From Intention To Action: A Conceptual Model Of Cyberstander Intervention In Tiktok Cyberbullying Among Malaysian Youth

From Intention to Action: A Conceptual Model of Cyberstander Intervention in Tiktok Cyberbullying among Malaysian Youth

Richard CM^1*, Ninggal MT² and Musa N³

¹Faculty of Social Sciences and Humanities, Open University Malaysia, Malaysia

²Vice President/Deputy Vice-Chancellor (Academic & Research), Faculty of Social Sciences and Humanities, Open University Malaysia, Malaysia

³Faculty of Social Sciences and Humanities, Open University Malaysia, Malaysia

^*Corresponding author

DOI: https://dx.doi.org/10.47772/IJRISS.2025.909000364

Received: 02 September 2025; Accepted: 10 September 2025; Published: 11 October 2025

ABSTRACT

Cyberbullying on social media presents a growing challenge for Malaysian youth, particularly in digital environments where harmful behaviour is visible yet rarely addressed. This study proposes a conceptual model explaining how cyberstanders, who witness online aggression without direct involvement, transition from passive intention to active intervention. Grounded in Neo-Ecological Theory, the Social Identity Model of Deindividuation Effects, and Dual Process Theory, the model integrates environmental, social, cultural, and cognitive dimensions of cyberstander decision-making. Key influences include collectivist values and social harmony, peer conformity, and concerns for social reputation. Platform-specific affordances such as anonymity and algorithmic visibility are also considered, with TikTok employed as a case context to illustrate these dynamics. Dual Process Theory distinguishes between emotionally reactive responses and deliberate evaluative reasoning in the intervention process. The model provides a theory-driven foundation for culturally relevant digital citizenship curricula, ethical platform design, and targeted intervention strategies by situating these constructs within ecological systems and cognitive frameworks. The proposed framework seeks to guide initiatives that empower Malaysian youth to participate more actively and responsibly in online environments.

Keywords: cyberbullying, cyberstander intervention, social media, Malaysian youth, TikTok

INTRODUCTION

The widespread adoption of social media has transformed how young people communicate, express themselves, and participate in public discourse. Platforms such as TikTok, Instagram, and Facebook have enabled greater visibility and immediacy in youth interactions, often blurring the lines between entertainment, identity expression, and social regulation. However, the same features that make these platforms engaging, such as virality, anonymity, and public interaction, have also contributed to environments that facilitate cyberbullying (Hinduja & Patchin, 2019; Kowalski et al., 2014). Although this study foregrounds TikTok due to its distinctive affordances and high levels of youth engagement in Malaysia, it recognises that harmful behaviours and bystander responses are rarely confined to one platform. Content originating on TikTok often circulates across Instagram Reels, YouTube Shorts, and messaging applications such as WhatsApp and Telegram. Acknowledging these cross-platform dynamics strengthens the applicability of the proposed model and reflects how young people experience cyberbullying in interconnected digital ecosystems.

Cyberbullying, broadly defined as the intentional and repeated infliction of harm via digital technologies, is a growing global concern that disproportionately affects adolescents and young adults (Giumetti & Kowalski, 2022). In Southeast Asia, including Malaysia, the rising accessibility of smartphones and social platforms has intensified these concerns. According to the Malaysian Communications and Multimedia Commission (MCMC, 2022), more than 70% of internet users aged 15–24 reported witnessing or experiencing online harassment. Among the most common complaints received by the MCMC were cases of defamation, impersonation, sexual harassment, and offensive or threatening messages, often facilitated through social messaging platforms like WhatsApp and Telegram.

One particularly devastating example of this crisis was the case of Esha, a 30-year-old Malaysian Indian woman who died by suicide in July 2024 after enduring sustained cyberbullying on TikTok. The harassment, which was largely anonymous and widely circulated online, revealed the platform’s failure to take timely action despite receiving multiple user reports. The subsequent RM100 fine issued to the perpetrator ignited national outrage. It led to the introduction of the “Esha Clause” under Section 507D(2) of the Penal Code, which criminalises digital communication that provokes self-harm. Esha’s death became a catalyst for public discourse on the emotional toll of digital aggression, the inadequacy of existing legal protections, and the urgent need for systemic reform in online safety governance (Parliament of Malaysia, 2024).

This public reckoning brought attention to widespread concerns about online safety and a growing loss of confidence in institutional mechanisms for addressing digital harm. According to the Malaysian Communications and Multimedia Commission’s Internet Users Survey 2022, 35.3% of respondents aged 15 to 24 reported feeling unsafe when expressing opinions online. A total national sample of 2,401 respondents and an estimated youth representation of 700 individuals corresponds to approximately 247 young people. Respondents most frequently cited fears of retaliation, public shaming, and doxxing. These threats are often linked to anonymous accounts on platforms with limited local moderation, such as TikTok and Telegram. Many users who experienced harassment reported difficulty identifying the perpetrators or obtaining timely responses from platform administrators. These experiences reflect deeper structural problems in enforcement and regulatory coordination, particularly between national authorities and transnational digital service providers.

While regulation and platform design shape the conditions under which online aggression occurs, user behaviour also plays a crucial role in determining its escalation or mitigation. Among these behaviours, bystander responses have received growing attention for their potential influence on outcomes. Bystanders are individuals who witness online harassment without directly participating as either perpetrators or victims. In digital settings, this role has evolved into what scholars now refer to as cyberstanders, users who observe harmful interactions within online spaces such as social media feeds, comment sections, or messaging threads. This term reflects the specific affordances of online environments, including persistent visibility, real-time interaction, anonymity, and algorithmic amplification, all of which shape how witnessing occurs and what options for response are available. Importantly, cyberstanders are not merely passive observers shaped by cultural and technological structures; many actively negotiate ethical dilemmas, exercise empathy, and adopt subtle strategies such as private victim support or anonymous reporting. Recognising this agency alongside structural determinants ensures that youth are positioned as digital citizens capable of moral judgement and prosocial decision-making.

Henares-Montiel, Benítez-Hidalgo, Ruiz-Pérez, Pastor-Moreno, and Rodríguez-Barranco (2022) found that a substantial proportion of cyberbullying incidents involve cyberstanders, highlighting both their prevalence and potential influence. Recent research has demonstrated that these users can either intervene to support victims or remain silent, which may unintentionally legitimise harmful behaviours. Bleize et al. (2022) showed that inaction among cyberstanders is often shaped by perceived peer group norms and a lack of accountability within digital platforms. When individuals choose not to respond, their silence has been associated with the normalisation of abuse, increased psychological distress among victims, and the prolonged presence of hostile online environments.

Despite the growing body of literature on cyberbullying bystanders, much of the existing research is focused on adolescents in Western contexts and tends to address either offline incidents or generalised online environments (Patterson et al., 2021; Slonje et al., 2013). There remains a limited understanding of how youth in collectivist, non-Western societies, such as Malaysia, respond to cyberbullying as cyberstanders, particularly in terms of whether they choose to intervene, remain passive, or support aggressors. Preliminary findings suggest that cultural norms, including conflict avoidance, collectivism, and concern for personal reputation, may discourage individuals from confronting aggressors or supporting victims (Balakrishnan & Norman, 2020; Nagar et al., 2022). Furthermore, these dynamics are not experienced uniformly: ethnicity, gender, and urban–rural environments can influence how collectivist expectations are interpreted and enacted in practice. Additionally, platform-specific factors such as anonymity, visibility of interactions, and algorithmic content promotion affect how users perceive harm, responsibility, and personal risk (Steen et al., 2023; Yuan & Liu, 2023).

Existing models of cyberstander behaviour often overlook the combined influence of culturally embedded values, peer group expectations, cognitive processing styles, youth agency, and the specific design features of digital platforms. Most frameworks focus exclusively on individual psychological mechanisms, such as moral disengagement and risk perception, or external social pressures, such as conformity and fear of group rejection. These approaches rarely examine how such factors interact within real-world digital environments. To address this theoretical limitation, the present study proposes an integrated model of cyberbullying bystander intervention that draws on three distinct but complementary perspectives: Neo-Ecological Theory (NET), which emphasises context sensitivity and nested environmental systems; Dual Process Theory (DPT), which differentiates between intuitive and deliberative decision-making; and the Social Identity Model of Deindividuation Effects (SIDE), which explains how group identity influences behaviour under conditions of anonymity.

Together, these frameworks explain how Malaysian youth process cyberbullying incidents on TikTok while offering conceptual relevance for cross-platform behaviours. By integrating structural, cultural, social, cognitive, and ethical dimensions, this study constructs a context-specific model that acknowledges diversity within Malaysian youth and highlights their capacity for active moral engagement in digital spaces.

MATERIALS AND METHODS

This study uses a conceptual, theory-driven approach to explain how Malaysian youth respond as cyberstanders in cyberbullying contexts. TikTok is the focal platform, but cross-platform dynamics are acknowledged throughout. Conceptual research does not involve data collection. Instead, it synthesises existing studies to clarify ideas, identify gaps, and build testable frameworks for future work (Creswell & Clark, 2018). Kaye et al. (2022) note that this form of synthesis helps capture the layered nature of online behaviour.

A targeted review of more than 30 peer-reviewed sources was conducted through Scopus, Web of Science, and Google Scholar. The selection spanned five areas:

1. Youth cyberbullying and digital aggression (Kowalski et al., 2014; Hinduja & Patchin, 2019).
2. Bystander roles and intervention typologies (DeSmet et al., 2016; Bastiaensens et al., 2014).
3. Social media design features, with emphasis on TikTok’s interface and algorithmic visibility (Steen et al., 2023; Yuan & Liu, 2023).
4. Socio-cultural norms in Southeast Asia include collectivism and conflict avoidance (Balakrishnan & Norman, 2020; Nagar et al., 2022).
5. Theories of decision-making, moral agency, and identity in online spaces (Kahneman, 2011; Spears & Lea, 1992; Navarro & Tudge, 2023).

This review also included Malaysian studies reflecting differences across ethnicity, gender, and urban–rural youth. Cross-platform research was added to acknowledge that bullying and bystander responses often move beyond TikTok into Instagram, YouTube Shorts, or messaging apps.

Theoretical Framework Selection

Three theoretical frameworks were selected for their complementarity in explaining cyberbullying bystander behaviour in the digital age: Neo-Ecological Theory (NET), the Social Identity Model of Deindividuation Effects (SIDE), and Dual Process Theory (DPT). Each framework contributes a distinct explanatory lens. NET provides an environmental perspective, SIDE offers a social lens, and DPT contributes a cognitive and ethical dimension. Together, these form the foundation of the proposed model.

Neo-Ecological Theory (NET). As adapted by Navarro and Tudge (2023), NET extends Bronfenbrenner’s ecological systems theory by explicitly incorporating virtual contexts and technological structures. It explains behaviour as the outcome of interactions across multiple nested systems:

• Microsystem (direct digital interactions, e.g., TikTok’s interface).
• Mesosystem (connections between online and offline spheres).
• Exosystem (indirect influences such as institutional policies or parental regulation).
• Macrosystem (cultural values and societal norms, such as social harmony and deference to authority in Malaysia; Patel & Quan-Haase, 2023).
• Chronosystem (life-course transitions, including Arnett’s (2000) concept of emerging adulthood as a stage of identity exploration and social sensitivity).

By situating digital environments like TikTok within these nested layers, NET clarifies how platform affordances and cultural expectations jointly structure youth responses.

Social Identity Model of Deindividuation Effects (SIDE). While NET outlines where behaviour occurs, SIDE addresses how group identity shapes individual actions under anonymity or low identifiability conditions. SIDE proposes that when personal accountability is reduced, behaviour aligns with perceived group norms (Spears & Lea, 1992; Postmes et al., 1998). On TikTok, influencer-led trends and viral comment threads often form temporary in-groups. These dynamics can encourage bystanders to amplify harmful behaviour to maintain status, avoid exclusion, or reinforce group identity (Chan et al., 2022). SIDE therefore explains how reputational pressures and conformity inhibit moral intervention.

Dual Process Theory (DPT). Finally, DPT introduces a cognitive and ethical layer by distinguishing between two modes of thinking: System 1, which is fast, intuitive, and affect-driven, and System 2, which is slower, deliberate, and analytical (Kahneman, 2011). In cyberbullying situations, youth may feel immediate emotional impulses (e.g., empathy, fear, anger) but subsequently weigh reputational risk, peer backlash, and perceived efficacy before deciding whether to act (Brust-Renck et al., 2021; Călinescu, 2023). Importantly, by extending System 2 to include moral reasoning and ethical deliberation, DPT highlights that youth are not only constrained by external pressures but also capable of exercising agency and responsibility.

Framework Integration. Together, NET, SIDE, and DPT provide a triangulated conceptual foundation. NET explains where and when cyberstander behaviour occurs, SIDE explains who and with which group dynamics, and DPT explains how mental processes and ethical choices unfold. Their convergence reflects the complexity of cyberstander behaviour in fast-paced, socially mediated, and culturally embedded spaces such as TikTok. Moreover, because the constructs they illuminate—anonymity, peer influence, cultural values, and moral judgement—are not platform-exclusive, the integrated model is also conceptually relevant to cross-platform interactions on Instagram, YouTube Shorts, and WhatsApp.

Construct Derivation and Theoretical Mapping

The theory-informed literature review identified seven constructs that consistently shape bystander intervention. These determinants appear across studies of cyberbullying, social media behaviour, and psychology, and together they reflect both structural pressures and youths’ own agency. The constructs are:

1. Cultural values (e.g., collectivism, social harmony);
2. Peer influence and group conformity;
3. Social reputation management;
4. Anonymity and deindividuation;
5. Platform visibility and algorithmic exposure;
6. Emotional triggers (System 1); and
7. Reflective evaluation (System 2).

To ensure the model is conceptually coherent and practically meaningful, each construct is aligned with the three theoretical frameworks. This alignment shows how cultural values, social dynamics, and cognitive processes intersect to shape bystander behaviour. Table 1 illustrates this mapping by linking each construct to its theoretical foundation.

Table 1: Key constructs and their mapping to theoretical domains

These constructs form the foundation of the proposed conceptual model. Their inclusion reflects consistent patterns reported across the reviewed literature and their theoretical importance within each framework. For example, collectivist orientations—common among Malaysian youth—are frequently linked with passive bystander behaviour, as individuals seek to avoid interpersonal conflict (Nagar et al., 2022). Likewise, algorithm-driven visibility has been shown to heighten reputational anxiety, which in turn reduces the likelihood of intervention (Steen et al., 2023).

Conceptual Model Construction

The proposed conceptual model (Figure 1) integrates the seven constructs across four core domains: individual, social, cultural, and platform. These domains interact to influence whether a bystander intervenes, remains silent, or even reinforces cyberbullying. The model highlights the dynamic interplay between structural affordances, social identity pressures, and cognitive–emotional processes that shape decision-making.

Unlike traditional linear models, this framework does not assume a fixed sequence of steps. Instead, it emphasises bidirectional and situational interactions. For example, an immediate emotional response (System 1) may be suppressed by anticipated peer backlash, while reflective reasoning (System 2) may be overridden by cultural norms that discourage confrontation. The positioning of constructs within ecological layers reflects the architecture of NET, while the internal tension between intuition and reflection reflects the dual-process logic of DPT. These dynamics are further influenced by SIDE, particularly through identity salience and the pressures of group conformity.

Figure 1. Conceptual model of cyberbullying bystander intervention among Malaysian youth on TikTok. The model illustrates the integration of cultural, social, platform, and individual domains, with youth agency positioned as a cross-cutting influence in decision-making processes.

Note: This figure is an adapted conceptual representation from the author’s ongoing doctoral research framework. It is presented here for publication purposes and forms part of a larger study in progress. The model is shown linearly for clarity, but the relationships are recursive and situational: ecological contexts continuously interact with decision processes, and prior outcomes shape future bystander responses.

RESULTS AND DISCUSSION

This study proposes a conceptual model that integrates Neo-Ecological Theory (NET), the Social Identity Model of Deindividuation Effects (SIDE), and Dual Process Theory (DPT) to explain cyberbullying bystander behaviour among Malaysian youth on TikTok. The model, presented in Figure 1, positions intervention as the outcome of intersecting domains: cognitive-emotional processes, social identity cues, cultural norms, and technological affordances. By combining these perspectives, the model moves beyond linear behavioural explanations and provides a systems-level account of digital bystander decision-making.

Conceptual Overview: Four Interacting Domains

The model comprises four interrelated domains: individual, social, cultural, and platform. These are not separate layers but interactive forces that shape how youth assess, interpret, and respond to cyberbullying.

Individual domain (DPT)Dual Process Theory illustrates the internal tension between intuitive, emotionally driven reactions (System 1) and reflective, evaluative thought processes (System 2) (Kahneman, 2011). Youth may initially feel an empathetic or fearful impulse to intervene, but this is often mediated by a more analytical cost–benefit assessment that questions their role, possible backlash, or the effectiveness of intervention (Brust-Renck et al., 2021). The model reframes bystander inaction not as apathy but as a product of cognitive dissonance. Crucially, it also highlights youth agency: through System 2’s reflective reasoning, young people can exercise moral judgement, resisting peer pressure or cultural norms even when these discourage intervention.

Social domain (SIDE)

SIDE emphasises identity salience, peer conformity, and reputational concerns. In TikTok environments shaped by group trends, fandom cultures, and viral comment threads, behaviour often aligns with the prevailing tone, whether supportive, silent, or complicit (Spears & Lea, 1992; Postmes et al., 1998). In semi-anonymous spaces, Malaysian youth may withhold intervention not from disagreement but from fear that it will be socially unendorsed. Within collectivist cultures, the risk of exclusion or negative judgement further suppresses action (Chan et al., 2022; Nagar et al., 2022). Yet youth demonstrate subtle agency through private support, discreet reporting, or symbolic gestures of solidarity. These quieter strategies show that social norms constrain but do not eliminate moral action.

Cultural domain (NET)

The cultural layer reflects Malaysia’s collectivist values, conflict avoidance, and respect for authority (Balakrishnan & Norman, 2020). Inaction may therefore represent a preference for group harmony rather than moral disengagement. However, cultural values can also be reinterpreted: harmony framed as collective care enables prosocial responses without direct confrontation. This demonstrates that cultural norms are not only restrictive but also provide pathways for ethical action when creatively redefined by youth.

Platform domain

TikTok’s design, algorithmic amplification, comment visibility, and relative anonymity shape opportunities and risks for bystander action (Steen et al., 2023; Yuan & Liu, 2023). Anonymity can empower users to intervene safely, while visibility anxiety can inhibit action due to fear of reputational damage (Zhu et al., 2024). These affordances can reinforce passivity or lower thresholds for intervention depending on context. Significantly, such dynamics extend beyond TikTok: Instagram Reels, YouTube Shorts, and WhatsApp groups exhibit similar algorithmic and visibility pressures. Recognising this cross-platform relevance strengthens the model’s applicability and prevents overreliance on a single platform.

Model Contributions and Distinctions

The integration of Neo-Ecological Theory (NET), the Social Identity Model of Deindividuation Effects (SIDE), and Dual Process Theory (DPT) provides a layered theoretical contribution. Whereas most frameworks emphasise either psychological processes or social dynamics, and seldom account for platform-specific design, this model brings these perspectives together. It theorises bystander intervention as the outcome of multilevel, interacting systems—ranging from neural cognition to social visibility and cultural norms (Navarro & Tudge, 2023; Kahneman, 2011; Chan et al., 2022).

The model also departs from linear decision-making frameworks such as Latané and Darley’s (1968) five-step process. In digital spaces, decisions are rarely sequential, shaped by concurrent influences including emotional impulses, cultural expectations, peer norms, and technological affordances (Postmes et al., 1998; Balakrishnan & Norman, 2020). A young person may feel moral obligation and confidence to intervene yet remain inactive because of reputational risks or visibility anxiety (Zhu et al., 2024). This recursive and multi-directional structure reflects the complexity of online bystander behaviour. By highlighting youth agency, the model avoids deterministic readings and underscores that reflective reasoning can empower some young people to act differently even when pressures align against intervention (Brust-Renck et al., 2021).

Platform specificity further distinguishes this framework. TikTok operates as a communication tool and an attention economy structured by algorithmic amplification and social signalling (Steen et al., 2023; Yuan & Liu, 2023). These affordances directly shape decision points: algorithmic curation, for example, can expose users to harmful content without active searching, placing them in passive bystander roles. Similar mechanisms are evident across Instagram Reels, YouTube Shorts, and WhatsApp groups, suggesting that the model applies across the wider ecology of short-form and algorithmically driven platforms.

Finally, the model embeds analysis within Malaysia’s cultural context. Many cyberbullying models are grounded in Western individualist assumptions, whereas this framework incorporates collectivist ethics, social harmony, and conflict-avoidance norms (Nagar et al., 2022; Patel & Quan-Haase, 2023). By situating bystander behaviour within these cultural values, the model provides a culturally grounded explanation of how both moral disengagement and prosocial inhibition manifest in collectivist societies.

Implications for Research and Practice

The model has implications for digital education, platform design, and cyber-wellbeing policy.

Education
The model highlights the need for educators to move beyond general awareness campaigns and strengthen moral reasoning, emotional self-regulation, and digital self-efficacy in youth (DeSmet et al., 2016). Practical strategies include structured role-play, value clarification activities, and culturally relevant narratives that normalise digital courage. By embedding these activities in curricula, students can rehearse ethical decision-making in safe contexts and learn to view intervention as an achievable responsibility.

Platform design

The model recommends integrating design nudges that actively support bystander action for platform developers. Effective measures include prompts when harmful content is detected, anonymous reporting mechanisms, and interface features reinforcing collective support (Zhu et al., 2024). These interventions can shift perceived norms and reduce hesitation linked to visibility anxiety or reputational risk. Although developed with TikTok in mind, such tools are equally relevant to other short-form and group-based platforms such as Instagram Reels, YouTube Shorts, and WhatsApp.

Policy and public messaging

For policymakers and campaign designers, the model underscores the importance of culturally attuned framing. Rather than presenting intervention as confrontation, campaigns can highlight it as an act of shared responsibility and care for community and social honour. Such framing aligns with collectivist values and may increase moral engagement among Malaysian youth. Recognising youth agency in this context means treating them as active digital citizens rather than passive recipients of policy. Campaigns and curricula should therefore provide both the confidence and the cultural framing that empower youth to intervene.

CONCLUSION

This study proposed a conceptual model of cyberbullying bystander intervention among Malaysian youth, integrating Neo-Ecological Theory (NET), the Social Identity Model of Deindividuation Effects (SIDE), and Dual Process Theory (DPT). By uniting environmental structures, social identity dynamics, and cognitive–emotional decision-making processes, the model provides an interdisciplinary account of how youth navigate cyberbullying on TikTok. It also responds to the urgent need for theory-grounded research on digital behaviour in Southeast Asia, where platform use is intensive but research remains limited.

The model contributes to theory by bridging conceptual silos. It extends NET into the digital domain through platform-specific layers, applies SIDE to bystander roles rather than perpetrators, and deepens cognitive explanations through DPT. It captures the multi-directional tensions youth face, balancing moral intent with social risk, empathy with group pressure, and platform exposure with personal agency. This layered approach positions the model for adaptation across varied online ecosystems and future empirical validation.

The framework also offers practical guidance for educators, platform developers, and policymakers. It supports the creation of culturally sensitive digital literacy programmes, ethical platform affordances, and strategies that empower bystanders. Crucially, it reframes cyberstander action not as isolated heroism but as a culturally informed, context-dependent process that can be fostered with the right structural and social cues.

Several limitations must be acknowledged. First, the model remains conceptual and requires empirical validation. Future research should operationalise constructs such as identity salience, visibility anxiety, and digital harmony values through qualitative methods (e.g., interviews, think-aloud protocols) and quantitative techniques (e.g., structural equation modelling, experimental designs). Second, while elements such as algorithmic amplification and moral disengagement may generalise across contexts, the focus on Malaysian youth and TikTok introduces cultural and technological specificity that limits transferability. Comparative studies in other collectivist societies and across platforms such as Instagram Reels, YouTube Shorts, and Discord could test its wider relevance. Finally, further exploration is needed of scenarios such as group bullying, indirect exposure through algorithmic feeds, and the long-term effects of repeated non-intervention on moral disengagement. Longitudinal and cross-platform designs could clarify how bystander behaviour evolves over time.

In conclusion, this conceptual model provides a foundation for understanding the ecology of cyberbullying bystander intervention. It offers a scaffold for research, educational practice, and policy reform that aligns with Malaysian youth’s lived experiences and cultural realities. It also holds potential relevance for youth in other digitally networked societies.

ACKNOWLEDGEMENTS

This study was supported by Open University Malaysia through the Centre for Research and Innovation (CRI). The author gratefully acknowledges the institutional funding provided as part of the university’s research development initiative. The views expressed in this paper are those of the author and do not necessarily reflect the official policy or position of the institution.

DECLARATION OF INTEREST STATEMENT

The author declares that there is no conflict of interest.

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