Utility of Smartphone Telemedical Consultations for Peritonsillar Abscess Diagnosis and Triage

Importance

Telemedicine is rapidly gaining traction as a way to reduce costs and connect patients with medical experts outside their local communities. Peritonsillar abscess (PTA) is a logical pathologic condition to evaluate for effectiveness of remote diagnosis given its prevalence and the paucity of on-site otolaryngologists at many institutions.

Objective

To explore the potential of otolaryngology telemedical consultation in triaging and diagnosing patients with suspected PTA.

Design, Setting, and Participants

A comparative effectiveness research study was conducted from January 1 to June 30, 2018, at 3 tertiary care hospitals among 31 consecutive patients aged 18 to 85 years for whom the otolaryngology department was consulted to assess for PTA. Statistical analysis was conducted from July 1 to September 30, 2018.

Interventions

Telemedical evaluation of suspected PTA by 5 attending otolaryngologists blinded to patients' history aside from the chief report of odynophagia. Otolaryngologists rated each patient video on whether they believed the patient had a PTA and whether the case warranted prompt evaluation by an otolaryngologist. Predictions were compared with the criterion standard of drainage or negative needle aspiration. Otolaryngologists additionally assessed video quality.

Main Outcomes and Measures

Rates of accurate diagnosis and triage of PTA based on otolaryngologists' review of oropharyngeal examinations recorded using standard smartphone cameras, as well as percentage of videos of oropharyngeal examinations using standard smartphone cameras deemed of sufficiently high quality for clinical decision-making.

Results

A total of 31 patients (16 women [51.6%]; mean age, 31.9 years [range, 18-62 years]) were recruited, and 16 patients (51.6%) had a PTA. Comparing otolaryngologists' predictions with PTA status by the criterion standard, the prediction was consistent with that of the criterion standard 81% of the time averaged across otolaryngologists (mean diagnostic accuracy, 0.81). Similarly, the mean diagnostic accuracy was 0.83 when comparing the otolaryngologist's suggestion for a prompt in-person evaluation with actual PTA status by the criterion standard. Comparing patients who were deemed to require prompt otolaryngology evaluation and those with PTA by the criterion standard, mean sensitivity was 90%. Videos were rated as of sufficiently high quality to make a diagnosis in 154 of 155 videos (99.4%).

Conclusions and Relevance

This study suggests that telemedical consultation is a viable, cost-conscious, efficient, and safe approach to PTA management. Despite having some difficulty diagnosing PTAs based on "history concerning for PTA" and oropharyngeal video alone, otolaryngologists are able to determine, with high sensitivity, which patients require prompt otolaryngology evaluation. The recording of consistently high-quality video using a standard smartphone camera is achievable without formal training.

Prestin as an Otologic Biomarker of Cisplatin Ototoxicity in a Guinea Pig Model

Objective

To evaluate (1) whether changes in serum prestin aid in early detection of cisplatin ototoxicity, (2) the role of diltiazem as an otoprotectant, and (3) whether prestin levels are sensitive to effects of diltiazem.

Study Design

Experimental animal study.

Setting

Translational research laboratory.

Subjects

Twenty female guinea pigs.

Methods

Two groups of 10 guinea pigs were used. The relationship between serum prestin levels and auditory brainstem response (ABR) thresholds was compared between the groups. All animals had baseline blood draws and ABR thresholds recorded prior to cisplatin administration. Intraperitoneal cisplatin bolus (8 mg/kg) was administered followed by 5 consecutive days of intratympanic (IT) diltiazem (2 mg/kg) or sham IT-saline injection. Serum prestin levels and ABR thresholds were measured at days 1, 2, 3, 7, and 14 postcisplatin.

Results

In sham, IT-saline–treated animals, mean prestin levels were elevated above baseline on days 1 to 7. The prestin levels were significantly elevated from baseline on day 1 ( P < .001), while significant ABR threshold elevations did not occur until day 2 ( P = .028) for click-evoked ABRs and day 3 ( P = .041) for tones. In diltiazem-treated animals, prestin levels were not elevated above baseline but ABR thresholds were elevated on days 1 to 3. However, the thresholds returned toward baseline on days 7 and 14.

Conclusion

Changes in serum prestin levels were detectable prior to shifts in ABR thresholds in a guinea pig cisplatin ototoxicity model. These changes did not occur in diltiazem-treated animals. Prestin may serve as a biomarker of cochlear injury that is sensitive to therapeutic interventions in cisplatin ototoxicity.

Purkinje cell degeneration and control mice: responses of single units in the dorsal cochlear nucleus and the acoustic startle response

The cartwheel cell is the most numerous inhibitory interneuron of the dorsal cochlear nucleus (DCN). It is expected to be an important determinant of DCN function. To assess the contribution of the cartwheel cell, we examined the discharge characteristics of DCN neurons and behavioral measures in the Purkinje cell degeneration (pcd) mice, which lack cartwheel cells, and compared them to those of the control mice. Distortion product otoacoustic emissions and auditory brainstem-evoked response thresholds were similar between the two groups. Extracellularly recorded DCN single units in ketamine/xylazine-anesthetized mice were classified according to post-stimulus time histogram (PSTH) and excitatory-inhibitory response area (EI-area) schemes. PSTHs recorded in mouse DCN included chopper, pauser/buildup, onset, inhibited and nondescript types. EI-areas recorded included Types I, II, III, I/III, IV and V. There were no significant differences in the proportions of various unit types between the pcd and control mice. The pcd units had slightly lower thresholds to characteristic frequency tones; however, they had spontaneous rates, thresholds to noise, and maximum driven rates to noise that were similar to those of the control units. Pcd mice had smaller startle amplitudes, but startle latency, prepulse inhibition/augmentation and facilitation by a background tone were comparable between the two groups. From these results, we conclude that DCN function in response to relatively simple acoustic stimuli is minimally affected by the absence of the cartwheel cells. Future studies employing more complex and/or multimodal stimuli should help assess the role of the cartwheel cells.