key: cord-265934-wjdxqj8h
authors: Singh, Amrita K.; Kasle, David A.; Jiang, Roy; Sukys, Jordan; Savoca, Emily L.; Z. Lerner, Michael; Kohli, Nikita
title: A Review of Telemedicine Applications in Otorhinolaryngology: Considerations During the Coronavirus Disease of 2019 Pandemic
date: 2020-10-01
journal: Laryngoscope
DOI: 10.1002/lary.29131
sha: 
doc_id: 265934
cord_uid: wjdxqj8h

OBJECTIVE/HYPOTHESIS: Review the published literature of telemedicine's use within otorhinolaryngology (ORL), highlight its successful implementation, and document areas with need of future research. STUDY DESIGN: State of the Art Review. METHODS: Three independent, comprehensive searches for articles published on the subject of telemedicine in ORL were conducted of literature available from January 2000 to April 2020. Search terms were designed to identify studies which examined telemedicine use within ORL. Consensus among authors was used to include all relevant articles. RESULTS: While several, small reports document clinical outcomes, patient satisfaction, and the cost of telemedicine, much of the literature on telemedicine in ORL is comprised of preliminary, proof‐of‐concept reports. Further research will be necessary to establish its strengths and limitations. CONCLUSIONS: Particularly during the coronavirus disease of 2019 pandemic, telemedicine can, and should, be used within ORL practice. This review can assist in guiding providers in implementing telemedicine that has been demonstrated to be successful, and direct future research. Laryngoscope, 2020

Telemedicine has enabled providers to care for patients in increasingly efficient, effective, and costsaving manners. 1, 2 Many specialties have taken advantage of these technologies, primarily in triaging new patients and for follow-up of postoperative patients. [3] [4] [5] [6] [7] [8] [9] [10] While the utilization of telemedicine has gradually increased over the past decades in the United States, 11 the 2019 novel coronavirus (coronavirus disease of 2019 ) pandemic has thrust both its necessity and implementation into the forefront of medical practice. Similar to other medical fields, otorhinolaryngology (ORL) is experiencing challenges in attempting to maximize continued quality patient care, while minimizing risk to patients and providers. 12, 13 ORL presents unique barriers to telemedicine implementation due to pervasive necessity of in-person examination techniques and procedures. 14 The objective of this review is to document the manners in which telemedicine has already been implemented across the various subspecialties of ORL as a guide for current practitioners, highlight limitations of telemedicine, and elucidate areas in need of further study.

Three independent searches of Scopus, PubMed, Google Scholar, and Google for articles published on the subject of telemedicine in ORL were conducted from January 2000 to April 2020 ( Fig. 1 ). Search terms were designed to identify studies which examined telemedicine use within ORL (Appendix S1). A total of 219 unique articles were found. Articles were sorted according to the following categories: head and neck oncology, otology/neurotology, laryngology, rhinology, facial plastic and reconstructive surgery, and pediatrics, and selected based on relevance. Case reports, and articles with a focus outside ORL were excluded. A qualitative literature review was summarized (Table I) . Implications for practice and potential opportunities for additional investigation were discussed and established among all authors.

Findings. Compared to the other ORL subspecialties, head and neck surgical oncology has demonstrated relatively wide adoption of telemedicine (Table II) . A study conducted by Dorrian et al. concluded that initial assessment by telemedicine lowered equipment costs for providers, travel costs for patients, and unnecessary transfers to specialist centers, without compromising diagnostic accuracy or patient satisfaction. 17 Within the Veterans Affairs (VA) system, Beswick et al. demonstrated the safe use of a telemedicine protocol for preoperative visits in patients with high-grade head and neck malignancies. 18 Kohlert et al. found that head and neck surgical oncology cases accounted for 48.6% of all ORL consults to a regional electronic consulting service. 19 Head and neck cancer care plans are often developed in a multi-disciplinary tumor board that includes otolaryngologists, pathologists, radiologists, medical and radiation oncologists. Several studies note that a combination of real-time videoconferencing, and safely shared laboratory, imaging, and pathology data facilitate tumor board workflow, streamlining cooperation between colleagues. [20] [21] [22] Lastly, telemedicine has proven effective in easing provider demands in the postoperative setting. Rimmer et al. reported that, in appropriately selected patients, telemedicine postoperative visits were safe, time-saving, and satisfactory to patients. 21 Recent studies on remote free flap monitoring provide clear examples of how telemedicine can not only expedite care, but also improve patient outcomes. 23 Similarly, Hwang and Mun found that sharing of digital photographs of flaps between providers facilitated better communication within the care team, earlier detection of flap compromise, and ultimately increased overall flap survival. 24 Recommendations for practice. We strongly recommend that telemedicine be utilized to expedite workup of new tumors, especially when there is concern for highgrade/aggressive pathology. This can be accomplished through streamlining referral systems, obtaining imaging based on electronic consultation, and hosting multi- disciplinary discussions on audio/visual platforms. Furthermore, we recommend that telemedicine be strongly considered in postoperative head and neck surgery visits when feasible. Successful use of remote free flap monitoring suggests there is also a role for inpatient head and neck telemedicine implementation (Table I) . There is a further need for controlled studies comparing telemedicine to in-person assessment of head and neck cancer patients in terms of cost, safety, surveillance adherence, and oncologic outcomes.

Findings. The field of otology/neurotology demonstrated early adaptation of telemedicine, driven by a high patient volume and lack of specialist centers, particularly in rural settings. Advances in recorded otoscopy have bolstered promise in remote evaluation, but given the degree of specialized training and equipment required, concerns exist regarding the accuracy and safety of these technologies (Table III) .

In a landmark study, Kokesh et al. described a "store-and-forward model (SAF)," wherein audiologists and advanced practice providers obtain patient histories and otologic examinations and forward these to otolaryngologists. [25] [26] [27] Compared to in-person visits, SAF evaluations demonstrated decreased wait times and reduced patient travel costs.

Recent technological advances have allowed for the recording and storage of otoscopic examinations, allowing for SAF neurotology consults, with high level of accordance with in-person diagnoses. 16, [28] [29] [30] [31] [32] [33] With a focus on otitis media, Biagio et al. used video-otoscopy recordings in children recorded by facilitators with limited training. 16 The quality of the video-otoscopy recordings was noted to be acceptable or better in 87% of cases. In a study by Erkkola-Anttinen et al., parents of pediatric patients were trained to use otoscopes attached to smartphones for diagnosis of acute otitis media, though videos of sufficient technical quality were only obtained in 67% of cases. 34 The primary concerns regarding video-otoscopy are poor image quality and examination reliability. Subtle findings such as mild retraction pocket, atelectasis, pinhole perforation, or small cholesteatoma may not be apparent on low-quality images. 34 Other limitations include access to at-home equipment, such as otoscopes, specula, and imagecapturing devices, as well as high-speed internet needed to transmit high-resolution images. [34] [35] [36] Telehealth has been applied to tinnitus rehabilitation, cochlear implant fitting, programming, and maintenance, as well as hearing aid assessment and programming. 37, 38 A VA study of tinnitus management utilizing a skills education program delivered via telephone showed far greater improvement in symptom management than the wait-list group. 39 Luryi et al. examined the role of telemedicine in cochlear implant programming of VA patients, and concluded that cochlear implant threshold, comfort, and impedance levels were readily obtained via telehealth and did not differ significantly to in-person sessions. 15 When assessing the feasibility of remote evaluation of cochlear implant candidacy, Fletcher et al. reported comparable testing results across remote and in-person conditions in a within-subject control study. 40 Despite the demonstrated applicability of telemedicine to neurotology, there is documented needs for improvement. Several studies note that a reliable standardized grading scale or diagnostic guide could be of significance in remote evaluation of otitis media to ensure more uniform, standardized assessments. 31, 41 Recommendations for practice. We recommend that telemedicine be used for the diagnosis, workup, and management of otologic pathologies in select circumstances (Table I) . The feasibility of remote evaluation and programming of both hearing aids and cochlear implants have been demonstrated and may be particularly useful in rural areas with limited access to care. Auditory rehabilitation following cochlear implantation is another promising application for remote health, yet does not come without risks (Table I) . Further research assessing the use of telemedicine in diagnosing and triaging inner ear pathologies, otologic/neurotologic tumors, and other common pathologies is warranted.

Findings. To assess the feasibility of remote vocal rehabilitation, Mashima et al. compared treatment outcomes between patients seen in person or by video teleconference. 42 The authors reported no differences in outcomes between the groups, supporting noninferior use of telemedicine in vocal rehabilitation. Doarn et al. developed an online portal to provide home practice support for children between weekly voice therapy sessions. 43 In addition to facilitating increased communication with clinicians, the study documented an increase in patient adherence to therapy recommendations.

While telemedicine has been successfully applied to vocal rehabilitation, it faces challenges in diagnosis of laryngeal pathologies the examination of which requires technical skill and experience (Table IV) . Given the significant challenges of transmission risk and limited PPE in the COVID-19 pandemic, alteration of typical methods of voice and swallowing triage, evaluation, and management must be considered. To address this, Ku et al. published clinical practice guidelines for the management of dysphagia in the COVID-19 pandemic, suggesting use of telemedicine for triage and remote evaluation. 44 For remote voice and swallowing disorder diagnosis, one strategy is the use of non-image-based tools like voice recordings, as described by Wormald et al. 45 Using an automated speech analysis system, the authors demonstrated 92% sensitivity and 75% specificity for detecting vocal fold paralysis. With regards to other laryngeal pathology, computed tomography (CT) scans and ultrasonography have the benefit of being noninvasive and amenable to store-and-forward telemedicine although such may miss early, small glottic cancers and subtle laryngeal lesions. 46 proxy practitioner capable of performing the procedure would be necessary, such as a speech and language pathologist or primary care provider. As in otology, any remote diagnostic modalities must prioritize high-quality imaging to meet standards of care. 51 Recommendations for practice. We strongly recommend that telemedicine be applied to voice therapy, as it has been shown to meet standards of care with increased provider and patient satisfaction. Machine learning-driven detection of vocal pathologies has also shown to be effective, and further studies examining this diagnostic modality are warranted. There has been early investigation into fiberoptic laryngoscopy with remote analysis by otolaryngologists, but this practice has not been well-established and faces barriers to implementation. Imaging is an option to supplement and, at times, replace in-person laryngoscopy, but further research is needed to demonstrate its reliability.

Findings. Similar to laryngoscopy, nasal endoscopy is considered high risk for exposure to COVID-19. 52 Furthermore, anesthetic sprays have aerosolizing potential, which increases risk of transmission not just to the direct provider but to adjacent personnel. Due to the clinical needs and risks of nasal endoscopy, investigating alternatives to this procedure is of significant interest (Table V) . CT sinus imaging can be used as an alternative to endoscopy. 53 A number of studies have revealed high diagnostic concordance between nasal endoscopy and CT in the evaluation of sinus disorders. 53, 54 An obvious benefit is that any diagnostic imaging is especially amenable to remote evaluation. Another alternative is remote intranasal imaging, with setups similar to those described for video-otoscopy or laryngoscopy. A small number of studies have described systems for remotely performed nasal endoscopy with digital recording and SAF transmission, including use of smartphone-compatible systems, though this has similar limitations to neurotolgy and laryngology with regards to implementing remote procedures. 55, 56 Epistaxis is another common rhinologic referral and may be amenable to remote evaluation. 52, 57 Telemedicine can help identify triggers, risk factors, and manage mild bleeding in low-acuity patients. Red flags in the patient history or failure to control bleeding with conservative measures should prompt in-person evaluation. 52 Specifically regarding follow-up care in rhinology, Khanwalkar et al. used mobile technology to track postoperative outcomes following septoplasty and functional endoscopic sinus surgery. 58 Mobile technology has also been successfully used in the management of allergic rhinitis. 59 Recommendations for practice. Telemedicine has demonstrated applicability in rhinology, and we recommend that it be used for follow-up in the management of allergic rhinitis (AR). Further study is needed in remote management of nonallergic rhinosinusitis. While there is a need to limit intranasal endoscopy in the time of COVID-19, sole use of CT imaging for diagnosis is a deviation from standards of care and may have medicolegal implications. Further research is needed to establish the efficacy of CT as a substitute to nasal endoscopy. Development of guidelines for triage and remote evaluation of potentially emergent conditions such as epistaxis and invasive processes is also needed.

Findings. Telemedicine is readily applicable to many aspects of facial plastic and reconstructive surgery (Table VI) . Evaluation of facial soft tissue relationships and defects is already heavily based on digital photographic documentation and analysis. 60, 61 As such, assessment of facial trauma may be particularly amenable to remote assessment. Fonseca et al. reported high concordance between in-person evaluations of facial trauma patients and evaluations carried out through smartphone videoconferencing with review of CT imaging. 62 A remote approach for triage can avoid unnecessary transfers for patients that do not require urgent intervention, and possibly reduce length of hospitalization.

Frequent video or image-based communication between patient and provider may improve patient satisfaction by facilitating closer postoperative followup and wound care. After telemedicine was utilized by a VA Plastic Surgery Department for assessment of nonurgent pathologies like skin lesions and wound care, 83% of patients reported that they would prefer telemedicine over traditional evaluation for similar future visits. 63 High levels of patient satisfaction were also achieved with smartphone-based follow-up of facial cosmetic surgery and reviewing images remotely. 64, 65 These reports of improved patient experience likely stem from improved perception of communication.

Limitations for telemedicine implementation in facial plastic surgery include the ability to obtain and transmit appropriately oriented, high-quality images for facial analysis, as well as the barriers to patient-surgeon relationship which, while affected in all sub-specialties, are particularly important in this arena. 61 Recommendations for practice. We recommend that telemedicine be used in certain niches within facial plastic and reconstructive surgery such as facial trauma and wound management. While facial analysis can be achieved remotely, questions remain on how to readily obtain high-resolution photos with properly lighting and orientation. Areas of needed study include viability of remote facial soft tissue image capture and feasibility of remote surgical planning for cosmetic surgery.

Findings. Many disorders in pediatric ORL overlap with adults, and the application of telemedicine to pediatric ORL complaints, such as otitis media, has been described in the previous sections. Telemedicine has a wide applicability in pediatric ORL for obtaining patient history and assessing need for common surgeries such as obstructive sleep apnea, recurrent tonsillitis, and recurrent otitis media (Table VII) . 66, 67 Telemedicine has also been used for postoperative follow-up of common pediatric ORL procedures, such as tonsillectomy and adenoidectomy. 68 For general pediatric care in the outpatient setting, telemedicine may improve communication with parents. 69 Telemedicine has also been used to evaluated and manage pediatric acute tympanostomy tube otorrhea. Shaffer and Dohar reported that 83% of patients were diagnosed and treated without emergency room or office assessment, with no adverse outcomes recorded. 70 Recommendations for practice. We recommend that telemedicine be used when feasible to enhance communication and access between parents and providers in pediatric ORL, and to streamline referrals and work-up prior to in-patient consultation. Further study is required to identify and describe most impactful applications. Common pediatric emergencies like aerodigestive foreign bodies and postoperative complications like posttonsillectomy hemorrhage, however, will continue to require urgent in-person evaluation.

In the era of COVID-19, minimizing virus transmission has become a critical part of patient care, propelling telemedicine into the forefront of the healthcare conversation. To help meet the urgent need for telehealth implementation, federal agencies have increased coverage and suspended barriers to telehealth utilization. 71-73 A general limitation of telemedicine is that patients in rural or Insurance Portability and Accountability Act requirements broadening the technological applications that may be used to implement telehealth communications with patients during the COVID-19 pandemic. 72 Furthermore, the Office of Inspector General of the HHS has waived telehealth co-payments for Medicare patients. 73 While many states have temporarily relaxed licensure requirements to allow physicians to provide telemedicine across state and Medicare began reimbursing audio-only visits at the same rate as video and inperson visits reimbursement reform may be necessary to ensure that a full range of telehealth services is covered by insuring providers. 75,76 Furthermore, remotely assisting personnel must seek payment directly from the billing physician, requiring a contractual arrangement with the physician. 77 Fortunately, telemedicine is not new to ORL, and has precedents in each of the main subspecialties ( Table I) . Applications of telemedicine within ORL, as in other fields, fall into three distinct categories: synchronous care with and without assistant providers, as well as asynchronous care or SAF. Synchronous care without assistance includes interactions between the otolaryngologist and the patient without an assistant. These evaluations have been proven useful for head and neck oncology triaging and postoperative visits, vocal rehabilitation, endoscopic sinus surgery postoperative evaluation, allergic rhinitis management, facial trauma evaluation, and facial plastic postoperative evaluation. [17] [18] [19] 25, 45, 58, 60, 62, 64 The second category involves synchronous care with the presence of an assistant. Such assistants may be able to perform or facilitate remote diagnostic procedures such as inpatient flap checks, otoscopic evaluation, voice rehabilitation, and swallowing evaluation, as well as pre-and postoperative evaluation of pediatric patients. 23, 35, 36, 44, 45, [66] [67] [68] 70 Personnel must have adequate experience and training, without which the patient may be significantly at risk of pain, injury, or misdiagnosis. 15, 52 Robust telehealth networks must be created, wherein otolaryngologists can easily work with a patient's primary care provider to offer remote services and consultation. 60 The third category is asynchronous care or SAF telemedicine, in which primary data are collected, transmitted to the consultant, and evaluated at a later time point. Pathologies appropriate for asynchronous care are inherently nonurgent. Utilization of SAF techniques have already proven useful in head and neck oncology consultations, remote otologic and audiologic evaluation, cochlear implant and hearing aid management, laryngeal ultrasonography, nasolaryngoscopy, as well as CT sinus review. 16, 19, [26] [27] [28] [29] 31, 32, 34, 35, 38, 39, 41, [49] [50] [51] [52] [53] [54] [55] [56] [57] CONCLUSION Telemedicine has been successfully utilized to varying degrees in the past. Further studies must include rigorous design controls, and standardization of populations and outcome measures to reduce heterogeneity and improve applicability. 78 The COVID-19 pandemic has propelled its necessity and utilization into the mainstays of current ORL practice. Now is the time to establish standards of practice that are safe, effective, and affordable for providers and patients.

AKS and DAK conceptualized and designed the study, performed literature reviews, drafted and critically revised the manuscript. RJ, JS, ELS, and ML critically reviewed, performed and interpreted data/literature reviews, and revised the manuscript. NK conceptualized and designed the study, critically reviewed the manuscript draft and revisions. 

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