Telehealth in the times of SARS-CoV-2 infection for the otolaryngologist

Telemedicine evaluation of new head and neck patients at a tertiary academic clinic during the coronavirus disease 2019 pandemic

INTRODUCTION

Coronavirus disease 2019 accelerated the use of virtual visits within health care. We examined the utility of telemedicine for conducting visits in a tertiary head and neck practice.

METHODS

A retrospective study was conducted on patients presenting via video to a tertiary-level head and neck clinic between January 2020 and December 2020. Patient demographics were collected in addition to visit indication, diagnostic imaging/tests at the time of visit, and post-visit plan. Visits were deemed successful if evaluation by video was sufficient in determining a clinical plan and did not require deferment of recommendations for subsequent in-person consult visits and/or work-up (labs, imaging). Logistic regression was performed to identify variables that served as significant predictors of successful video visits.

RESULTS

A total of 124 video visits were reviewed. Video visits were successful for the initial evaluation 88.7% of the time (n = 110). Computerized tomographic scans were the most available diagnostic test, available for 54% of patients (n = 67), followed by biopsy report 30.6% (n = 38). Visit indication had a statistically significant effect on whether a treatment plan could be made (p = 0.024). For new patients with parotid masses (n = 42), definitive treatment plans could be made 97.6% of the time (n = 41). Patients presenting with an indication of thyroid mass (odds ratio: 0.19 (confidence interval: 0.00072-0.50), p = 0.018) and other neck mass (odds ratio: 0.035 (confidence interval: 0.0014, 0.90), p = 0.043) were at significantly lesser odds than parotid patients to have a successful video visit.

DISCUSSION

In this study, virtual visits were successful for a high percentage of head and neck visits, particularly among patients seeking evaluation for parotid-related concerns.

Artificial intelligence and tele-otoscopy: A window into the future of pediatric otology

Telehealth in otolaryngology is gaining popularity as a potential tool for increased access for rural populations, decreased specialist wait times, and overall savings to the healthcare system. The adoption of telehealth has been dramatically increased by the COVID-19 pandemic limiting patients' physical access to hospitals and clinics. One of the key challenges to telehealth in general otolaryngology and otology specifically is the limited physical examination possible on the ear canal and middle ear. This is compounded in pediatric populations who commonly present with middle ear pathologies which can be challenging to diagnose even in the clinic. To address this need, various otoscopes have been designed to allow patients, their parents, or primary care providers to image the tympanic membrane and middle ear, and send data to otolaryngologists for review. Furthermore, the ability of these devices to capture images in digital format has opened the possibility of using artificial intelligence for quick and reliable diagnostic workup. In this manuscript, we provide a concise review of the literature regarding the efficacy of remote otoscopy, as well as recent efforts on the use of artificial intelligence in aiding otologic diagnoses.

Otoendoscopes to Enhance Telemedicine During the COVID-19 Pandemic

OBJECTIVES

As telemedicine has become increasingly utilized during the COVID-19 pandemic, portable otoendoscopy offers a method to perform an ear examination at home. The objective of this pilot study was to assess the quality of otoendoscopic images obtained by non-medical individuals and to determine the effect of a simple training protocol on image quality.

METHODS

Non-medical participants were recruited and asked to capture images of the tympanic membrane before and after completion of a training module, as well as complete a survey about their experience using the otoendoscope. Images were de-identified, randomized, and evaluated by 6 otolaryngologists who were blinded as to whether training had been performed prior to the image capture. Images were rated using a 5-point Likert scale.

RESULTS

Completion of a training module resulted in a significantly higher percentage of tympanic membrane visible on otoendoscopic images, as well as increased physician confidence in identifying middle ear effusion/infection, cholesteatoma, and deferring an in-person otoscopy (P < .0001). However, even with improved image quality, in most cases, physicians reported that they would not feel comfortable using the images to for diagnosis or to defer an in-person examination. Most participants reported that the otoendoscope was simple to use and that they would feel comfortable paying for the device.

CONCLUSIONS

At-home otoendoscopes can offer a sufficient view of the tympanic membrane in select cases. The use of a simple training tool can significantly improve image quality, though often not enough to replace an in-person otoscopic exam.

Telephone clinic outcomes during the coronavirus disease 2019 pandemic: results from an ENT department

Objective

To study the impact of telemedicine on patient outcomes during a nationwide lockdown to halt the spread of coronavirus disease 2019.

Methods

A retrospective study was conducted to examine telemedicine consultations of newly referred patients over 7 days during a national lockdown. Overall outcomes of telephone clinics were recorded, measured as either patient discharged, imaging requested, patient referred to another specialty, further telephone follow up required, patient initiated follow up or face-to-face appointment required.

Results

Data were collected from 104 patients. Outcomes showed that 17 patients were discharged, 15 had imaging requested, 11 were referred to another specialty, 11 had further telemedicine appointments, 31 had patient-initiated follow up and 19 received face-to-face appointments. Overall, 57 per cent of patients avoided hospital visits and 17 per cent required face-to-face appointments. Of higher risk patients, 49 per cent were managed remotely. After eight months, no significant morbidity or mortality was reported.

Conclusion

Almost half of the higher risk patients avoided a hospital visit. The majority of patients were managed remotely, and thus the risk and spread of infection were reduced. Telemedicine has an important role in ENT out-patients.

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 remote consultation to enhance diagnostic accuracy of bedside transthoracic echocardiography during COVID-19 pandemic

Objective

The aim of this study was to evaluate the clinical significance of remote consultation over bedside transthoracic echocardiography (RC‐B‐TTE) for patients with coronavirus disease 2019 (COVID‐19).

Methods

Five frontline echocardiographers performed and interpreted B‐TTE for 30 patients with COVID‐19 in the isolation wards, and the on‐site B‐TTE reports (OSR) were generated. Then remote consultation over the 30 B‐TTE studies was conducted by two experienced echocardiographic consultants while blinded to the OSR, and the corresponding remote consultation reports (RCR) were generated. Subsequently, the five frontline echocardiographers were convened together to discuss the difference between the OSR and RCR, and to confirm the correct interpretation and the misdiagnosis using a “majority‐vote” consensus as the diagnostic “gold standard”. Afterwards the reasons for the misdiagnosis were given by the frontline echocardiographers themselves. The inter‐rater agreement between the OSR and the “gold standard” was assessed using Kappa coefficient and percent agreement.

Results

Complete correctness of the 30 copies of the RCR were determined by the 5 frontline echocardiographers. The reliability of the OSR in the findings of cardiac chamber dilation, left ventricular hypertrophy and pulmonary hypertension were weak (Kappa <0.6). The reliability of the OSR in the recognition of major cardiac abnormalities was very weak (Kappa =0.304, percent agreement =63.3%). Misdiagnosis of major abnormalities was found in 11 copies of OSR (11/30, 36.7%).

Conclusions

The protocol of RC‐B‐TTE has shown noticeable superiority in ameliorating diagnostic accuracy of echocardiography, which should be generalized to clinical practice during the COVID‐19 or similar pandemic.

Diagnostic concordance of telemedicine for otolaryngology, head and neck surgery in regional Australia

BACKGROUND

The use of telehealth during the COVID-19 pandemic has emerged as both a necessary and significant tool in the provision of safe and timely healthcare in the field of otolaryngology. Increased access to specialist care in a regional setting is an additional benefit. Variation in diagnostic accuracy of telehealth consultations may affect diagnosis and management. Therefore, our aim is to determine the diagnostic concordance of telemedicine for otolaryngology in an Australian regional setting with physical consultations.

METHODS

Retrospective review was conducted for all patients who received an initial telemedicine appointment over a 7-month period during the COVID-19 pandemic in regional Victoria, Australia. Data were collected regarding initial diagnosis and management from telemedicine consultations, subsequent physical appointment findings and management and intraoperative findings. Statistical analysis was performed using Prism (version 8.0, GraphPad).

RESULTS

Two hundred and fifty-nine patients were included. The most common conditions referred were for consideration of tonsillectomy with or without adenoidectomy (44.0%). Overall diagnostic concordance of the initial referrer was 63.3% and for telephone appointments, it was 81.9%. Concordance of recommended treatment plans between telephone and physical appointments was 96.9%.

CONCLUSION

Although physical appointments are an essential aspect of practice in OHNS, there are significant benefits of phone only telemedicine within the context of a global pandemic which were compounded by a regional setting. Paediatric patients were found to have the highest concordance of diagnosis and treatment plans.

Self-monitoring of the tympanic membrane: An opportunity for telemedicine during times of COVID-19 and beyond

The interest for telemedicine has increased since the COVID-19 pandemic because of the risk of infection. Recently, commercial companies started selling digital USB-otoscopes (DUO) that can be connected to a mobile phone. These DUOs are inexpensive (costing approximately $6–35 each) and make it possible to visualize the whole tympanic membrane. Here, we illustrate the case of a patient who had operative correction of a tympanic membrane retraction, and who self-monitored the tympanic membrane in the course of time. Additionally, we discuss the use of DUOs in otolaryngology telemedicine practice. The use of simple digital USB otoscopes provides a promising method to assess and monitor the tympanic membrane remotely. However, more research is needed to establish the role of DUOs in telemedicine.

Telehealth tinnitus therapy during the COVID-19 outbreak in the UK: uptake and related factors

OBJECTIVE

The Audiology Department at the Royal Surrey County Hospital usually offers face-to-face audiologist-delivered cognitive behavioural therapy (CBT) for tinnitus rehabilitation. During COVID-19 lockdown, patients were offered telehealth CBT via video using a web-based platform. This study evaluated the proportion of patients who took up the offer of telehealth sessions and factors related to this.

DESIGN

Retrospective service evaluation.

STUDY SAMPLE

113 consecutive patients whose care was interrupted by the lockdown.

RESULTS

80% of patients accepted telehealth. The main reasons for declining were not having access to a suitable device and the belief that telehealth appointments would not be useful. Compared to having no hearing loss in the better ear, having a mild or moderate hearing loss increased the chance of declining telehealth by factors of 3.5 (p = 0.04) and 14.9 (p = 0.038), respectively. High tinnitus annoyance as measured via the visual analogue scale increased the chance of declining telehealth appointments by a factor of 1.4 (p = 0.019).

CONCLUSIONS

Although CBT via telehealth was acceptable to most patients, alternatives may be necessary for the 20% who declined. These tended to have worse hearing in their better ear and more annoying tinnitus.

Unique Challenges for Otolaryngology Patients During the COVID-19 Pandemic

The coronavirus disease 2019 (COVID-19) pandemic has drastically altered health care delivery and utilization. The field of otolaryngology in particular has faced distinct challenges and an increased risk of transmission as day-to-day procedures involve intimate contact with a highly infectious upper respiratory mucosa. While the difficulties for physicians have been thoroughly discussed, the unique challenges of patients have yet to be considered. In this article, we present challenges for patients of otolaryngology that warrant thoughtful consideration and propose solutions to address these challenges to maintain patient-centered care both during and in the aftermath of the COVID-19 pandemic.