Online ENT Visits During COVID-19

At the 2019 Academy of Otolaryngology meeting, Dr. John Kokesh, Dr. David Cognetti, Dr. Davy Cohen, and I presented a panel titled “Telemedicine, practical tips for your implementation into your daily practice.”

To help physicians and ENTs seeking to quickly adopt telemedicine into their practice, I have posted my slides from this panel below. The slides describe the currently available tools for telemedicine and discuss the pros/cons of different platforms, as well as cost and use cases. *I have added an additional slide into this presentation relating to recent changes made by HHS during the COVID-19 crisis.**the academy has graciously made the video of the full talk available to everyone on YouTube. The link is also below! It can also be found for members at The AAO-HNS website under the 2019 annual meeting webcast.

If you are a provider trying to increase access for your patients during this uncertain time, please feel free to reach out to me directly with any questions about this talk or telemedicine in general. 

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YouTube: Telemedicine: Practical Tips for Implementation into your daily practice

What can an ENT do via an online or telemedical or telehealth visit?

What can an ENT do via an online or telemedical or telehealth visit?

While everyone understands the utility of seeing a psychiatrist or a primary care physician via video chat, it can be hard to see how a specialist visit can be done online. Still, my experience and the available evidence suggests it can be really helpful. Additionally, currently during the coronavirus pandemic, the American Academy of Otolaryngology Head and Neck Surgery is recommending all providers limit patient care to urgent and emergent in-person visits. 

To begin, I would argue that most of the diagnosis for any medical specialty comes from the doctor actively listening to the patient’s story and symptoms and asking poignant questions. 

Furthermore, most experienced physicians have a sort of ‘spider sense’ about who is sick and worrisome, and whose symptoms can be monitored for a bit longer. Video chat allows us to determine this by actually seeing the patient face-to-face. 

In ENT, through the use of video, we can examine a lot of the facial anatomy. 

Things we can do:

-a decent cranial nerve exam 

-evaluate any swelling or skin lesions 

-check eye/neck/tongue/facial muscle movements 

-assess bleeding

-with the use of a camera flash or flashlight, you can actually get a decent oral cavity exam

IMG_9096

(This isn’t as good as an exam with a tongue blade, but it certainly allows visualization!)

-with some software, the patient or a family member can even transmit an ear exam of anterior nose exam if they purchase a device like the firefly otoscope 

Together, all of this information can provide an ENT with a good sense of how to begin treating a patient. More importantly, it can help an ENT to determine whether a patient needs to be seen in the office or not. 

What can’t be done online? (Why an ENT may ultimately want to schedule an in-person visit)

The beauty of online visits is that it helps to determine who may need to be seen in-person at an office. 

For some symptoms, we will need to perform a hands-on exam at our office to ensure we are not missing anything concerning (like an infection or cancer). 

Often, your doctor may want to use a microscope or endoscope to examine a patient more closely. We call this ‘endoscopy,’ and it is typically quick and pain-free. It allows us to examine internal regions of the body or regions of the body that cannot be adequately observed with the naked eye. When making certain diagnoses, this type of in-person observation can provide vital information. 

I have included some endoscopy images below to give a sense of how much detail and anatomy we can observe with a physical exam in the office. 

(Above: on the viewers left a normal eardrum, on the viewers right a septal spur in the nose)

Should a patient be seen online or in person? The beauty is a patient doesn’t necessarily need to decide. Many ENTs are now offering online visits as a screening method. Depending on the results of your online or telehealth visit, your doctor may or may not ask you to come into the office. 

 

Article in the AAO-HNS Bulletin: Transition to in-office treatments

As a surgeon, I see firsthand that many of the advances in techniques for surgery are directly associated with new medical devices. Part of the challenge of my job is balancing an appropriate skepticism of new technology with an intellectual curiosity and drive to find innovation that can improve my patients’ lives.

Recently, the FDA reached out to the Academy of Otolaryngology to seek our opinion on a new medical device for our field. I think one of the most important reasons to be an active member of the Academy is it gives physicians a voice in the direction of new innovation. It’s only through this constant dialogue between innovators and clinicians that we can keep improving patient outcomes.

Rahul Shah MD and I wrote a quick article discussing the Academy’s consideration of and opinion on the recent FDA approval of the Tusker TULA device in this month’s bulletin. You can read our article below.

Article: Transition to in-office treatments

One of the trends we will continue to see in Otolaryngology and all of healthcare is a transition from operating-room based procedures to in-office procedures. These tend to be safer for patients, who avoid the risks of general anesthesia, but also more cost-effective for our healthcare system because they avoid the large facility fees often associated with hospital-based procedures. The other benefit in-office treatments offer is quicker access to care, since they don’t require physicians to coordinate with a hospital, where multiple physicians often share operating-room time. This aligns well with the other trend we will see in healthcare, as well as all fields, of patients wanting faster means of solving their problems. Ultimately, the combination of being safer, more cost-effective, and quicker will lead to this in-office field burgeoning.

ENT and telemedicine: BPPV telemedicine consults are feasible and could save money

We will be exhibiting the initial results of our tele-medical BPPV consult study as a poster for the Triological Society session at the Combined Otolaryngology Spring Meetings for 2017.Telemedical BPPV Consults Poster .001Discussion posted below for ease of reading:

Within our small sample size, a number of patients who were referred for an evaluation of their dizziness had initially undergone a CT or MRI in the emergency department to evaluate their complaint of dizziness.

Our initial proof of concept study found that for a small sample size, remote diagnosis of BPPV via telemedical consults is possible with high specificity. Based on the specificity, it is appears unlikely that a trained otologist or neurologist reviewing videos of ocular findings of a DHT would misdiagnose a more concerning cause of dizziness as BPPV. Thus, this could easily serve as a screening tool to quickly triage dizzy patients into those requiring more costly work-up and those who do not.

While other authors have suggested using video-oculography [3] or educational algorithms [4] to help distinguish benign versus concerning causes of dizziness, the barriers to adoption of these methods are the cost of equipment and ER workflow. However, due to the prevalence of HIPAA-compliant texting applications and the ubiquity of smartphones, adoption of smartphone-based video consults into an ER workflow is feasible. This is supported by a recent survey of worldwide ER physicians, which found that many wanted assistance with evaluating and distinguishing causes of dizziness [5]. While academic centers may have neurologists or otolarygologists on call, rural and community centers could gain access to these specialists through telemedical means.

Since the DHT is easily taught, having an otolaryngologist interpret the resulting eye movements remotely may increase usage of the test and may lead to cost savings.