserting the significance of implementing periodic mental health screening programs for medical students, early diagnosis of high-risk individuals, and early interventions through confidential access to mental health services to prevent further harm to the students' health. The impact of financial burden on medical students’ elevated the GAD-2 score; as well as poor lifestyle, i.e. habits such as unhealthy diet, increased hours of using smart devices, low sleep quality and low satisfaction with religious practices, which are all modifiable risk factors of GAD.

Under-detection of frailty syndrome or sarcopenia can result in significant mortality and morbidity among elderly patients, especially in old-age mental health settings. Therefore, it is crucial to ensure doctors are equipped with the competency of early identification and management of frailty syndrome. To date, there is limited information about any systematic approaches to assess and improve the knowledge, attitude, and practice of doctors about frailty syndrome. This literature review is aimed to identify the tools used to assess the knowledge of doctors about frailty syndrome and the available educational intervention to improve doctors’ knowledge.

A literature search was performed in Google Scholar, PubMed, SCOPUS, Ovid, and EMBASE using the keywords of “frailty syndrome” AND “knowledge” AND “doctors”. Data collected included the assessment tool used to understand the knowledge level and the intervention used to improve the knowledge. The inclusion criteria were: studies published in English in the last 10 years which assessed the knowledge of doctors about frailty syndrome.

There were five studies fulfilling the inclusion criteria after the title and abstract screening, two from the Americas, two from Europe, and one from Australia.

The target group of studies involved general practitioners and doctors working in the primary healthcare setting (three), orthopaedic surgeons (one), and doctors working in the trauma setting (one). Two of the studies included non-medical healthcare practitioners as their participants.

One study used qualitative semi-structured individual interviews, two used a self-report questionnaire, one combined knowledge testing and self-report questionnaire, and one study compared the clinical assessment with a validated tool.

Only one study provided an educational intervention, i.e., a single-day training course conducted by three geriatricians.

Despite a comprehensive search, there were limited studies identified on this topic. The methods used to assess doctors’ knowledge about frailty syndrome are heterogeneous and no standardised tool has been identified in the process. There is only one study using educational intervention to improve knowledge, which was found to be effective and sustainable based on the change in self-perception, i.e. Kirkpatrick Level 1 of evaluation. There is a need to develop systematic assessment approaches or tools and training modules to improve the knowledge of doctors about frailty syndrome. Nevertheless, this review is limited only to studies published in English.

This study aimed to present experience with surgical treatment of laryngeal cleft cases through both open and endoscopic approaches.

A retrospective evaluation of all patients diagnosed as having a laryngeal cleft in a tertiary hospital over 10 years was performed. Pre-operative data, conservative and surgical management of cases, and outcomes were collected, tabulated and analysed.

This study included 43 patients aged from 2 to 44 months with a median of 9.19 months. Concerning management technique, 12 patients had conservative treatment and the remaining 31 underwent a surgical procedure (of them, 20 patients underwent endoscopic intervention and 11 had the open surgical technique). In the open group, we used either tibial periosteum (six cases) or harvested costal cartilage (five cases).

Surgical management in the form of endoscopic Coblation-assisted or an open approach is indicated in severe cases or mild cases not responding to conservative management.