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

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(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. 

 

Telemedicine in Otolaryngology Panel Discussion at the Academy Meeting

It was an honor to sit on the panel for a presentation on ‘Telemedicine: practical tips for implementation into your daily practice’ at this past years’ Academy of Otolaryngology Head and Neck Surgery Annual Meeting. Since it was in New Orleans, I wasn’t that upset about traveling to the city of Jazz and beignets.IMG_5654.JPG

I was honestly surprised and impressed by how well the talk was attended, and it was great to see so many other otolaryngologists looking to incorporate telemedicine into their practice to improve patient care.

The other members of the panel were inspiring: Dr. John Kokesh helped create a system of telehealth to provide otolaryngology care to the underserved across the vast distances of Alaska, and Dr. David Cognetti has been utilizing telehealth in an urban settings in innovative ways to improve the quality of Jefferson University Health’s Head and Neck Cancer Care. If you have an interest in telemedicine in ENT, you should read about these two innovators work.

The full video of the panel can be found on the AAO-HNS website, under the AcademyU (however you must be an Academy member to view it).

We hope to expand upon the panel next year. Thank you to everyone who attended.

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.

 

Surgeon Workflow Matters in Device Design

This post was originally posted on the Device Talk blog for Medical Drug and Diagnostic Industry Online. You may find it here: http://www.mddionline.com/blog/devicetalk/surgeon-workflow-matters-device-design-07-28-16

Engineers, take note: paying attention to how a clinician operates can lead to a well-designed device that enjoys widespread adoption.

Manan Shah, MD and Timothy O’Brien, MD

Processed with Snapseed.

In print, Sept. 2016 edition

As clinicians, we know that surgical devices need to fit into the flow of a procedure in order to be used frequently. A key example of this is the coblator device, which is used during tonsillectomies. The coblator demonstrates how one company’s solution to a simple surgical design problem resulted in widespread adoption despite other potential drawbacks.

Tonsillectomies are one of the most common procedures performed by otolaryngologists. Despite the frequency of the procedure, the authors of a recent study from Michigan State University pointed out that there “is no consensus regarding optimal surgical technique or instrument selection.” The most common technique involves the use of a monopolar electrocautery, which applies energy directly to tissues to generate heat and burn the tissue. A newer technique uses the coblator device, which employs low-temperature radiofrequency ablation to break molecular bonds in the tissue. The coblator is used by many otolarygologists even though it costs more than monopolar electrocautery and the data on its benefits are mixed.

Why Do Surgeons Use the Coblator?

The key to grasping the coblator’s popularity is understanding the steps of a tonsillectomy surgery. The coblator device, offered by Smith & Nephew, was designed to combine a suction tool, an ablation tool for dissection, and coagulation tool to control bleeding. This combination fits ideally into the tonsillectomy workflow because surgeons often switch between two tools to achieve all of this during the procedure. From a surgeon’s perspective, the engineers of the coblator were able to combine two separate instruments that surgeons often use successively during a tonsillectomy.

A monopolar cautery burns in a thin line, like a knife. It is a fine instrument that assists in dissecting the tonsils out of the mouth while leaving the throat muscles untouched. But each tonsil has a number of blood vessels that connect to it and supply the tonsil with blood. When the surgeon inevitably comes across one of these vessels, the thin, knife-like burn of the monopolar cautery is often not enough to stop vessel bleeding. As a result, blood quickly fills the mouth, obscuring the surgeon’s view. The surgeon is forced to quickly switch to a suction cautery to remove the blood, regain visualization of the vessel, and then use a more diffuse cone of cautery to coagulate the vessel.

The required switch between the monopolar cautery and the suction cautery takes time, and vessels bleed quickly. While surgical assistants are fast, the surgeon must wait—hand outstretched—for the next device, while watching the patient’s mouth fill with blood. In contrast, with the coblator, the suction cautery is already built into the device, so surgeons can simply move their foot to a different controller pedal in order to activate the coagulation tool and stop the bleeding, without ever removing the instrument from the patient’s mouth. The coblator allows surgeons to single-handedly control the vessel bleed more quickly, decreasing time and blood loss.

Because of how the monopolar electrocautery works, it cannot simply be combined with a suction cautery, which is why a new device was developed. The designers of the coblator understood the workflow of a tonsillectomy, recognized the need for a combined excising and coagulation tool, and were able to produce a new tool that streamlines the workflow and makes the surgeon more comfortable when performing a tonsillectomy.

What Does the Data Say?

The data on the benefits of coblation are uncertain. The concept behind coblation is that using a lower-temperature method to remove the tonsils should lead to less collateral damage to surrounding tissues. The hypothesis is that decreased collateral damage leads to decreased post-operative pain and better healing. Many surgeons adhere to this line of logic and believe that decreased pain to the patient is worth the extra cost of using the coblator device.

Studies using tissue samples have confirmed that there is decreased depth of tissue injury using the coblator compared to the monopolar cautery. However, a number of studies have also found that there is no significant difference in post-op pain survey scores between the two techniques. Some surgeons argue that the pain-survey results are due to poor study design, and a Cochrane review of studies on coblators cites a lack of strong studies as a potential cause of the uncertainty over the outcomes of the two techniques. Further recent studies still have not settled the debate on post-op pain benefit. Accordingly, the comparative data remains unclear as to how the outcomes of the two techniques compare.

While many surgeons assert that they use the coblator with the intension of decreasing post-operative pain for the patient, a review of the literature suggests that there is also a more visceral reason for their preference: the lack of switching tools gives a sense of decreased patient blood loss. But the data is mixed. While some studies show a significant difference in blood loss, others do not, and there are even concerns raised about higher risks of post-operative bleeding. Additionally, while some argue that surgeons use coblation simply to save time, studies fail to show any significant decrease in operative time.

The coblator device costs more than a traditional monopolar electrocautery. While both devices require a stand-alone controller unit, most hospitals already stock the monopolar cautery controller units, because monopolar cautery devices are used in a number of different surgeries. In contrast, the coblation device requires the purchase of an entirely new controller not typically stocked by hospitals. On top of this, the disposable unit for each procedure costs more for the coblator than for the monopolar cautery. The Thottam et al. study from Michigan State University estimated that the average overall combined cost of both the instrument and the anesthesia for the coblation technique amounted to $244.32 per procedure, versus only $30.04 per procedure for the monopolar electrocautery. It is important to understand that the reimbursement for a tonsillectomy is the same, regardless of which device is used. Because neither the hospital nor the surgeon is paid more to use the coblator device, facilities may actually incentivize surgeons to avoid using the coblator to save the hospital money.

Overall, there is not yet an obvious consensus among surgeons over whether to use the coblator or the traditional monopolar electrocautery. Until more conclusive data can be obtained, each surgeon must ultimately utilize the device that they feel provides the best outcome for their patients. An ideal device would have strong clinical data and save our healthcare system resources. However, even with equivocal data and higher costs, the coblator has gained support among surgeons because of its ability to seamlessly fit into the tonsillectomy workflow and address perceived risks by the surgeon.

Personally, I am more familiar with the monopolar electrocautery device, so I prefer using that tool and my patients do well. Still, whenever I run into a case that requires frequent switching between the monopolar electrocautery and the suction cautery, I can’t help but think about the coblator. It is a great example of how engineers understood the needs of the surgeon and developed technology to improve surgical workflow.

Medical device designers and engineers need to understand exactly how a surgeon will interact with their device. For innovators, observing procedures and discovering points of inefficiency, like the tool switching moments in a tonsillectomy, can provide opportunities for improvement. Overall, understanding how to make the healthcare team more comfortable can increase efficiency, and most importantly, benefit the patient.

Manan Shah, MD is a biomedical engineer and current resident in Otolaryngology at the University of Connecticut

Timothy O’Brien, MD is a board certified Otolaryngologist and an assistant clinical professor at the University of Connecticut School of Medicine

The authors have no financial ties, royalties, or relationships with any of the companies or devices in this article.