Utility of Smartphone Telemedical Consultations for Peritonsillar Abscess Diagnosis and Triage

Diagnostic accuracy and management concordance of otorhinolaryngological diseases through telehealth or remote visits: A systematic review & meta-analysis

INTRODUCTION

COVID-19 has led to delays in providing healthcare in both emergency and non-emergency settings, especially in surgical subspecialties which rely heavily on referrals and in-person visits. Without an established telehealth infrastructure, many otorhinolaryngological departments experienced decreases in consultations. Telemedicine has attempted to bridge the gap between pre- and post-pandemic periods by creating a safe avenue of communication between otorhinolaryngologists and patients. This review hopes to address the accuracy of telemedicine in patient diagnosis and management.

METHODS

Searches were conducted since study conception until June 30, 2022, on multiple databases including PubMed, SCOPUS, and CINAHL for this systematic review and meta-analysis. Diagnostic accuracy, management accuracy, kappa, sensitivity, specificity, positive predictive value (PPV), and negative predictive value (NPV) were meta-analyzed by comparing virtual visits to in-person visits (gold standard).

RESULTS

Nineteen studies were included in this review. A total of 1518 patients were included across all studies. When comparing virtual visits against in-person visits, accurate diagnosis was made in 86.2% [82.1,89.9, I2 = 73.5%, P < 0.0001] of patients and management accuracy was 91.5% [86.1,95.7, I2 = 81.8%, P < 0.0001] when treating patients. Kappa value determining interrater reliability was 0.8 [0.7,0.9, I2 = 81.8%, P < 0.0001].

CONCLUSION

Our data suggest that diagnostic and management concordance is above 80% when comparing diagnosis and management strategies in patients who underwent both telehealth and in-person visits with an otorhinolaryngologist. In uncomplicated patients, telehealth might be a reliable source for diagnosis and management however, in-person consultation is likely still required for pathologies in which physical exam, imaging or procedural elements represent a vital component of the work-up.

Peritonsillar Abscess Outcomes with and Without Computed Tomography: A Retrospective Cohort Study

OBJECTIVES

Peritonsillar abscess (PTA) is a common deep space head and neck infection, which can be diagnosed with or without computed tomography (CT). CT poses a risk for false positives, leading to unnecessary abscess drainage attempts without benefit, whereas needle or open aspiration without imaging could potentially lead to missed abscess in need of treatment. This study considered the utility and impact of obtaining CT scans in patients with suspected PTA by comparing outcomes between CT and non-CT usage.

METHODS

Retrospective cohort analysis using TriNetX datasets compared the outcomes of two cohorts: PTA without CT and PTA with CT. Measured outcomes included incision and drainage; quinsy adenotonsillectomy; recurrent PTA; airway emergency/obstruction; repeat emergency department (ED) visits; and need for antibiotics, opiates, or steroids. Odds ratios (OR) were calculated using a cohort analysis.

RESULTS

The CT usage group had increased odds of receiving antibiotics (OR 3.043, [2.043-4.531]), opiates (OR 1.614, [1.138-1.289]), and steroids (OR 1.373, [1.108-1.702]), as well as a higher likelihood of returning to the ED (OR 5.900, [3.534-9.849]) and developing a recurrent PTA (OR 1.943, [1.410-2.677]). No significant differences were observed in the incidence of incision and drainage, quinsy adenotonsillectomy, or airway emergency/obstruction.

CONCLUSION

Our study indicated that CT scans for PTA diagnosis were associated with increased prescription of antibiotics, opioids, steroids, return ED visits, and recurrent PTA. Future prospective trials are needed to determine if the use of CT scans indicates higher patient acuity that explains the potential negative outcomes.

LEVEL OF EVIDENCE

Level II Laryngoscope, 2024.

[Design of a predictive score table for peritonsillar infection based on signs and symptoms]

BACKGROUND

Peritonsillar infection (PTI) is a reason for urgent consultation due to intense throat discomfort. A delayed or inaccurate diagnosis can jeopardize the upper aerodigestive tract and be fatal in its evolution. Our objective was to develop a predictive model for the presence of IPA helping in its rapid detection.

PATIENTS AND METHODS

A 66-month retrospective observational study from 2017 was carried out in a county and tertiary referral hospitals, registering data from all patients diagnosed with PTI and a proportional volume of subjects with pharyngeal symptoms without PTI. Collection of clinical, exploratory and demographic data among participants. Their higher relative risk of PTI presence allowed them to be considered as variables to be tested. Development of a scoring scale for the probability of suffering from it and logistic regression analysis, obtaining the ROC curve with the best diagnostic correlation. Internal validation and estimation of the predictive values of the model.

RESULTS

On 348 cases of PTI, the assessment scale scored the presence of six variables: trismus (3), unilateral dysphagia-odynophagia (2), velar bulging (2), reflex otalgia (1), pharyngolalia (1) and age between 16 and 46 years (1). With a range of 0-10, a cut-off ≥6 offered a sensitivity of 96.1%, a specificity of 93.9%, and an efficiency of 94.9%. The area under the ROC curve was 0.979.

CONCLUSIONS

The internal validation of this model based on signs and symptoms makes it a very useful tool for early detection of PTI in otorhinolaryngology and primary care.

Are Computed Tomography Scans Necessary for the Diagnosis of Peritonsillar Abscess?

Background Peritonsillar abscess is one of the most common deep-space infections of the head and neck, accounting for significant healthcare costs in the United States. Contributing to this expenditure is the trend of increased usage of computed tomography (CT), particularly in the emergency department. However, CT can be falsely positive for peritonsillar abscess, prompting unnecessary drainage attempts that yield no purulence. The false positive findings question the accuracy of CT in diagnosing peritonsillar abscess. Objectives The objective of the study was to compare the accuracy of CT with clinical exam to assess if CT is warranted in peritonsillar abscess diagnosis. Methods A retrospective study was performed of patients presenting to eight Orlando emergency departments with throat pain from January 1, 2013, to April 30, 2013. Patients with clinical diagnoses of peritonsillar abscesses were reviewed. A note was made whether CT was performed and if peritonsillar abscess was seen. The reads were compared to the results of procedural intervention for abscess drainage to assess the accuracy of CT in diagnosing peritonsillar abscess. Results There were 116 patients diagnosed with peritonsillar abscess, of which 99 underwent CT scans to aid in diagnosis. Among these 99 patients, 23 received procedural intervention, with 16 having a return of purulence (69.6%), and seven remaining without purulence (30.4%). Conclusion This study highlights the potential inaccuracies of CT scan in diagnosing peritonsillar abscess, as 30.4% of scans interpreted as abscess lacked purulence on intervention. Given these findings, clinicians could serve as better fiscal stewards by using history and exam to guide management in the majority cases with infectious processes of the oropharynx.

Utility of telephone visits at an urban safety-net hospital during 2020: A retrospective review

Objective

During COVID-19, otolaryngology clinics rapidly implemented telehealth programs in accordance with social distancing guidelines and institutional policies. Our objectives are to evaluate the usefulness of telephone audio visits for underserved patients seeking otolaryngological care at an urban safety-net hospital and identify patient factors associated with telephone visit attendance.

Methods

In a retrospective review of all adult telephone visits in 2020, we compared the demographics and visit characteristics of patients who attended telehealth versus in-person visits and patients who attended versus missed telehealth visits. Univariable and multivariable regressions were utilized to identify predictors of missing telehealth visits.

Results

We identified 318 telehealth encounters completed by 254 patients (72.8% were of racial/ethnic minority; 76.3% had low-income, need-based insurances; 43.7% had limited English proficiency). The most common chief complaints were related to head and neck oncology (n = 85, 26.7%), otology/neurotology (n = 74, 23.3%), and general otolaryngology (n = 69, 21.7%). The following actions were executed during telephone visits: behavioral and/or medication patient education (n = 152, 47.8%); sharing testing/imaging/tumor board results (n = 125, 39.3%); referrals to another department (n = 103, 32.4%); rendering a new diagnosis (n = 98, 30.8%); changing medications (n = 60, 18.9%). Less than half of telephone visits (46.2%) resulted in in-person follow-up, most commonly for in-person exams. The distribution of race/ethnicity differed between attended in-person appointments versus telephone visits (p = .01), but race and ethnicity were not significant predictors of telephone visit attendance.

Conclusion

Despite limited diagnostic capabilities, telephone audio visits can be an effective and accessible tool for providing continuity and advancing care in socially disadvantaged patients.

Level of evidence

IV.

COVID-19 and the resurgence of telehealth in otolaryngology

The objective of this review is to examine the impact of the ongoing Coronavirus disease 2019 (COVID-19) pandemic on the use of telehealth in Otolaryngology. The use of telemedicine rose dramatically during the pandemic to meet the need for continued patient care while allowing for physical separation of providers and patients. Telemedicine has been used to evaluate patients with a variety of pathologies including dysphonia, vertigo, and anosmia. Innovative use of at-home exams, such as video-otoscopy has aided providers in overcoming challenges associated with a highly specialized physical exam. The use of telemedicine in Otolaryngology will likely remain essential in the post-pandemic era and has promising results for improving clinical efficiency.

Views and needs of people who at high-risk of gestational diabetes mellitus for the development of mobile health applications: A descriptive qualitative research (Preprint)

Background

Early prevention of gestational diabetes mellitus (GDM) can reduce the incidence of not only GDM, but also adverse perinatal pregnancy outcomes. Moreover, it is of great significance to prevent or reduce the occurrence of type 2 diabetes. Mobile health (mHealth) apps can help pregnant women effectively prevent GDM by providing risk prediction, lifestyle support, peer support, professional support, and other functions. Before designing mHealth apps, developers must understand the views and needs of pregnant women, and closely combine users’ needs to develop app functions, in order to better improve user experience and increase the usage rate of these apps in the future.

Objective

The objective of this study was to understand the views of the high-risk population of gestational diabetes mellitus on the development of mobile health apps and the demand for app functions, so as to provide a basis for the development of gestational diabetes mellitus prevention apps.

Methods

Fifteen pregnant women with at least one risk factor for gestational diabetes were recruited from July to September 2021, and were interviewed via a semistructured interview using the purpose sampling method. The transcribed data were analyzed by the traditional content analysis method, and themes were extracted.

Results

Respondents wanted to develop user-friendly and fully functional mobile apps for the prevention of gestational diabetes mellitus. Pregnant women's requirements for app function development include: personalized customization, accurate information support, interactive design, practical tool support, visual presentation, convenient professional support, peer support, reasonable reminder function, appropriate maternal and infant auxiliary function, and differentiated incentive function.These function settings can encourage pregnant women to improve or maintain healthy living habits during their use of the app

Conclusions

This study discusses the functional requirements of target users for gestational diabetes mellitus prevention apps, which can provide reference for the development of future applications.

Utility of Telemedicine for Diagnosis and Management of Laryngology-Related Complaints during COVID-19

Objectives/Hypothesis

To investigate the concordance in diagnosis and management between initial telemedicine visits and subsequent in‐person visits with laryngoscopy for laryngology‐related complaints during COVID‐19.

Study Design

Retrospective cohort study.

Methods

Patients who presented to a tertiary care center with laryngology‐related complaints (voice, swallowing, airway, general throat complaints and others) and completed initial telemedicine visits and subsequent in‐person visits with laryngoscopy between March and October 2020 were included (n = 250). Preliminary diagnoses and managements provided during initial telemedicine visits were compared with the diagnoses and managements during subsequent in‐person visits with laryngoscopy. Multivariable logistic regression analysis was performed to compare concordance rates in diagnosis and management by chief complaint categories after adjusting for relevant demographic and clinical factors.

Results

Overall concordance rates in diagnosis and management between the initial telemedicine visit and subsequent laryngoscopy exam were 86.1% and 93.7%, respectively. Mean (standard deviation) days until laryngoscopy from the initial visit were 21.2 (23.0). Concordance rates were not associated with patient's age, gender, preferred language, provider, telemedicine visit duration, or days until laryngoscopy. Management concordance rate was relatively lower among patients with general throat complaints in comparison with voice‐related complaints (odds ratio: 0.27; 95% confidence interval: 0.08–0.90). Management changes after laryngoscopy included need for further imaging, procedures, voice therapy, and referral to other specialists.

Conclusion

Concordance rates in diagnosis and management remained high between the initial telemedicine visit and subsequent in‐person visit with laryngoscopy for new patients presenting with laryngology‐related complaints during the COVID‐19 pandemic. While laryngoscopy is still essential to confirm diagnosis and provide appropriate management, telemedicine may be a feasible alternative to provide suitable empiric therapy until laryngoscopy can be safely performed.

Level of Evidence

4 Laryngoscope, 132:831–837, 2022

Using telemedicine to facilitate social distancing in otolaryngology: A systematic review

OBJECTIVES

As the coronavirus 2019 pandemic puts strains on current models of otolaryngology practice, telemedicine is an attractive way for otolaryngologists to reduce in-person appointments while still addressing the health of their patients. This systematic review of the literature aims to identify the evidence basis for using telemedicine in otolaryngology practice to limit person-to-person interactions while achieving comparable quality to in-person services.

METHODS

The authors gathered articles from three databases (Embase, PubMed and Web of Science), performed a comprehensive literature review of articles published on telemedicine since 2002, and selected articles for inclusion based on their relevance to otolaryngology and the potential of the intervention to improve patient social distancing.

RESULTS

A total of 7153 articles were identified from the initial query. After review, 35 met the inclusion criteria. Of the included articles, 32 (91%), found their specific telemedicine intervention to be effective when compared to in-person services. Twenty articles (57%) were related to remote otoscopy. Other telemedical interventions included videoconferencing for peri-operative visits, diagnosis of peritonsillar abscess, telephone-based voice evaluations and evaluation of nasal fractures.

CONCLUSIONS

Video-otoscopy is the most well-supported telemedical intervention which limits physical contact between otolaryngologists and their patients. Other interventions have also demonstrated efficacy but have yet to be as widely validated as video-otoscopy. Telehealth facilitators play a key role in providing high-quality telehealth services. More invasive procedures, such as laryngoscopy, require further evidence to demonstrate definite benefits in a telemedicine setting.