Patient Use of Low-cost Digital Videoscopes and Smartphones for Remote Ear and Oropharyngeal Examinations.

Importance: During the novel coronavirus disease 2019 pandemic, telehealth has become a vital component of health care delivery. For otolaryngology evaluations, examination of the ear and oropharynx is important but difficult to achieve remotely. Objective: To assess the feasibility of patient use of low-cost digital videoscopes and smartphones for examination of the ear and oropharynx. Design, Setting, and Participants: A prospective quality improvement study was conducted in an academic adult otolaryngology clinic including 23 patients who presented for an in-person appointment and owned a smartphone device. The study was conducted from July 1 to 15, 2020. Interventions: Participants were asked to capture pictures and videos of their ear canals and oropharynx with digital videoscopes and their smartphones under real-time guidance over a telehealth platform. They were then surveyed about their experience. Main Outcomes and Measures: The primary outcomes were ratings by health care clinicians and a blinded otolaryngologist reviewer of image acceptability. Secondary outcomes included participant time to image acquisition and willingness to purchase digital videoscopes for telehealth use. Results: Of the 23 participants included, 14 were women (61%); mean age was 50 years (range, 21 to 80 years). Of the images obtained using the digital otoscope ear examination, 95% were considered acceptable by the health care clinicians and 91% were considered acceptable by the blinded reviewer; 16 participants (70%) reported that the otoscope was easy to use. The mean time to acquire images for both ears was 114 seconds (95% CI, 84-145 seconds). Twenty-one participants (91%) were willing to pay for a digital otoscope for telehealth use. For the oropharyngeal examination, a greater proportion of smartphone video examinations were considered acceptable by clinicians (63% acceptability) and the blinded reviewer (55%) compared with the digital endoscope (clinicians, 40%; blinded reviewer, 14%). The mean time required for the oropharyngeal examination smartphone video capture was shorter at 35 seconds compared with both the digital endoscope (difference, -27 seconds; 95% CI, -7 to -47 seconds) and smartphone photo capture (difference, -53 seconds; 95% CI, -20 to -87 seconds). Conclusions and Relevance: Digital otoscopes and smartphones apparently can facilitate remote head and neck physical examination in telehealth. Digital otoscopes were useful for ear examinations, and smartphone videos appeared to be the most useful for oropharyngeal examinations. Further studies are required to determine specific diagnostic capabilities in various telehealth practice settings.

Comprehensive Community Screening of Otological Patients by Trained Technicians Using a Telemedicine Device: An Efficient and Cost-Effective Way to Triage Patients With Ear Diseases.

OBJECTIVE: To emphasize the benefits of tele-otology in community screening of patients with ear diseases. METHODS: A retrospective study of all patients screened and treated under the Shruti tele-otology program between 2013 and 2019 was conducted. It involved screening, diagnosis, medical management, surgical intervention, and rehabilitation using hearing aid. The study focused on underprivileged and underserved community of rural and urban slums across 12 states of India. The study was conducted using a telemedicine device called ENTraview, that is, a camera-enabled android phone integrated with an otoscope and audiometry screening. RESULT: A total of 810 746 people were screened, and incidence of various ear diseases was recorded. Ear problems were found in 265 615 (33%) patients, of which 151 067 (57%) had impacted wax, 46 792(18%) had chronic suppurative otitis media, 27 875 (10%) had diminished hearing, 12 729 (5%) had acute otitis media and acute suppurative otitis media (ASOM), and 27 152 (10%) had problems of foreign body, otomycosis, and so on. Of the total 265 615 referred patients, 20 986 (8%) reported for treatment and received treatment at a significantly reduced cost through Shruti program partners. The conversion rate of nonsurgical and surgical procedure was also compared, and it was found that, while 9% of the patients opted for nonsurgical treatment, only 3% opted for surgery in the intervention group giving a significant P value of .00001. CONCLUSION: The potential for telemedicine to reduce inequalities in health care is immense but remains underutilized. Shruti has largely been able to bridge this gap as it is an innovative, fast, and effective programs that address the ear ailment in the community.

The Utility of the Maxillary Heuwieser for Oropharyngeal Foreign Body Removal Under Nebulized Local Anesthesia: A Case Series.

We describe a novel and safe use of existing instrumentation in the removal of select foreign bodies in the upper aerodigestive tract to minimize health-care costs. A retrospective review of 4 cases involving visualized upper aerodigestive tract foreign bodies were identified via flexible laryngoscopy and extracted under local anesthesia from 2016 to 2018. All 4 patients were not in any airway distress and underwent successful removal of the foreign body, which included 2 fishbones, a sewing pin, and a wire bristle with a maxillary Heuwieser or giraffe instrument under flexible laryngoscopy visualizing using local anesthesia without complications. No foreign bodies were dislodged. The use of a maxillary Heuwieser and flexible laryngoscopy visualization is safe, allows for removal of otherwise difficult to reach foreign bodies at the bedside, improving patient comfort, obviates the need for general anesthesia to the patient, and minimizes health-care costs.

Heads-up Surgery: Endoscopes and Exoscopes for Otology and Neurotology in the Era of the COVID-19 Pandemic.

A new era of surgical visualization and magnification is poised to disrupt the field of otology and neurotology. The once revolutionary benefits of the binocular microscope now are shared with rigid endoscopes and exoscopes. These 2 modalities are complementary. The endoscope improves visualization of the hidden recesses through the external auditory canal or canal-up mastoidectomy. The exoscope provides an immersive visual experience and superior ergonomics compared with binocular microscopy. Endoscopes and exoscopes are poised to disrupt the standard of care for surgical visualization and magnification in otology and neurotology.

Getting Started with Endoscopic Ear Surgery.

Because endoscopic technology has matured over the past several decades, ear surgeons have increasingly used endoscopy to address some of the limitations of operative microscopy. The wide field of view and high-resolution images provided by endoscopes allow for improved visualization of the tympanic cavity using minimally invasive surgical portals compared with the standard operative binocular microscope. The endoscope is becoming an essential tool in the otologist's armamentarium. In this article, the authors discuss rationale for endoscopic ear surgery, terminology and classification, surgical indications, essential equipment, surgical ergonomics, and practical steps to incorporate endoscopic ear surgery into practice.

Two-drape closed pocket technique: minimizing aerosolization in mastoid exploration during COVID-19 pandemic.

BACKGROUND: Mastoidectomy is associated with extensive bone-drilling which makes it a major aerosol generating procedure. Considering the ongoing COVID-19 global pandemic, it is essential to devise methods to minimize aerosolization and hence ensure safety of the healthcare workers during the operative procedure. METHODS: Two disposable surgical drapes are used to create a closed pocket prior to commencement of mastoid bone-drilling. This limits aerosolization of bone-dust in the external operating theatre environment. CONCLUSION: Two-drape closed pocket technique is an easy, cost-effective and safe method to limit aerosolization of tissue particles during mastoidectomy.

Strategies for the practice of otolaryngology and head and neck surgery during the monitoring phase of COVID-19. / Estrategias para la práctica de la otorrinolaringología y cirugía de cabeza y cuello durante la fase de control de la COVID-19.

The appearance of a new coronavirus disease called COVID-19 at the end of 2019 and its pandemic expansion in the world has changed the usual practice of the specialty of Otorhinolaryngology (ENT). After a phase of exponential growth of infections, it has been possible to enter a phase of control of the spread of the disease in which the possibility of infection persists, and the appearance of new cases is considered acceptable by the health system. The aim of this document is to review the available evidence and propose strategies and recommendations for the medical-surgical practice of otorhinolaryngology and head and neck surgery, which allow establishing the usual activity, adapting the safety and efficacy standards to the current situation. Therefore, it is required to identify and classify patients according to criteria of infectious-immunological status, and to establish recommendations for protection in consultations, hospitalization and the operating room, which avoid the transmission of the disease to other users and healthcare personnel, in the specific context of the development of our specialty. This document is the result of the collaboration of all the scientific commissions and the SEORLCCC COVID-19 committee.

A Sustainable and Scalable Multidisciplinary Airway Teaching Mission: The Operation Airway 10-Year Experience.

OBJECTIVE: To address whether a multidisciplinary team of pediatric otolaryngologists, anesthesiologists, pediatric intensivists, speech-language pathologists, and nurses can achieve safe and sustainable surgical outcomes in low-resourced settings when conducting a pediatric airway surgical teaching mission that features a program of progressive autonomy. STUDY DESIGN: Consecutive case series with chart review. SETTING: This study reviews 14 consecutive missions from 2010 to 2019 in Ecuador, El Salvador, and the Dominican Republic. METHODS: Demographic data, diagnostic and operative details, and operative outcomes were collected. A country's program met graduation criteria if its multidisciplinary team developed the ability to autonomously manage the preoperative huddle, operating room discussion and setup, operative procedure, and postoperative multidisciplinary pediatric intensive care unit and floor care decision making. This was assessed by direct observation and assessment of surgical outcomes. RESULTS: A total of 135 procedures were performed on 90 patients in Ecuador (n = 24), the Dominican Republic (n = 51), and El Salvador (n = 39). Five patients required transport to the United States to receive quaternary-level care. Thirty-six laryngotracheal reconstructions were completed: 6 single-stage, 12 one-and-a-half-stage, and 18 double-stage cases. We achieved a decannulation rate of 82%. Two programs (Ecuador and the Dominican Republic) met graduation criteria and have become self-sufficient. No mortalities were recorded. CONCLUSION: This is the largest longitudinal description of an airway reconstruction teaching mission in low- and middle-income countries. Airway reconstruction can be safe and effective in low-resourced settings with a thoughtful multidisciplinary team led by local champions.

Should I Buy This? A Decision-Making Tool for Surgical Value-Based Purchasing.

Many considerations affect the value that a new instrument or product may generate in a surgical practice. This review serves as a guide for surgeons considering new purchases and/or wishing to advocate for hospital acquisition of new items. A summary of data from academic and industry practices is presented, with pertinent examples using relevant surgical devices such as disposable devices, laparoscopic trocars, and otologic endoscopes. Surgeons considering incorporating a new instrument or technology within their practice should weigh the following factors before decision making: patient and clinical care factors, surgeon and care team factors, and hospital factors such as cost, revenue, and sourcing. A surgeon well-versed in stakeholder interests who is involved in the purchase of a new instrument may have significant influence in value-based decision making that not only affects his or her practice but ultimately maximizes value for the patient.

Endonasal instrumentation and aerosolization risk in the era of COVID-19: simulation, literature review, and proposed mitigation strategies.

BACKGROUND: International experience with coronavirus 2019 (COVID-19) suggests it poses a significant risk of infectious transmission to skull base surgeons, due to high nasal viral titers and the unknown potential for aerosol generation during endonasal instrumentation. The purpose of this study was to simulate aerosolization events over a range of endoscopic procedures to obtain an evidence-based aerosol risk assessment. METHODS: Aerosolization was simulated in a cadaver using fluorescein solution (0.2 mg per 10 mL) and quantified using a blue-light filter and digital image processing. Outpatient sneezing during endoscopy was simulated using an intranasal atomizer in the presence or absence of intact and modified surgical mask barriers. Surgical aerosolization was simulated during nonpowered instrumentation, suction microdebrider, and high-speed drilling after nasal fluorescein application. RESULTS: Among the outpatient conditions, a simulated sneeze event generated maximal aerosol distribution at 30 cm, extending to 66 cm. Both an intact surgical mask and a modified VENT mask (which enables endoscopy) eliminated all detectable aerosol spread. Among the surgical conditions, cold instrumentation and microdebrider use did not generate detectable aerosols. Conversely, use of a high-speed drill produced significant aerosol contamination in all conditions tested. CONCLUSION: We confirm that aerosolization presents a risk to the endonasal skull base surgeon. In the outpatient setting, use of a barrier significantly reduces aerosol spread. Cold surgical instrumentation and microdebrider use pose significantly less aerosolization risk than a high-speed drill. Procedures requiring drill use should carry a special designation as an "aerosol-generating surgery" to convey this unique risk, and this supports the need for protective personal protective equipment.

A Surgical Simulator for Tympanostomy Tube Insertion Incorporating Capacitive Sensing Technology to Track Instrument Placement.

We describe a device engineered for realistic simulation of myringotomy and tympanostomy tube insertion that tracks instrument placement and objectively measures operator proficiency. A 3-dimensional computer model of the external ear and cartilaginous external auditory canal was created from a normal maxillofacial computed tomography scan, and models for the bony external auditory canal and tympanic cavity were created with computer-aided design software. Physical models were 3-dimensionally printed from the computer reconstructions. The external auditory canal and tympanic cavity surfaces were coated with conductive material and wired to a capacitive sensor interface. A programmable microcontroller with custom embedded software completed the system. Construct validation was completed by comparing the run times and total sensor contact times of otolaryngology faculty and residents.

Clinical applications of three-dimensional printing in otolaryngology-head and neck surgery: A systematic review.

OBJECTIVES: Medical three-dimensional (3D) printing, the fabrication of handheld models from medical images, has the potential to become an integral part of otolaryngology-head and neck surgery (Oto-HNS) with broad impact across its subspecialties. We review the basic principles of this technology and provide a comprehensive summary of reported clinical applications in the field. METHODS: Standard bibliographic databases (MEDLINE, Embase, Cumulative Index to Nursing and Allied Health Literature, Web of Science, and The Cochrane Central Registry for Randomized Trials) were searched from their inception to May 2018 for the terms: "3D printing," "three-dimensional printing," "rapid prototyping," "additive manufacturing," "computer-aided design," "bioprinting," and "biofabrication" in various combinations with the terms: "ptolaryngology," "head and neck surgery," and "otology." Additional articles were identified from the references of retrieved articles. Only studies describing clinical applications of 3D printing were included. RESULTS: Of 5,532 records identified through database searching, 87 articles were included for qualitative synthesis. Widespread implementation of 3D printing in Oto-HNS is still at its infancy. Nonetheless, it is increasingly being utilized across all subspecialties from preoperative planning to design and fabrication of patient-specific implants and surgical guides. An emerging application considered highly valuable is its use as a teaching tool for medical education and surgical training. CONCLUSIONS: As technology and training standards evolve and as healthcare moves toward personalized medicine, 3D printing is emerging as a key technology in patient care in Oto-HNS. Treating physicians and surgeons who wish to stay abreast of these developments will benefit from a fundamental understanding of the principles and applications of this technology. Laryngoscope, 129:2045-2052, 2019.

Endoscopy in otolaryngology utilising smartphone as the capturing device.

Mobile technology has been a significant development. With the advent of smartphones and many applications, it is possible to integrate endoscopic instruments. This is a study where the authors were able to use a smartphone as the capturing device for endoscopic examinations and were able to get satisfactory results on all but two of the 52 patients, doing four endoscopic examinations commonly being performed in otolaryngology clinics: rigid nasal endoscopy, rigid laryngoscopy, otoscopy and flexible fiberoptic naso-laryngoscopy. This article reveals their experience.

Ideal Characteristics of a Laser-Protected Endotracheal Tube: ABEA and AHNS Member Survey and Biomechanical Testing.

OBJECTIVES: To determine the characteristics of laser-protected endotracheal tubes (LPETs) valued by otolaryngologists performing transoral laser surgery in the head and neck and to measure LPET stiffness. METHODS: An online questionnaire was completed by American Broncho-Esophagological Association (ABEA) and American Head and Neck Society (AHNS) members. LPET distal end compliance was measured in a biomechanics laboratory. RESULTS: A total of 228 out of 2109 combined ABEA and AHNS members completed the survey. The following LPET characteristics, which were properties of the Medtronic Laser-Shield II tube (MLST), were highly valued: softness and flexibility, surface smoothness, and a tight-to-shaft balloon (all P < .01). Prior to industry-driven discontinuation of the MLST, 52% of surgeons (78% of fellowship-trained laryngologists [FTLs]) reported using it; afterward, 58% reported using the stainless steel, Mallinckrodt Laser-Flex tube (MLFT). Forty-six percent of all respondents (69% of FTLs) did not consider cost being a factor in LPET choice. Biomechanical testing revealed the distal end of the MLST to be 3.45 times more compliant than the MLFT ( P < .01). CONCLUSION: Members of the ABEA and AHNS, particularly FTLs, highly value distinguishing properties of the now discontinued MLST. Manufacturers should consider this in the design of new LPETs.

High-Level Disinfection of Otorhinolaryngology Clinical Instruments: An Evaluation of the Efficacy and Cost-effectiveness of Instrument Storage.

Objectives Despite increasing interest in individual instrument storage, risk of bacterial cross-contamination of otorhinolaryngology clinic instruments has not been assessed. This study is the first to determine the clinical efficacy and cost-effectiveness of standard high-level disinfection and clinic instrument storage. Methods To assess for cross-contamination, surveillance cultures of otorhinolaryngology clinic instruments subject to standard high-level disinfection and storage were obtained at the start and end of the outpatient clinical workday. Rate of microorganism recovery was compared with cultures of instruments stored in individual peel packs and control cultures of contaminated instruments. Based on historical clinic data, the direct allocation method of cost accounting was used to determine aggregate raw material cost and additional labor hours required to process and restock peel-packed instruments. Results Among 150 cultures of standard high-level disinfected and co-located clinic instruments, 3 positive bacterial cultures occurred; 100% of control cultures were positive for bacterial species ( P < .001). There was no statistical difference between surveillance cultures obtained before and after the clinic day. While there was also no significant difference in rate of contamination between peel-packed and co-located instruments, peel packing all instruments requires 6250 additional labor hours, and conservative analyses place the cost of individual semicritical instrument storage at $97,852.50 per year. Discussion With in vitro inoculation of >200 otorhinolaryngology clinic instruments, this study demonstrates that standard high-level disinfection and storage are equally efficacious to more time-consuming and expensive individual instrument storage protocols, such as peel packing, with regard to bacterial contamination. Implications for Practice Standard high-level disinfection and storage are equally effective to labor-intensive and costly individual instrument storage protocols.

The clinical impact of bedside fiberoptic laryngoscopic recording on a tertiary consult service.

OBJECTIVES/HYPOTHESIS: Fiberoptic laryngoscopy is dependent on accurate descriptions of examination findings. Traditional recording methods can be impractical for inpatient consults. Therefore, we aim to determine the utility of a smartphone-coupled portable recording system with flexible laryngoscopy for transmitting information between resident and attending physicians in a real-time setting. STUDY DESIGN: Pilot prospective study in a tertiary academic hospital. METHODS: This is a prospective study of inpatient consultations in a tertiary referral hospital over a 3-month period from April 2015 to June 2015. Flexible laryngoscopy was performed by a resident physician, and mobile recordings were relayed to an attending physician. Concordance of laryngoscopy interpretations between resident and attending physicians as well as changes in management were documented. RESULTS: Seventy-nine fiberoptic examinations were recorded and compared. Each consult was categorized as follows: airway evaluation (AE) (43%, 34/79), voice evaluation (VE) (3.7%, 3/79), dysphagia (D) (24%, 19/79), and aerodigestive tract mass/pathology (ADM) (29.1%, 23/79). Nine examinations showed discordance between resident and attending interpretations. Inter-rater agreement was good, with a kappa value of 0.747 (95% confidence interval: 0.643-0.851). The frequency of discordant exams within each group was as follows: AE (15%, 5/34), VE (33%, 1/3), D (11%, 2/19), and ADM (4.3%, 1/23). In five patients, changes in laryngoscopy interpretation changed clinical management. Seven nondiscordant exams had a change in management after attending review. Of the 79 exams, only one required repeat flexible laryngoscopy by the attending physician. CONCLUSIONS: Portable recording of flexible laryngoscopy is an effective tool for timely management of inpatient consultations. LEVEL OF EVIDENCE: 4. Laryngoscope, 128:818-822, 2018.