Chronic Ear Disease.

Chronic ear disease is composed of a spectrum of otologic disorders intrinsically tied to Eustachian tube dysfunction. Presentation can range from asymptomatic findings on physical examination to critically ill patients with intracranial complications. Internists represent the first line in diagnosis of these conditions, making awareness of the common signs and symptoms essential. With surgical management often required, partnership between internal medicine and otolaryngology is fundamental in the management of patients with chronic ear disease.

Trends in Otitis Media and Myringotomy With Tube Placement Among American Indian and Alaska Native Children and the US General Population of Children After Introduction of the 13-valent Pneumococcal Conjugate Vaccine.

BACKGROUND: American Indian/Alaska Native (AI/AN) children have experienced higher otitis media (OM) outpatient visit rates than other US children. To understand recent trends, we evaluated AI/AN OM rates before and after 13-valent pneumococcal conjugate vaccine introduction. METHODS: We analyzed outpatient visits listing OM as a diagnosis among AI/AN children <5 years of age from the Indian Health Service National Patient Information Reporting System for 2010-2013. OM outpatient visits for the general US child population <5 years of age were analyzed using the National Ambulatory Medical Care and National Hospital Ambulatory Care Surveys for 2010-2011. RESULTS: The 2010-2011 OM-associated outpatient visit rate for AI/AN children (63.5 per 100/year) was similar to 2010-2011 rate for same-age children in the general US population (62.8) and decreased from the 2003 to 2005 AI/AN rate (91.4). Further decline in AI/AN OM visit rates was seen for 2010-2011 to 2012-2013 (P < 0.0001). The AI/AN infant OM visit rate (130.5) was 1.6-fold higher than the US infant population. For 2010-2011, the highest AI/AN OM visit rate for <5 year olds was from Alaska (135.0). CONCLUSIONS: AI/AN <5-year-old OM visits declined by one third from 2003-2005 to 2010-2011 to a rate similar to the US general population <5 years. However, the AI/AN infant OM rate remained higher than the US infant population. The highest AI/AN <5-year-old OM rate occurred in Alaska.

The Alaska experience using store-and-forward telemedicine for ENT care in Alaska.

This article discusses the development, evaluation, and growth of telemedicine in Alaska. Store-and-forward telemedicine has been used to deliver ear, nose, and throat (ENT) care to rural Alaska since 2002. It has proved valuable in the treatment of many conditions of the head and neck, and it is particularly well suited for the diagnosis and treatment of ear disease. Usage has grown steadily as telemedicine has become widely accepted. Store-and-forward telemedicine has been shown within the Alaska Native Health System to improve access for care and reduce wait times, as well as decrease travel-associated costs for patients.

Innovation in Indian healthcare: using health information technology to achieve health equity for American Indian and Alaska Native populations.

The US Indian health system utilizes a diverse range of health information technology and innovative tools to enhance health service delivery for American Indians and Alaska Natives. This article provides an overview of efforts and experience using such tools to achieve health equity for American Indian and Alaska Native communities. Specific attention is given to the Indian Health Service Electronic Health Record and to two examples of telehealth innovation.

Preoperative planning for ear surgery using store-and-forward telemedicine.

OBJECTIVE: To determine if store-and-forward telemedicine can be used to accurately plan ear surgery. STUDY DESIGN: Case series with chart review. SETTING: Tertiary care hospital. SUBJECTS AND METHODS: Charts were reviewed for elective major ear surgeries resulting from telemedicine referrals during a 13-month period. The store-and-forward telemedicine referrals (electronic consultations) included clinical history, digital images, and audiology data. Consultants reviewed each telemedicine case and documented the recommended surgery and estimated operative time. These charts were matched with patients seen in person during a standard evaluation and had identical surgeries recommended. For the telemedicine evaluation and in-person evaluation groups, the recommended surgeries were compared with actual surgeries performed and the estimated time was compared with the actual operative time. RESULTS: Forty-five ear surgeries were recommended by the telemedicine evaluation and were matched with 45 surgeries from the standard evaluation and included tympanoplasty with or without canalplasty, mastoidectomy, stapes surgery, and myringoplasty. Telemedicine and in-person evaluation accurately predicted the surgery 89 percent and 84 percent of the time, respectively. The average difference of "actual time" and "estimated time" for the actual surgical procedures performed was not statistically different between the two groups: 32 minutes for the telemedicine evaluation group and 35 minutes for the in-person evaluation group. CONCLUSION: Store-and-forward telemedicine is as effective as in-person evaluation for planning elective major ear surgery.

The impact of telehealth on wait time for ENT specialty care.

Audiology in rural Alaska has changed dramatically in the past 6 years by integrating store and forward telemedicine into routine practice. The Audiology Department at the Norton Sound Health Corporation in rural Nome Alaska has used store-and-forward telemedicine since 2002. Between 2002 and 2007, over 3,000 direct audiology consultations with the Ear, Nose, and Throat (ENT) Department at the Alaska Native Medical Center in Anchorage were completed. This study is a 16-year retrospective analysis of ENT specialty clinic wait times on all new patient referrals made by the Norton Sound Health Corporation providers before (1992-2001) and after the initiation of telemedicine (2002-2007). Prior to use of telemedicine by audiology and ENT, 47% of new patient referrals would wait 5 months or longer to obtain an in-person ENT appointment; this dropped to 8% of all patients in the first 3 years with telemedicine and then less than 3% of all patients in next 3 years using telemedicine. The average wait time during the first 3 years using telemedicine was 2.9 months, a 31% drop compared with the average wait time of 4.2 months for the preceding years without telemedicine. The wait time then dropped to an average of 2.1 months during the next 3 years of telemedicine, a further drop of 28% compared with the first 3 years of telemedicine usage.

Traveling an audiologist to provide otolaryngology care using store-and-forward telemedicine.

This project increased access to otolaryngology services by having an audiologist travel to remote Alaska and communicate with an otolaryngologist using store-and-forward electronic consultation. The audiologist was instructed to effectively image appropriate parts of the otolaryngology exam and create telemedicine cases that included clinical histories, images, audiograms, tympanograms, otoacoustic emission testing and/or other documents. The otolaryngology consultants reviewed new referrals as well as follow up cases and made treatment and triage recommendations. Over a 57 month period, 54 trips were made to 14 villages providing 197 clinic service days. The 1,458 patient encounters resulted in referral for surgery or special diagnostic testing 26%, referral for monitoring 23%, starting of medications 19%, referral to regional ENT clinic 15%, and referral to another specialty 5%. Approximately 27% patients did not need to see the otolaryngologist and were triaged out of the specialty clinic. The total cost to run this project was $141,114. Travel was prevented for 85% encounters, resulting in travel cost avoidance in airfare of $496,420. These services were provided at a significantly lower cost and with fewer burdens to the patients when compared to the standard referral system. An audiologist that travels to remote locations and uses store-and-forward telemedicine can rapidly deliver otolaryngology services. This model is a proven mechanism of efficient healthcare delivery that may be expanded to other specialties.

Digital images for postsurgical follow-up of tympanostomy tubes in remote Alaska.

OBJECTIVE: To determine if video otoscope still images of the tympanic membrane taken in remote clinics are comparable to an in-person microscopic examination for follow-up care. DESIGN: Comparative concordance, diagnostic reliability. METHODS: Community health aide/practitioners in remote Alaska imaged 70 ears following tympanostomy tube placement. The patients were then examined in person by two otolaryngologists. Images were later reviewed at 8 and 14 weeks. RESULTS: Intraprovider concordance for physical examination findings was: "Tube in," 94 percent -97 percent (kappa = 0.89-0.94); "Tube patent," 94 percent -97 percent (kappa = 0.89-0.94); "Drainage," 90 percent -96 percent (kappa = -0.04-0.38); "Perforation," 90 percent -96 percent (kappa = 0.61-0.82); "Granulation," 97 percent -100 percent (kappa = 0.49-1.0); "Middle ear fluid," 88 percent -96 percent (kappa = 0.28-0.71); "Retracted," 83 percent -91 percent (kappa = 0.26-0.58). These agreement rates are similar to interprovider concordance when two otolaryngologists examine the same patient in person. Intraprovider concordance for diagnoses was 76 percent -80 percent (kappa = 0.64-0.71) and 77 percent -88 percent (kappa = 0.66-0.81) when poor images were excluded. Interprovider diagnostic concordance for the in-person exam was 89 percent (kappa = 0.83). CONCLUSION: Video-otoscopy images of the tympanic membrane are comparable to an in-person examination for assessment and treatment of patients following tympanostomy tubes. Store-and-forward telemedicine is an acceptable method of following patients post tympanostomy tube placement.

Telehealth in Alaska: delivery of health care services from a specialist's perspective.

Integrating store-and-forward telemedicine into the ANMC ENT practice for remotely located patients has improved access for care as well as the quality of care for our patients. The involvement of the ANMC ENT department in the design of the telemedicine system was critical. Yet building the telemedicine service required creative measures to encourage use and careful management of our capacity to receive a growing number of cases. Cost savings due to avoided travel have been readily apparent, based on the high cost of travel in Alaska, The improvement in departmental productivity was an unexpected yet welcome outcome. Much of the current research in telemedicine appropriately focuses on the applicability of this modality to clinical problems. Our four years experience indicates that one of the challenges in the future will be to integrate telemedicine with the existing infrastructure of medicine so that it can more easily become part of mainstream practice.

A comparison of in-person examination and video otoscope imaging for tympanostomy tube follow-up.

The objective of this study was to determine if video otoscope still images (640 x 480 pixel resolution) of the tympanic membrane following surgical placement of tympanostomy tubes are comparable to an in-person microscopic examination. Forty patients having undergone tympanostomy tube placement in both ears were independently examined in-person by two otolaryngologists and imaged using a video otoscope and telemedicine software package. The two physicians later reviewed images at 6 and 12 weeks. Physical examination findings and diagnosis were documented and compared for their concordance using kappa statistics. For both physicians, the intraprovider concordance between the in-person examination and the corresponding image review was high for each of the physical examination findings: Tube In 93-94% (K 0.85-0.87), Tube Patent 86-93% (K 0.74-0.85), Drainage 94-98% (K 0.42-0.66), Perforation 85-98% (K 0.40-0.84), Granulation 95-99% (K -0.01 to 0.00), Middle Ear Fluid 89-91% (K -0.03 to 0.50), and Retracted 89-94% (K 0.13-0.43). These agreement rates are similar to the normal interprovider concordance observed when two physicians independently examined the same patient in-person for physical exam findings: Tube In 96% (K 0.93), Tube Patent 94% (K 0.88), Drainage 96% (K 0.56), Perforation 90% (K 0.60), Granulation 96% (K 0.39), Middle Ear Fluid 88% (K 0.14), and Retracted 91% (K 0.43). For both physicians, the intraprovider diagnostic concordance between the in-person examination and the corresponding image review was high 79-85% (K 0.67-0.76). The interprovider diagnostic concordance for the in-person exam was 88% (K 0.81). The interprovider diagnostic concordance when two physicians independently reviewed all images was 84% (K 0.74), and 89% (K 0.80) when poor images were excluded. This study demonstrates that physician review of video otoscope images is comparable to an in-person microscopic examination. Store-and-forward video otoscopy may be an acceptable method of following patients post-tympanostomy tube placement.