Diagnostic accuracy of the video otoscope in tympanic membrane perforation

OBJECTIVE

The video otoscope has already proven to be useful for the diagnosis of several pathologies, so the objective of this study was to evaluate the diagnostic accuracy of the video otoscope in cases of tympanic membrane perforation.

METHODS

This is a diagnostic accuracy study performed at the hearing health division of a tertiary-level referral hospital. Patients older than 8 years of age who had any symptom that could be related to perforation (otalgia, otorrhea, tinnitus, and/or hypoacusis) were invited to participate in the study. Participants were evaluated by three different diagnostic methods (otomicroscope, conventional otoscope, and video otoscope) performed by three different evaluators in a blind fashion. The microscope was considered the reference standard.

RESULTS

176 patients were evaluated, totaling 352 tympanic membranes. Twenty-seven tympanic membrane perforations were diagnosed by the microscope, a prevalence of 7.7%. The video otoscope showed a sensitivity of 85.2% (95% CI 81.5%‒88.9%), specificity of 98.1% (95% CI 96.7%‒99.5%) and accuracy of 97.1% (95% CI 95.4 %-98.8 %). The conventional otoscope showed a sensitivity of 96.3% (95% CI 94.3-98.3), specificity of 98.8% (95% CI 97.7-99.9) and accuracy of 98.6% (95% CI 97.4-99.8). The Kappa value between the microscope and the video otoscope was 0.8 and between the microscope and the conventional otoscope was 0.9. Regarding the participants' perception, 53.4% (p< 0.001) considered the video otoscope as the best method for understanding the tympanic membrane condition presented by them.

CONCLUSIONS

The video otoscope showed relevant sensitivity and specificity for clinical practice in the diagnosis of tympanic membrane perforation. Moreover, this is an equipment that can facilitate the patient's understanding of the otologic pathology presented by him/her. In this regard, this method may be important for better patient compliance, requiring further studies to evaluate this hypothesis.

LEVEL OF EVIDENCE

Is this diagnostic or monitoring test accurate? (Diagnosis)-Level 2 (Individual cross-sectional studies with consistently applied reference standard and blinding).

The use of clinical photography to aid in the triage of ENT patient referrals

Waiting lists for Ear, Nose and Throat (ENT) outpatient appointments are currently the longest that they have ever been. The Aneurin Bevan University Health Board has adopted a unique Clinical Photography ENT triage service to tackle this. General Practitioner referrals are triaged by ENT consultants, to identify those patients in whom otoscopic imaging could be used to detect a serious otological condition or to enable virtual management. They are triaged to Clinical Photography, to undergo digital imaging which is reviewed in a virtual clinic alongside the initial referral. 72 patients have completed the pathway, with 51.3% discharged without requirement for face-to-face consultant appointment. 9.7% were upgraded to urgent or 2 week waits. This intervention is predicted to help identify patients on the waiting list with potentially serious disease so that they do not wait excessively, and to reduce waiting times for outpatient appointments in ENT.

Diagnostic accuracy and management concordance of otorhinolaryngological diseases through telehealth or remote visits: A systematic review & meta-analysis

INTRODUCTION

COVID-19 has led to delays in providing healthcare in both emergency and non-emergency settings, especially in surgical subspecialties which rely heavily on referrals and in-person visits. Without an established telehealth infrastructure, many otorhinolaryngological departments experienced decreases in consultations. Telemedicine has attempted to bridge the gap between pre- and post-pandemic periods by creating a safe avenue of communication between otorhinolaryngologists and patients. This review hopes to address the accuracy of telemedicine in patient diagnosis and management.

METHODS

Searches were conducted since study conception until June 30, 2022, on multiple databases including PubMed, SCOPUS, and CINAHL for this systematic review and meta-analysis. Diagnostic accuracy, management accuracy, kappa, sensitivity, specificity, positive predictive value (PPV), and negative predictive value (NPV) were meta-analyzed by comparing virtual visits to in-person visits (gold standard).

RESULTS

Nineteen studies were included in this review. A total of 1518 patients were included across all studies. When comparing virtual visits against in-person visits, accurate diagnosis was made in 86.2% [82.1,89.9, I² = 73.5%, P < 0.0001] of patients and management accuracy was 91.5% [86.1,95.7, I² = 81.8%, P < 0.0001] when treating patients. Kappa value determining interrater reliability was 0.8 [0.7,0.9, I² = 81.8%, P < 0.0001].

CONCLUSION

Our data suggest that diagnostic and management concordance is above 80% when comparing diagnosis and management strategies in patients who underwent both telehealth and in-person visits with an otorhinolaryngologist. In uncomplicated patients, telehealth might be a reliable source for diagnosis and management however, in-person consultation is likely still required for pathologies in which physical exam, imaging or procedural elements represent a vital component of the work-up.

Experience with Telemedicine in a Tertiary Academic Otologic Clinic During the COVID-19 Pandemic

OBJECTIVE

To examine the utility of telemedicine in a tertiary otologic practice.

STUDY DESIGN

Retrospective case series.

SETTING

Tertiary neurotology clinic.

PATIENTS

Consecutive adult patients presenting via video visit between January 2020 and January 2021.

INTERVENTIONS

Televideo modality to conduct visits with patients seeking evaluation for new concerns, second opinions, or routine follow-up for established conditions.

MAIN OUTCOME MEASURES

Success of the televideo visit defined by the televideo visit being sufficient for determining a definitive plan and not requiring deferment of recommendations for a subsequent in-person visit.

RESULTS

A total of 102 televideo visits were performed among 100 unique patients. Of those, 92 (90.2%) visits were for second opinions or evaluation of new concerns, most commonly for vestibular schwannoma (n = 32, 31.4%), followed by sensorineural hearing loss (n = 20, 19.6%). Other visits were conducted for early postoperative follow-up and established general follow-up. In 91.2% of cases (n = 93), patients were successfully evaluated and provided recommendations from the initial video visit. All visits with patients having a diagnosis of meningioma (n = 7), and nearly all with vestibular Schwannoma (97%, n = 31) and sensorineural hearing loss (95%, n = 19) were successful. Of the 79 patients offered surgery as one potential treatment option, 31 patients underwent surgery at our institution by time of review. Patients with unsuccessful visits (n = 9, 8.8%) were advised to schedule additional in-person diagnostic imaging, vestibular testing, or cochlear implant candidacy evaluation to establish a more definitive care plan.

CONCLUSION

Virtual televideo visits were successful for a high percentage of selected patients seen at a tertiary neurotology practice, particularly those seeking evaluation of vestibular schwannoma or sensorineural hearing loss.

Smartphone-based artificial intelligence using a transfer learning algorithm for the detection and diagnosis of middle ear diseases: A retrospective deep learning study

BACKGROUND

Middle ear diseases such as otitis media and middle ear effusion, for which diagnoses are often delayed or misdiagnosed, are among the most common issues faced by clinicians providing primary care for children and adolescents. Artificial intelligence (AI) has the potential to assist clinicians in the detection and diagnosis of middle ear diseases through imaging.

METHODS

Otoendoscopic images obtained by otolaryngologists from Taipei Veterans General Hospital in Taiwan between Jany 1, 2011 to Dec 31, 2019 were collected retrospectively and de-identified. The images were entered into convolutional neural network (CNN) training models after data pre-processing, augmentation and splitting. To differentiate sophisticated middle ear diseases, nine CNN-based models were constructed to recognize middle ear diseases. The best-performing models were chosen and ensembled in a small CNN for mobile device use. The pretrained model was converted into the smartphone-based program, and the utility was evaluated in terms of detecting and classifying ten middle ear diseases based on otoendoscopic images. A class activation map (CAM) was also used to identify key features for CNN classification. The performance of each classifier was determined by its accuracy, precision, recall, and F1-score.

FINDINGS

A total of 2820 clinical eardrum images were collected for model training. The programme achieved a high detection accuracy for binary outcomes (pass/refer) of otoendoscopic images and ten different disease categories, with an accuracy reaching 98.0% after model optimisation. Furthermore, the application presented a smooth recognition process and a user-friendly interface and demonstrated excellent performance, with an accuracy of 97.6%. A fifty-question questionnaire related to middle ear diseases was designed for practitioners with different levels of clinical experience. The AI-empowered mobile algorithm's detection accuracy was generally superior to that of general physicians, resident doctors, and otolaryngology specialists (36.0%, 80.0% and 90.0%, respectively). Our results show that the proposed method provides sufficient treatment recommendations that are comparable to those of specialists.

INTERPRETATION

We developed a deep learning model that can detect and classify middle ear diseases. The use of smartphone-based point-of-care diagnostic devices with AI-empowered automated classification can provide real-world smart medical solutions for the diagnosis of middle ear diseases and telemedicine.

FUNDING

This study was supported by grants from the Ministry of Science and Technology (MOST110-2622-8-075-001, MOST110-2320-B-075-004-MY3, MOST-110-2634-F-A49 -005, MOST110-2745-B-075A-001A and MOST110-2221-E-075-005), Veterans General Hospitals and University System of Taiwan Joint Research Program (VGHUST111-G6-11-2, VGHUST111c-140), and Taipei Veterans General Hospital (V111E-002-3).

Community health workers and mHealth systems for hearing screening in rural Nicaraguan schoolchildren

Background

We aimed to investigate the effectiveness of using minimally trained community health workers (CHW) to screen schoolchildren in rural Nicaragua for hearing loss using a tablet-based audiometric system integrated with asynchronous telehealth evaluations and mobile health (mHealth) appointment reminders.

Methods

A population-based survey was conducted using community health workers (CHWs) to perform tablet-based audiometry, asynchronous telehealth evaluations, and mHealth reminders to screen 3398 school children (7-9 years of age) in 92 rural Nicaraguan communities. The accuracy of screening, test duration, testing efficiency, telehealth data validity, and compliance with recommended clinic visits were analyzed.

Results

Minimally trained CHWs successfully screened children within remote rural schools with automated audiometry (test duration = 5.8 minutes) followed by manual audiometry if needed (test duration = 4.3 minutes) with an estimated manual audiometry validity of 98.5% based on a review of convergence patterns. For children who were referred based on audiometry, the otoscopy and tympanometry obtained during telehealth evaluations were high quality (as reviewed by 3 experts) in 44.6% and 80.1% of ears, respectively. A combination of automated short message service (SMS) text messages and voice reminders resulted in a follow-up compliance of 75.2%. No families responded to SMS messages alone.

Conclusions

Tablet-based hearing screening administered by minimally trained CHWs is feasible and effective in low- and middle-income countries. Manual audiometry was as efficient as automated audiometry in this setting. The physical exam tasks of otoscopy and tympanometry require additional training. Mobile phone messages improve compliance for confirmatory audiometry, but the utility of SMS messaging alone is unclear in this population.

The use of mobile devices in oculoplastic and oral and maxillofacial surgery: A systematic review

BACKGROUND

The use of smartphones in the United States has more than doubled since 2011. Mobile phone applications have versatile functions in ophthalmology, otolaryngology, and plastic surgery, such as increasing patient engagement in treatment, decreasing no-shows to appointments, and providing patient education. They also provide practical advantages to the clinician, including supplementing an otoscope, laryngoscope, or ophthalmoscope. Their use in oral and maxillofacial surgery (OMFS) and oculoplastic surgery has shown effectiveness for a variety of applications, such as for photography and medical reference. Research suggests that smartphones may improve clinical outcomes and efficiency.

OBJECTIVE

The goal of this study is to provide a comprehensive and up-to-date systematic review of the available literature investigating mobile phone use in oculoplastic surgery and OMFS.

METHODS

A query of terms relevant to oculoplastic surgery and OMFS was conducted using the databases PubMed, CINAHL, Web of Science, and PsychINFO to identify studies meeting inclusion criteria that investigated the implementation, efficacy, and outcomes of mobile device use in oculoplastic surgery and OMFS. A qualitative summary and discussion of the literature was subsequently synthesized.

RESULTS

Out of a total of 289 articles reviewed, 171 were removed due to duplication across the four databases. Of the 118 studies remaining, 19 of them were included within the final qualitative review after screening the abstracts and full text for relevance. The articles were published between 2005 and 2020 from 7 different countries. Review of the relevant articles showed three settings in which mobile devices were used: communication between providers, communication between providers and patients, and as surgical supplementation. The literature review included use of mobile device photography for quality improvement, visual representation of procedures for patient education, and improved communication amongst providers and patients in the setting of oculoplastics and OMFS.

CONCLUSION

Mobile device use has become ubiquitous across cultures worldwide. The literature suggests that mobile phone use in oculoplastic surgery and OMFS may improve clinical practice in multiple settings. However, further investigation is necessary to quantify the clinical benefits of mobile device use in oculoplastic and oral and maxillofacial surgery.

Smartphone-Enabled versus Conventional Otoscopy in Detecting Middle Ear Disease: A Meta-Analysis

Traditional otoscopy has some limitations, including poor visualization and inadequate time for evaluation in suboptimal environments. Smartphone-enabled otoscopy may improve examination quality and serve as a potential diagnostic tool for middle ear diseases using a telemedicine approach. The main objectives are to compare the correctness of smartphone-enabled otoscopy and traditional otoscopy and to evaluate the diagnostic confidence of the examiner via meta-analysis. From inception through 20 January 2022, the Cochrane Library, PubMed, EMBASE, Web of Science, and Scopus databases were searched. Studies comparing smartphone-enabled otoscopy with traditional otoscopy regarding the outcome of interest were eligible. The relative risk (RR) for the rate of correctness in diagnosing ear conditions and the standardized mean difference (SMD) in diagnostic confidence were extracted. Sensitivity analysis and trial sequential analyses (TSAs) were conducted to further examine the pooled results. Study quality was evaluated by using the revised Cochrane risk of bias tool 2. Consequently, a total of 1840 examinees were divided into the smartphone-enabled otoscopy group and the traditional otoscopy group. Overall, the pooled result showed that smartphone-enabled otoscopy was associated with higher correctness than traditional otoscopy (RR, 1.26; 95% CI, 1.06 to 1.51; p = 0.01; I² = 70.0%). Consistently significant associations were also observed in the analysis after excluding the simulation study (RR, 1.10; 95% CI, 1.00 to 1.21; p = 0.04; I² = 0%) and normal ear conditions (RR, 1.18; 95% CI, 1.01 to 1.40; p = 0.04; I² = 65.0%). For the confidence of examiners using both otoscopy methods, the pooled result was nonsignificant between the smartphone-enabled otoscopy and traditional otoscopy groups (SMD, 0.08; 95% CI, -0.24 to 0.40; p = 0.61; I² = 16.3%). In conclusion, smartphone-enabled otoscopy was associated with a higher rate of correctness in the detection of middle ear diseases, and in patients with otologic complaints, the use of smartphone-enabled otoscopy may be considered. More large-scale studies should be performed to consolidate the results.

Prevalence and characteristics of hearing and vision loss in preschool children from low income South African communities: results of a screening program of 10,390 children

BACKGROUND

The majority of children with sensory impairments live in low- and middle-income countries. More studies of hearing and vision impairment prevalence are needed, in order to generate more accurate estimates of trends in sensory impairments. This study aimed to estimate the prevalence and describe the characteristics of hearing and vision loss among preschool children (4-7 years) in an underserved South African community following community-based mobile health (mHealth) supported hearing and vision services.

METHODS

A screening program of sensory impairments was undertaken of children attending preschools in the communities of Khayelitsha and Mitchell's Plain, Cape Town, from September 2017 until June 2019. Hearing and vision screening were done by trained community health workers using mHealth technology. Children who failed hearing and vision screening were seen for follow-up assessments at their preschools. Follow-up assessments were conducted using smartphones that host point-of-care validated and calibrated hearing and vision testing applications (hearTest app, hearX Group, South Africa and PeekAcuity app, Peek Vision, United Kingdom). Descriptive statistical analysis and logistic regression analysis were conducted after extracting data from a secure cloud-based server (mHealth Studio, hearX Group) to Microsoft Excel (2016).

RESULTS

A total of 10,390 children were screened at 298 preschools over 22 months. Of the children screened, 5.6 and 4.4% of children failed hearing and vision screening respectively. Community-based follow-up hearing tests were done at the preschools on 88.5% (514) of children of whom 240 children (54.2% female) presented with hearing loss. A preschool-based follow-up vision test was done on 400 children (88.1%). A total of 232 children (46.1% female) had a vision impairment, and a further 32 children passed the test but had obvious signs of ocular morbidity. Logistic regression analysis found that age was a significant predictor of vision loss (p < 0.05), but not for hearing loss (p = 0.06). Gender was not a significant predictor of hearing (p = 0.22) or vision loss (p = 0.20).

CONCLUSIONS

Hearing loss is prevalent in at least 22 per 1000 and vision loss in at least 23 per 1000 preschool children in an underserved South African community. Timely identification of sensory losses can be facilitated through community-based hearing and vision services supported by mHealth technology.

New Approaches and Technologies to Improve Accuracy of Acute Otitis Media Diagnosis

Several studies have shown that in recent years incidence of acute otitis media (AOM) has declined worldwide. However, related medical, social, and economic problems for patients, their families, and society remain very high. Better knowledge of potential risk factors for AOM development and more effective preventive interventions, particularly in AOM-prone children, can further reduce disease incidence. However, a more accurate AOM diagnosis seems essential to achieve this goal. Diagnostic uncertainty is common, and to avoid risks related to a disease caused mainly by bacteria, several children without AOM are treated with antibiotics and followed as true AOM cases. The main objective of this manuscript is to discuss the most common difficulties that presently limit accurate AOM diagnosis and the new approaches and technologies that have been proposed to improve disease detection. We showed that misdiagnosis can be dangerous or lead to relevant therapeutic mistakes. The need to improve AOM diagnosis has allowed the identification of a long list of technologies to visualize and evaluate the tympanic membrane and to assess middle-ear effusion. Most of the new instruments, including light field otoscopy, optical coherence tomography, low-coherence interferometry, and Raman spectroscopy, are far from being introduced in clinical practice. Video-otoscopy can be effective, especially when it is used in association with telemedicine, parents' cooperation, and artificial intelligence. Introduction of otologic telemedicine and use of artificial intelligence among pediatricians and ENT specialists must be strongly promoted in order to reduce mistakes in AOM diagnosis.

Smartphone-enabled otoscopy: method evaluation in clinical practice

OBJECTIVE

To assess the diagnostic agreement between smartphone-enabled otoscopy and rigid otoendoscopy in tympanic membrane and middle ear diseases.

METHODS

A cross-sectional study was carried out to analyze otoscopies in patients seen at a general otorhinolaryngology (ORL) outpatient clinic, from June to December 2019. Eighty-three images of patients obtained from otoscopies performed through a smartphone device and a rigid endoscope were included, recorded, and stored for further analysis. The images were first analyzed by an experienced otologist, who assigned his diagnostic impression (defined as the gold standard) on each of the images. After this analysis, the images were displayed to a group of secondary raters (an experienced otorhinolaryngologist, a second-year resident in ORL, and a general practitioner). A questionnaire was applied related to each image.

RESULTS

There was high agreement between the smartphone device and the otoendoscopy images for all professionals, with a Kappa coefficient of 0.97 (p < 0.001). The smartphone device showed a diagnostic sensitivity of 81.1% and a specificity of 71.1%. As for the otoendoscopy, it showed a sensitivity of 84.7% and a specificity of 72.4%. The image classification as "2 = Good" was the most frequent one, with 34.9% for otoendoscopy and 31.6% for the smartphone device.

CONCLUSION

There was a high diagnostic agreement between smartphone device-guided otoscopy and the rigid otoendoscopy, demonstrating the feasibility of using this device in clinical practice.

LEVEL OF EVIDENCE: 3

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.

A Web-Based Deep Learning Model for Automated Diagnosis of Otoscopic Images

OBJECTIVES

To develop a multiclass-classifier deep learning model and website for distinguishing tympanic membrane (TM) pathologies based on otoscopic images.

METHODS

An otoscopic image database developed by utilizing publicly available online images and open databases was assessed by convolutional neural network (CNN) models including ResNet-50, Inception-V3, Inception-Resnet-V2, and MobileNetV2. Training and testing were conducted with a 75:25 breakdown. Area under the curve of receiver operating characteristics (AUC-ROC), accuracy, sensitivity, specificity, positive predictive value (PPV), and negative predictive value (NPV) were used to compare different CNN models' performances in classifying TM images.

RESULTS

Our database included 400 images, organized into normal (n = 196) and abnormal classes (n = 204), including acute otitis media (n = 116), otitis externa (n = 44), chronic suppurative otitis media (n = 23), and cerumen impaction (n = 21). For binary classification between normal versus abnormal TM, the best performing model had average AUC-ROC of 0.902 (MobileNetV2), followed by 0.745 (Inception-Resnet-V2), 0.731 (ResNet-50), and 0.636 (Inception-V3). Accuracy ranged between 0.73-0.77, sensitivity 0.72-0.88, specificity 0.58-0.84, PPV 0.68-0.81, and NPV 0.73-0.83. Macro-AUC-ROC for MobileNetV2 based multiclass-classifier was 0.91, with accuracy of 66%. Binary and multiclass-classifier models based on MobileNetV2 were loaded onto a publicly accessible and user-friendly website (https://headneckml.com/tympanic). This allows the readership to upload TM images for real-time predictions using the developed algorithms.

CONCLUSIONS

Novel CNN algorithms were developed with high AUC-ROCs for differentiating between various TM pathologies. This was further deployed as a proof-of-concept publicly accessible website for real-time predictions.

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

Practice of Telehealth in Otolaryngology: A Scoping Review in the Era of COVID-19

OBJECTIVE

The COVID-19 pandemic has spurred widespread adoption and advancement in telehealth activities, representing a marked change in otolaryngology practice patterns. The present study undertakes a scoping review of research focused on telehealth in otolaryngology (teleotolaryngology) to identify key themes and commonly utilized outcome measures that will assist future development in this growing field.

DATA SOURCES

PubMed, Embase, and Cochrane databases and reference review.

REVIEW METHODS

Per guidelines of the PRISMA Extension for Scoping Reviews, we performed database queries using a comprehensive search strategy developed in collaboration with research librarians at the Columbia University Irving Medical Center. We identified 596 unique references to undergo title and abstract review by 2 independent reviewers, leaving 439 studies for full-text review.

RESULTS

We included 285 studies for extraction of notable findings, leaving 262 unique studies after accounting for content overlap. We identified core outcome measures, including patient and provider satisfaction, costs and benefits, quality of care, feasibility, and access to care. Publication volume increased markedly over time, though only 4% of studies incorporated randomized study group assignment. Using an iterative approach to thematic development, we organized article content across 5 main themes: (1) exploration of teleotolaryngology evolution, (2) role in virtual clinical encounters, (3) applications in interdisciplinary care and educational initiatives, (4) emerging and innovative technologies, and (5) barriers to implementation.

CONCLUSION

This scoping review of teleotolaryngology documents its evolution and identifies current use cases, limitations, and emerging applications, providing a foundation from which to build future studies, inform policy decision making, and facilitate implementation where appropriate.

Continuation of telemedicine in otolaryngology post-COVID-19: Applications by subspecialty

Objective

The purpose of this paper is to review the literature and compile key clinically relevant applications of telemedicine for use in otolaryngology relevant to the post-COVID-19 era.

Study design

Systematic Literature Review.

Data sources

Pubmed and Google Scholar.

Review methods

Pubmed and Google Scholar were queried using combined key words such as “telemedicine,” “covid” and “otolaryngology.” The searches were completed in March–August 2020. Additional queries were made with particular subspecialty phrases such as “rhinology” or “otology” to maximize yield of relevant titles. Relevant articles were selected for abstract review. Applicable abstracts were then selected for review of the full text.

Results

Initial search identified 279 results. These were screened for relevance and 100 abstracts were selected for review. Abstracts were excluded if they were not in English, not related to otolaryngology, or if the full text was unavailable for access. Of these, 37 articles were selected for complete review of the full text.

Conclusion

The sudden healthcare closures during the COVID-19 pandemic resulted in a sharp increase in the use of telemedicine, particularly in subspecialty fields. Otolaryngologists are at a unique risk of infection resulting from the examination of the head and neck and aerosol-generating procedures due to the predilection of viral particles for the nasal cavities and pharynx. The COVID-19 pandemic may have served as a catalyst to implement telemedicine into clinical practice, however identifying ways to integrate telemedicine long term is key for a sustainable and viable practice in the post-COVID-19 era. Although many states are now finding themselves on the down-sloping side of their infection rate curve, many others remain at the apex. Additionally, the risk of future waves of this pandemic, or the onset of another pandemic, should not be overlooked. Practice modification guidelines that mitigate infection risk by utilizing telemedicine would be useful in these instances. Telemedicine can help to reduce infection spread by limiting unnecessary in-person interactions and help conserve personal protective equipment (PPE) by facilitating remote care with the added benefits of expanding care to broad geographic areas, limiting cost, time, and travel burden on patients and families, and enabling consistent follow up.

Current Status of Handheld Otoscopy Training: A Systematic Review

OBJECTIVE

Otoscopy is a frequently performed procedure and competency in this skill is important across many specialties. We aim to systematically review current medical educational evidence for training of handheld otoscopy skills.

METHODS

Following the PRISMA guideline, studies reporting on training and/or assessment of handheld otoscopy were identified searching the following databases: PubMed, Embase, OVID, the Cochrane Library, PloS Medicine, Directory of Open Access Journal (DOAJ), and Web of Science. Two reviewers extracted data on study design, training intervention, educational outcomes, and results. Quality of educational evidence was assessed along with classification according to Kirkpatrick's model of educational outcomes.

RESULTS

The searches yielded a total of 6064 studies with a final inclusion of 33 studies for the qualitative synthesis. Handheld otoscopy training could be divided into workshops, physical simulators, web-based training/e-learning, and smartphone-enabled otoscopy. Workshops were the most commonly described educational intervention and typically consisted of lectures, hands-on demonstrations, and training on peers. Almost all studies reported a favorable effect on either learner attitude, knowledge, or skills. The educational quality of the studies was reasonable but the educational outcomes were mostly evaluated on the lower Kirkpatrick levels with only a single study determining the effects of training on actual change in the learner behavior.

CONCLUSION

Overall, it seems that any systematic approach to training of handheld otoscopy is beneficial in training regardless of learner level, but the heterogeneity of the studies makes comparisons between studies difficult and the relative effect sizes of the interventions could not be determined.

Using telemedicine to facilitate social distancing in otolaryngology: A systematic review

OBJECTIVES

As the coronavirus 2019 pandemic puts strains on current models of otolaryngology practice, telemedicine is an attractive way for otolaryngologists to reduce in-person appointments while still addressing the health of their patients. This systematic review of the literature aims to identify the evidence basis for using telemedicine in otolaryngology practice to limit person-to-person interactions while achieving comparable quality to in-person services.

METHODS

The authors gathered articles from three databases (Embase, PubMed and Web of Science), performed a comprehensive literature review of articles published on telemedicine since 2002, and selected articles for inclusion based on their relevance to otolaryngology and the potential of the intervention to improve patient social distancing.

RESULTS

A total of 7153 articles were identified from the initial query. After review, 35 met the inclusion criteria. Of the included articles, 32 (91%), found their specific telemedicine intervention to be effective when compared to in-person services. Twenty articles (57%) were related to remote otoscopy. Other telemedical interventions included videoconferencing for peri-operative visits, diagnosis of peritonsillar abscess, telephone-based voice evaluations and evaluation of nasal fractures.

CONCLUSIONS

Video-otoscopy is the most well-supported telemedical intervention which limits physical contact between otolaryngologists and their patients. Other interventions have also demonstrated efficacy but have yet to be as widely validated as video-otoscopy. Telehealth facilitators play a key role in providing high-quality telehealth services. More invasive procedures, such as laryngoscopy, require further evidence to demonstrate definite benefits in a telemedicine setting.

Deep Learning for Classification of Pediatric Otitis Media

OBJECTIVES/HYPOTHESIS

To create a new strategy for monitoring pediatric otitis media (OM), we developed a brief, reliable, and objective method for automated classification using convolutional neural networks (CNNs) with images from otoscope.

STUDY DESIGN

Prospective study.

METHODS

An otoscopic image classifier for pediatric OM was built upon the idea of deep learning and transfer learning using the two most widely used CNN architectures named Xception and MobileNet-V2. Otoscopic images, including acute otitis media (AOM), otitis media with effusion (OME), and normal ears were obtained from our institution. Among qualified otoendoscopic images, 10,703 images were used for training, and 1,500 images were used for testing. In addition, 102 images captured by smartphone with WI-FI connected otoscope were used as a prospective test set to evaluate the model for home screening and monitoring.

RESULTS

For all diagnoses combined in the test set, the Xception model and the MobileNet-V2 model had similar overall accuracies of 97.45% (95% CI 96.81%-97.94%) and 95.72% (95% CI 95.12%-96.16%). The overall accuracies of two models with smartphone images were 90.66% (95% CI 90.21%-90.98%) and 88.56% (95% CI 87.86%-90.05%). The class activation map results showed that the extracted features of smartphone images were the same as those of otoendoscopic images.

CONCLUSIONS

We have developed deep learning algorithms for the successfully automated classification of pediatric AOM and OME with otoscopic images. With a smartphone-enabled wireless otoscope, artificial intelligence may assist parents in early detection and continuous monitoring at home to decrease the visit frequencies.

LEVEL OF EVIDENCE

NA Laryngoscope, 131:E2344-E2351, 2021.

Patterns and Perceptions of Smartphone Use Among Academic Neurologists in the United States: Questionnaire Survey

Background

Smartphone technology is ubiquitous throughout neurologic practices, and numerous apps relevant to a neurologist’s clinical practice are now available. Data from other medical specialties suggest high utilization of smartphones in routine clinical care. However, the ways in which these devices are used by neurologists for patient care–related activities are not well defined.

Objective

This paper aims to characterize current patterns of smartphone use and perceptions of the utility of smartphones for patient care–related activities among academic neurology trainees and attending physicians. We also seek to characterize areas of need for future app development.

Methods

We developed a 31-item electronic questionnaire to address these questions and invited neurology trainees and attendings of all residency programs based in the United States to participate. We summarized descriptive statistics for respondents and specifically compared responses between trainees and attending physicians.

Results

We received 213 responses, including 112 trainee and 87 attending neurologist responses. Neurology trainees reported more frequent use of their smartphone for patient care–related activities than attending neurologists (several times per day: 84/112, 75.0% of trainees; 52/87, 59.8% of attendings; P=.03). The most frequently reported activities were internet use, calendar use, communication with other physicians, personal education, and health care–specific app use. Both groups also reported regular smartphone use for the physical examination, with trainees again reporting more frequent usage compared with attendings (more than once per week: 35/96, 36.5% of trainees; 8/58, 13.8% of attendings; P=.03). Respondents used their devices most commonly for the vision, cranial nerve, and language portions of the neurologic examination. The majority of respondents in both groups reported their smartphones as “very useful” or “essential” for the completion of patient care–related activities (81/108, 75.0% of trainees; 50/83, 60.2% of attendings; P=.12). Neurology trainees reported a greater likelihood of using their smartphones in the future than attending neurologists (“very likely”: 73/102, 71.6% of trainees; 40/82, 48.8% of attendings; P=.005). The groups differed in their frequencies of device usage for specific patient care–related activities, with trainees reporting higher usage for most activities. Despite high levels of use, only 12 of 184 (6.5%) respondents reported ever having had any training on how to use their device for clinical care. Regarding future app development, respondents rated vision, language, mental status, and cranial nerve testing as potentially being the most useful to aid in the performance of the neurologic examination.

Conclusions

Smartphones are used frequently and are subjectively perceived to be highly useful by academic neurologists. Trainees tended to use their devices more frequently than attendings. Our results suggest specific avenues for future technological development to improve smartphone use for patient care–related activities. They also suggest an unmet need for education on effectively using smartphone technology for clinical care.

Feasibility of Asynchronous and Automated Telemedicine in Otolaryngology: Prospective Cross-Sectional Study

BACKGROUND

COVID-19 often causes respiratory symptoms, making otolaryngology offices one of the most susceptible places for community transmission of the virus. Thus, telemedicine may benefit both patients and physicians.

OBJECTIVE

This study aims to explore the feasibility of telemedicine for the diagnosis of all otologic disease types.

METHODS

A total of 177 patients were prospectively enrolled, and the patient's clinical manifestations with otoendoscopic images were written in the electrical medical records. Asynchronous diagnoses were made for each patient to assess Top-1 and Top-2 accuracy, and we selected 20 cases to conduct a survey among four different otolaryngologists to assess the accuracy, interrater agreement, and diagnostic speed. We also constructed an experimental automated diagnosis system and assessed Top-1 accuracy and diagnostic speed.

RESULTS

Asynchronous diagnosis showed Top-1 and Top-2 accuracies of 77.40% and 86.44%, respectively. In the selected 20 cases, the Top-2 accuracy of the four otolaryngologists was on average 91.25% (SD 7.50%), with an almost perfect agreement between them (Cohen kappa=0.91). The automated diagnostic model system showed 69.50% Top-1 accuracy. Otolaryngologists could diagnose an average of 1.55 (SD 0.48) patients per minute, while the machine learning model was capable of diagnosing on average 667.90 (SD 8.3) patients per minute.

CONCLUSIONS

Asynchronous telemedicine in otology is feasible owing to the reasonable Top-2 accuracy when assessed by experienced otolaryngologists. Moreover, enhanced diagnostic speed while sustaining the accuracy shows the possibility of optimizing medical resources to provide expertise in areas short of physicians.

Virtual care to increase military medical centre capacity in the primary health care setting: A prospective self-controlled pilot study of symptoms collection and telemedicine

INTRODUCTION

The Singapore Armed Forces (SAF) recognises the potential benefits and looks to harnessing telemedicine for primary health care services. In this prospective self-controlled pilot study, we aimed to evaluate the safety, efficiency and user satisfaction outcomes of virtual care (VC) at a military medical centre.

METHODS

Out of 320 patients seen during the study period, 28 were enrolled in this study and underwent on-premises VC, comprising digital symptoms collection and telemedicine in addition to the usual in-person physician consultation. Safety outcomes were measured based on the diagnostic concordance between physicians. Efficiency was measured based on consultation times, and user satisfaction was evaluated using a standard questionnaire.

RESULTS

There was a higher caseload of both upper respiratory infections and dermatological conditions in our population, in which telemedicine performed well. In terms of safety, telemedicine achieved a mean diagnostic concordance of 92.8% compared to in-person consultations. In terms of efficiency, consultation times were 26.2% - or 2 minutes and 15 seconds - shorter on average with telemedicine (p = 0.0488). User satisfaction was favourable, with 85.5% of patients satisfied with the VC experience.

DISCUSSION

This study has been invaluable in showing that on-premises telemedicine is a safe, efficient and effective means to extend and increase our surge capacity for primary health care. Our results have given us reasonable confidence to explore a larger-scale implementation in our network of military medical centres in the future.

A Review of Telemedicine Applications in Otorhinolaryngology: Considerations During the Coronavirus Disease of 2019 Pandemic

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, 131:744-759, 2021.

The Role of Patient-Site Facilitators in Teleaudiology: A Scoping Review

Purpose Teleaudiology helps improve access to hearing health care by overcoming the geographic gap between providers and patients. In many teleaudiology encounters, a facilitator is needed at the patient site to help with hands-on aspects of procedures. The aim of this study was to review the scope and nature of research around patient-site facilitators in teleaudiology. We focused on identifying the facilitators' background, training, and responsibilities. Method To conduct this scoping review, we searched PubMed, CINAHL, and Embase. To be included, studies needed to address teleaudiology; be experimental/quasi-experimental, correlational/predictive, or descriptive; be published in English; and include the use of a facilitator at the patient location. Results A total of 82 studies met the inclusion criteria. The available literature described a number of different individuals in the role of the patient-site facilitator, including audiologists, students, and local aides. Fifty-seven unique tasks were identified, including orienting the client to the space, assisting with technology, and assisting with audiology procedures. The largest number of studies (n = 42) did not describe the facilitators' training. When reported, the facilitators' training was heterogenous in terms of who delivered the training, the length of the training, and the training content. Conclusions Across studies, the range of duties performed by patient-site facilitators indicates they may have an important role in teleaudiology. However, details are still needed surrounding their background, responsibilities, and training. Future research is warranted exploring the role of the patient-site facilitator, including their impact on teleaudiology service delivery. Supplemental Material https://doi.org/10.23641/asha.12475796.

SelectStitch: Automated Frame Segmentation and Stitching to Create Composite Images from Otoscope Video Clips

Background and Objective: the aim of this study is to develop and validate an automated image segmentation-based frame selection and stitching framework to create enhanced composite images from otoscope videos. The proposed framework, called SelectStitch, is useful for classifying eardrum abnormalities using a single composite image instead of the entire raw otoscope video dataset. Methods: SelectStitch consists of a convolutional neural network (CNN) based semantic segmentation approach to detect the eardrum in each frame of the otoscope video, and a stitching engine to generate a high-quality composite image from the detected eardrum regions. In this study, we utilize two separate datasets: the first one has 36 otoscope videos that were used to train a semantic segmentation model, and the second one, containing 100 videos, which was used to test the proposed method. Cases from both adult and pediatric patients were used in this study. A configuration of 4-levels depth U-Net architecture was trained to automatically find eardrum regions in each otoscope video frame from the first dataset. After the segmentation, we automatically selected meaningful frames from otoscope videos by using a pre-defined threshold, i.e., it should contain at least an eardrum region of 20% of a frame size. We have generated 100 composite images from the test dataset. Three ear, nose, and throat (ENT) specialists (ENT-I, ENT-II, ENT-III) compared in two rounds the composite images produced by SelectStitch against the composite images that were generated by the base processes, i.e., stitching all the frames from the same video data, in terms of their diagnostic capabilities. Results: In the first round of the study, ENT-I, ENT-II, ENT-III graded improvement for 58, 57, and 71 composite images out of 100, respectively, for SelectStitch over the base composite, reflecting greater diagnostic capabilities. In the repeat assessment, these numbers were 56, 56, and 64, respectively. We observed that only 6%, 3%, and 3% of the cases received a lesser score than the base composite images, respectively, for ENT-I, ENT-II, and ENT-III in Round-1, and 4%, 0%, and 2% of the cases in Round-2. Conclusions: We conclude that the frame selection and stitching will increase the probability of detecting a lesion even if it appears in a few frames.

Development of video otoscopy quiz using a smartphone adaptable otoscope

Background

Otoscopy examination can be challenging. Traditional teaching uses still image illustrations. Newer attempts use video samples to simulate the otoscopy exam which is a dynamic process.

Aims/Objective: To assess whether recorded otoscopy videos from a smartphone adaptable otoscope can be used to develop a video-based otoscopy quiz which may be used for instructing and familiarizing participants to normal anatomy and pathologic ear conditions. To use this quiz to assess current pediatric residents’ competency of common otoscopy diagnosis.

Method and materials

This study was conducted in 2018. Video samples of ear pathology were collected at the Albany Medical Center using a smartphone adaptable otoscope- Cellscope. The videos were used to create a video otoscopy quiz (VOQ) without clinical vignettes. 45 pediatric residents from 3 academic institutions were evaluated with the quiz.

Results

The weighted mean for the VOQ was 66.90% (95%CI 58.89%–68.42%). The breakdown by questions are: myringosclerosis 72.88%, retraction pocket 80.65%, cholesteatoma 42.22%, hemotympanum 75.04%, tympanic membrane perforation 79.62%, cerumen impaction 95.46%, otitis externa 52.54%, otitis media with effusion 63.30%, acute otitis media 75.55%, normal ear 36.39%.

Conclusion

We found that videos of otoscopy exams can be obtained with a smartphone adaptable otoscope and validated to develop a video-based quiz, which may be used to supplement otoscopic instruction. Following our testing process, we found pediatric residents are relatively well equipped to identify ear pathology on VOQ.

Prospective Evaluation of a Smartphone Otoscope for Home Tympanostomy Tube Surveillance: A Pilot Study

OBJECTIVES

Recent technological advances have led to the capability of performing high resolution imaging of the tympanic membrane. Smartphone technologies and applications have provided the opportunity to capture digital images and easily share them. The smartphone otoscope device was developed as a simple system that can convert a smartphone into a digital otoscope. This device has the prospective ability to improve physician-patient communication and assist with the diagnosis and management of ear disease. Our objective was to evaluate the feasibility and physician/parental satisfaction using the Cellscope® smartphone attachment for at home tympanostomy tube monitoring.

METHODS

Children between 6 months and 15 years of age at an urban tertiary children's hospital that were scheduled for bilateral tympanostomy tube insertion or underwent bilateral tympanostomy tube surgery were prospectively enrolled in the study. Comparisons were made between parental home-recorded videos and findings during in-office otoscopy. Two independent otolaryngologists reviewed the videos and concordance between inter-rater agreements was calculated. Acceptability and use questionnaires were administered to physicians and parents.

RESULTS

There was good intra-rater agreement between traditional otoscopy and video-otoscopy for tube extruding, tube blocked and tube extruded with at least 80% agreement (P < .05) and excellent inter-rater agreement between physicians for nearly all tube variables (P < .0001) There was a high degree of satisfaction with this mode of surveillance. Parents and physicians agreed that the CellScope® smartphone was easy to use, helpful with the occurrence of acute events, and appeared to improve quality of care.

CONCLUSIONS

The CellScope® smartphone is feasible for use in tympanostomy tube surveillance. Use of the device may allow otolaryngologists to easily follow a child's tympanostomy tube remotely over time and offer greater parental satisfaction.

Pediatric, Family-Centered, "At-Home" Otologic Physical Examination in the COVID-19 Era

SARS-CoV-2, the novel coronavirus resulting in the present COVID-19 pandemic, has increased the otolaryngologist's reliance on telemedicine to manage outpatient pathology. The nature of telemedicine, however, limits a provider's ability to obtain a comprehensive physical examination, specifically of the tympanic membrane. Various smartphone-based otoscopic attachments are now available that facilitate patient-obtained otoscopic image capture of the tympanic membrane. Here, we present 3 cases in which a patient-purchased, over-the-counter otoscope was utilized to alter otologic management during the time of social distancing. Further research is necessary to improve our understanding the safety and efficacy of patient-based "at-home" otoscopic examination and to optimize the use of these devices.

Optical Identification of Middle Ear Infection

Ear infection is one of the most commonly occurring inflammation diseases in the world, especially for children. Almost every child encounters at least one episode of ear infection before he/she reaches the age of seven. The typical treatment currently followed by physicians is visual inspection and antibiotic prescription. In most cases, a lack of improper treatment results in severe bacterial infection. Therefore, it is necessary to design and explore advanced practices for effective diagnosis. In this review paper, we present the various types of ear infection and the related pathogens responsible for middle ear infection. We outline the conventional techniques along with clinical trials using those techniques to detect ear infections. Further, we highlight the need for emerging techniques to reduce ear infection complications. Finally, we emphasize the utility of Raman spectroscopy as a prospective non-invasive technique for the identification of middle ear infection.

Automatic detection of tympanic membrane and middle ear infection from oto-endoscopic images via convolutional neural networks

Convolutional neural networks (CNNs), a popular type of deep neural network, have been actively applied to image recognition, object detection, object localization, semantic segmentation, and object instance segmentation. Accordingly, the applicability of deep learning to the analysis of medical images has increased. This paper presents a novel application of state-of-the-art CNN models, such as DenseNet, to the automatic detection of the tympanic membrane (TM) and middle ear (ME) infection. We collected 2,484 oto-endoscopic images (OEIs) and classified them into one of three categories: normal, chronic otitis media (COM) with TM perforation, and otitis media with effusion (OME). Our results indicate that CNN models have significant potential for the automatic recognition of TM and ME infections, demonstrating a competitive accuracy of 95% in classifying TM and middle ear effusion (MEE) from OEIs. In addition to accuracy measurement, our approach achieves nearly perfect measures of 0.99 in terms of the average area under the receiver operating characteristics curve (AUROC). All these results indicate robust performance when recognizing TM and ME effusions in OEIs. Visualization through a class activation mapping (CAM) heatmap demonstrates that our proposed model performs prediction based on the correct region of OEIs. All these outcomes ensure the reliability of our method; hence, the study can aid otolaryngologists and primary care physicians in real-world scenarios.

Community health worker-based hearing screening on a mobile platform: A scalable protocol piloted in Haiti

OBJECTIVE

To establish the feasibility of a systematic, community health worker (CHW)-based hearing screening program that gathers Health Insurance Portability and Accountability Act-compliant electronic data (otoscopic images of tympanic membrane and audiometric evaluation) on a smartphone in an effort to streamline treatment options in resource-limited communities.

METHODS

This is a cross-sectional study in which four schools were screened in Port-au-Prince, Haiti, during in April 2018. A total of 122 subjects (61% female) aged 5-17 years underwent an initial brief audiometric screen followed by a more comprehensive air conduction audiometric evaluation if they failed their initial screen. Participants with more than 35-dB loss in any frequency on their comprehensive audiometric evaluation received endoscopic otoscopy.

RESULTS

Seventy-five percent of subjects (91/122) passed their initial screen. Of those who failed, 9% (4/44 ears) had a severe or profound hearing loss on comprehensive evaluation. Abnormal otoscopic findings (11/36 ears, 31%) included are cerumen impaction (n = 6), myringosclerosis (n = 3), tympanic membrane perforation (n = 1), and tympanic membrane retraction (n = 1). The average duration of the initial testing was 100 seconds (SD = 74 seconds), whereas the duration of comprehensive testing was 394 seconds (SD = 175 seconds). Extrapolating from these data, we estimate that a group of seven trained CHWs could gather formal audiologic and otologic data points for 100 children per hour using this protocol.

CONCLUSIONS

A systematic approach that utilizes local resources (CHWs) and existing infrastructure (cell phones and the Internet) can significantly reduce the burden of hearing healthcare specialists while simultaneously facilitating early diagnosis and management of disabling hearing loss in low-resourced settings.

LEVEL OF EVIDENCE

Level 4.

Development and Evaluation of an Objective Tympanic Membrane Visualization Assessment Technique

OBJECTIVES

To introduce an inexpensive method for objectively evaluating otoscopic visualization of the tympanic membrane wherein learners match what they visualize in standardized patients to tympanic membrane photographs.

METHODS

Two standardized patients had photographs taken of their tympanic membranes using a commercially-available digital otoscope. First- and third-year medical students were asked to perform an otoscopic examination on each patient using a conventional handheld otoscope and to match what they saw with the correct tympanic membrane image among distractor photographs belonging to other patients. The ability of students to match the standardized patients' tympanic membrane to the correct photographs was assessed before and after a didactic training session. These measurements were compared between the two cohort groups for construct validity.

RESULTS

Fifty-one first-year medical students (with no previous otoscopy experience) and 44 third-year medical students (with otoscopy experience from completing pediatric and family medicine clinical clerkships) were recruited to voluntarily participate in this study. At baseline, a larger percentage of third-year students correctly matched both tympanic membranes compared to first-year students (27% vs 8%, P < .01). After otoscopy training, correct matching of both tympanic membranes significantly improved among both first-year students (8-31%, P < .01) and third-year students (27-54%, P < .01).

CONCLUSION

The use of tympanic membrane photographs from standardized patients provides a novel technique for objectively assessing proficiency in otoscopic visualization of the middle ear. The concept is low cost, uses live patients, and can be easily implemented in pre-clinical instruction and beyond.

The role of smartphone applications in clinical practice: a review

OBJECTIVE

The number of medical mobile phone applications continues to grow. Although otorhinolaryngology-specific applications represent a small proportion, there are exciting innovations emerging for the specialty. This article will assess the number of applications available and review how they may be used in clinical practice.

METHOD

The application stores of the two most popular mobile phone platforms, Apple and android, were searched using multiple search terms.

RESULTS

A total of 107 ENT applications were identified and categorised according to intended use. Eight applications were reviewed in more detail and assessed on whether a doctor or allied health professional was involved in their design and if they were evidence-based.

CONCLUSION

There are a number of ENT-specific smartphone applications currently available. As the technology progresses, their scope has extended beyond being purely for reference. Nevertheless, it remains difficult to assess the validity and security of these applications.

Automated Classification of the Tympanic Membrane Using a Convolutional Neural Network

Precise evaluation of the tympanic membrane (TM) is required for accurate diagnosis of middle ear diseases. However, making an accurate assessment is sometimes difficult. Artificial intelligence is often employed for image processing, especially for performing high level analysis such as image classification, segmentation and matching. In particular, convolutional neural networks (CNNs) are increasingly used in medical image recognition. This study demonstrates the usefulness and reliability of CNNs in recognizing the side and perforation of TMs in medical images. CNN was constructed with typically six layers. After random assignment of the available images to the training, validation and test sets, training was performed. The accuracy of the CNN model was consequently evaluated using a new dataset. A class activation map (CAM) was used to evaluate feature extraction. The CNN model accuracy of detecting the TM side in the test dataset was 97.9%, whereas that of detecting the presence of perforation was 91.0%. The side of the TM and the presence of a perforation affect the activation sites. The results show that CNNs can be a useful tool for classifying TM lesions and identifying TM sides. Further research is required to consider real-time analysis and to improve classification accuracy.

Office-Based Diagnosis of Demodex Using Smartphone

Demodex is an important pathogen in ophthalmology. It is believed to cause a variety of eyelid and eyelash diseases. Currently, light microscopes are being used for imaging demodex. However, microscopes are not available everywhere. Also, it is not cost-effective to perform light microscopy in every case. In this case, we demonstrate a new method: imaging demodex using cell phone. A 90-diopter noncontact double aspheric lens was attached to the posterior camera of the smartphone with clear tape. An eyelash of a patient with blepharitis was removed. A video was taken using smartphone. There was a moving demodex parasite in the root of the eyelash. A clear video image could be taken using the smartphone. A smartphone and a 90-diopter lens are adequate for the imaging and diagnosis of demodex.

Smartphone Otoscopy Performed by Parents

Introduction: Implementation of pediatric telemedicine has been emphasized. We examined whether parents could perform smartphone otoscopy for the diagnosis of otitis media. Materials and Methods: We included children (6-35 months) attending day care with at least one episode of acute otitis media (AOM) within 90 days of the study entry. The timing for a teaching intervention was randomized. In the immediate teaching group, parents were taught smartphone otoscopy and cerumen was removed at the first visit. The delayed teaching group received the teaching intervention after 1 week's independent use. During the 60 study days, parents performed home examinations. The main outcome, the diagnostic quality of the tympanic membrane videos to determine healthy ear, otitis media with effusion (OME) and AOM diagnoses was measured with a structured video analysis independently by three physicians. Parents' experience was measured with a questionnaire. Results: AOM could be detected or excluded in 87% (609/699) of the videos during acute symptoms. After the teaching intervention, healthy ear, OME, or AOM could be diagnosed in 40% (521/1,293) of the videos. During the first week's intervention, one of the three diagnoses was attained in 33% (50/153) and in 12% (22/179) of the videos in the immediate and delayed teaching group, respectively (p < 0.001). The performance of the smartphone otoscopy examination was easy in 85% (35/41) of families. Discussion: After been taught, parents are able to perform smartphone otoscopy for the remote detection or exclusion of AOM. Conclusions: Future studies should assess the clinical usefulness of parent-performed smartphone otoscopy.

Smartphone Otoscopy Sans Attachment: A Paradigm Shift in Diagnosing Ear Pathologies

Objective

To study the validity of smartphone otoscopy.

Setting

Ear, nose, and throat (ENT) outpatient clinic of a tertiary care hospital in eastern India.

Study Design

Experimental study design to compare the efficacy of smartphone otoscopy with otoendoscopes.

Subjects and Methods

One hundred tympanic membranes (TMs) of 50 patients were examined and photographed by third-year senior residents (6 years of ENT training) using a zero-degree otoendoscope. The same 100 ears were then examined using a smartphone. Assistive light of the phone was used to illuminate the ear canal. The camera of the phone was focused to visualize and photograph the TM.

Results

Compared with the gold-standard otoendoscopes, smartphones could correctly diagnose 75% of the cases. Sensitivity and specificity of smartphone otoscopy were 87.8% and 80%, respectively. Positive predictive value was 90.6%, whereas negative predictive value was 75%. Smartphone otoscopy could correctly diagnose 88.57% of normal TMs, 86.36% of retracted TMs, and 82.85% of perforated TMs.

Conclusion

This modality of "smart otoscopy" has no added cost and can be used by most doctors after minimal training. It is an excellent teaching tool and can be used universally even in resource-limited settings.

Expanding the Capacity of Otolaryngologists in Kenya through Mobile Technology

Objective

To determine if reliable, objective audiologic data can be obtained by nonotolaryngology and nonaudiology practitioners using novel mobile technology in an effort to expand the capacity for early identification and treatment of disabling hearing loss in the developing world.

Study Design

Cross-sectional, proof-of-concept pilot study.

Setting

Screenings took place during an annual 2-week otolaryngology surgical mission in October 2016 in semirural Malindi, Kenya.

Subject and Methods

Eighty-seven patients (174 total ears) were included from 2 deaf schools (n = 12 and 9), a nondeaf school (n = 9), a tuberculosis ward (n = 8), and a walk-in otology clinic at a local hospital (n = 49). An automated, tablet-based, language-independent, clinically validated, play audiometry system and wireless otoscopic endoscopy via an iPhone or laptop platform was administered by Kenyan community health workers (CHWs) and nursing staff.

Results

Various degrees of hearing loss and otologic pathology were identified, including 1 child presumed to be deaf who was found to have unilaterally normal hearing. Other pathology included 2 active perforations, 2 healed perforations, 2 middle ear effusions, and 1 cholesteatoma. CHWs and nursing staff demonstrated proficiency performing audiograms and endoscopy. Patients screened in a deaf school were more likely to complete an unreliable audiogram than patients screened in other settings (P < .01).

Conclusion

This study demonstrates the feasibility of a non–otolaryngology-based hearing screening program. This may become an important tool in reducing the impact of hearing loss and otologic pathology in areas bereft of otolaryngologists and audiologists by allowing CHWs to gather important patient data prior to otolaryngologic evaluation.

Attitudes Toward e-Health: The Otolaryngologists' Point of View

INTRODUCTION

Online communication and the number of e-health applications have noticeably increased. However, little is known about the otolaryngologists' use behavior and their attitudes toward the potential of e-health. The aims of the study were to evaluate the documentation, information, and communication technologies used by otolaryngologists and to get a better understanding of their attitudes toward the potential of e-health for cross-sectoral patient care.

METHODS

A survey was developed and tested by otolaryngologists, healthcare-information technology experts, and health services researchers. A total of 334 otolaryngologists in private practice were asked to participate in this cross-sectional study. In total, 234 of them took part in the study, and 157 returned completed questionnaires. Statistical analysis was performed by using crosstabs, including chi-square tests, and multivariate logistic regressions. Results and Materials: Digital technologies are widely used by otolaryngologists (e.g., 89.6% use an electronic health record). However, the majority of intersectoral communication is still based on analogue techniques (e.g., fax use in 63.7%). From the otolaryngologists' perspectives, the potential of e-health for intersectoral care is mostly in appointment scheduling, further referrals to hospitals, and automated appointment reminders. The physicians' attitudes toward e-health are associated with their Internet use behavior in daily life (odds ratio = 4.30, confidence interval 1.11-16.64, p = 0.035) but not with their demographics.

DISCUSSION

The otolaryngologists are well prepared and have an overall positive attitude toward e-health for deeper use in cross-sectoral care. Therefore, e-health in otolaryngology needs more attention and resources for further studies, especially with a focus on quality and safety of care.

Tympanostomy Tube Placement vs Medical Management for Recurrent Acute Otitis Media in TRICARE-Insured Children

Objective To compare number of infections and health care utilization in children insured by TRICARE with recurrent acute otitis media (RAOM) managed surgically with tympanostomy tube (TT) placement compared with those managed medically. Study Design Retrospective matched cohort study. Setting TRICARE claims database from 2006 to 2010. Subjects and Methods We matched TRICARE beneficiaries ≤5 years of age diagnosed with RAOM who underwent TT placement with those managed medically using 1:1 coarsened-exact matching on age, sex, race, sponsor rank, and region. We used multivariable negative binomial regression to compare number of infections and health care utilization at 1 and 2 years. Outcomes were adjusted for rate of infection before treatment for RAOM, season of either TT placement or establishment of candidacy for TT placement, and comorbidities. Results Among 6659 pairs identified at 1-year follow-up, the TT group had fewer infections (1.96 vs 2.18, P < .001) and oral antibiotic prescriptions (1.52 vs 1.67, P < .001) but more visits to primary care physicians (4.36 vs 4.06, P < .0001) and otolaryngologists (1.21 vs 0.44, P < .0001) compared with the medically managed group. At 2-year follow-up, the benefits of TT placement were no longer seen. Conclusion TT placement for RAOM is associated with fewer infections and oral antibiotic prescriptions in the first year after surgery but more doctor visits. Benefits of TT placement do not appear to extend through the second year. Future research should investigate costs associated with TT placement vs medical management, as well as real-time health care utilization with impact on patient symptoms and quality of life.