10.14639/0392-100X-suppl.1-42-2022-04
Objective. The aim of this paper is to describe the application of a telemedicine (TM) syn- chronous model designed to deliver care during the Coronavirus Disease 2019 (COVID-19) pandemic to patients with head and neck disease.Methods. The first step was to identify the classes of patients eligible for tele-examination. Mild, flu-like symptomatology represents the characteristics of the typical patient who is a candidate for tele-examination. The standard requirements for TM include a computer associated with a digital camera, alternatively a smartphone or tablet. The TM platform is based on the LifesizeTM software, which can be freely downloaded.Results. The overall number of teleconsultations was 178, of which 163 (91.5%) were man- aged at home, while 15 (8.5%) were invited for in-presence examination. The number of patients coming from general practitioners was 98 (55.1%), from spoke units 52 (29.2%), patients needing prompt stabilisation and transfer to the hub centre were 20 (11.2%,) while 8 (4.5%) were immediately fast-tracked in the spoke unit after multi-professional tele-con- sultation.Conclusions. Telemedicine improves organisational models, and provides a scalable solu- tion to overcome problems of overcrowding, resources and time. Should these develop- ments continue, we could face to a gradual transition to a more digital and efficient health- care system.
text/xml
1827-675X
2108
en
Cesare Miani
http://creativecommons.org/licenses/by-nc-nd/4.0
ACTA Otorhinolaryngologica Italica
telemedicine
Clinical signs, telemedicine and online consultations in head and neck diseases during the SARS CoV-2 pandemic: an Italian experience
Text.Serial.Journal
https://www.actaitalica.it/
42
Annual congress report
2022-04-26
2022-04-06
2022-04-28
2022-04-28
S36-S45
1
Cesare Miani
2022/04/26
10.14639/0392-100X-suppl.1-42-2022-04
S36
Department of Otorhinolaryngology, Hospital of Tolmezzo, ASUFC Udine, Udine, Italy
1827-675X
telemedicine
S45
Clinical signs, telemedicine and online consultations in head and neck diseases during the SARS CoV-2 pandemic: an Italian experience
https://www.actaitalica.it/article/download/2108/768
42
ACTA OTORHINOLARYNGOLOGICA ITALICA 2022;42(SUPPL.1):S36-S45; doi: 10.14639/0392-100X-suppl.1-42-2022-04




Clinical signs, telemedicine and online consultations
in head and neck diseases during the SARS CoV-2
pandemic: an Italian experience
Segni clinici, telemedicina e visite online nelle malattie testa e collo
durante la pandemia SARS CoV-2: un’esperienza italiana
Massimo Robiony1, Salvatore Sembronio1, Alessandro Tel1, Elisabetta Ocello1, Jamile Karina Antonio2,
Marilena Graziadio2, Cesare Miani2
1
  Maxillofacial Surgery Department, Academic Hospital of Udine, Department of Medicine, University of Udine, Italy; 2 Department of
Otorhinolaryngology, Hospital of Tolmezzo, ASUFC Udine, Udine, Italy


SUMMARY
Objective. The aim of this paper is to describe the application of a telemedicine (TM) syn-
chronous model designed to deliver care during the Coronavirus Disease 2019 (COVID-19)
pandemic to patients with head and neck disease.
Methods. The first step was to identify the classes of patients eligible for tele-examination.
Mild, flu-like symptomatology represents the characteristics of the typical patient who is
a candidate for tele-examination. The standard requirements for TM include a computer
associated with a digital camera, alternatively a smartphone or tablet. The TM platform is
based on the Lifesize™ software, which can be freely downloaded.
Results. The overall number of teleconsultations was 178, of which 163 (91.5%) were man-
aged at home, while 15 (8.5%) were invited for in-presence examination. The number of
patients coming from general practitioners was 98 (55.1%), from spoke units 52 (29.2%),
patients needing prompt stabilisation and transfer to the hub centre were 20 (11.2%,) while
8 (4.5%) were immediately fast-tracked in the spoke unit after multi-professional tele-con-
sultation.
Conclusions. Telemedicine improves organisational models, and provides a scalable solu-
tion to overcome problems of overcrowding, resources and time. Should these develop-             Received: February 10, 2022
ments continue, we could face to a gradual transition to a more digital and efficient health-    Accepted: February 17, 2022
care system.
                                                                                                 Correspondence
KEY WORDS: head and neck diseases, COVID-19, telemedicine
                                                                                                 Massimo Robiony
                                                                                                 Maxillofacial Surgery Department, Academic Ho-
RIASSUNTO                                                                                        spital of Udine, Department of Medicine, Universi-
Obiettivo. L’obiettivo di questo articolo è descrivere l’applicazione di un modello sincrono     ty of Udine, via Colugna 50, 33100 Udine, Italy
di telemedicina (TM) per fornire assistenza, durante la pandemia di Coronavirus Disease          E-mail: massimo@robiony.it
2019 (COVID-19), ai pazienti con malattie testa e collo.
Metodi. Il primo passo è stato quello di identificare i pazienti eleggibili per un tele-esame.     How to cite this article: Robiony M, Sembronio
Una sintomatologia lieve rappresenta la caratteristica del tipico paziente candidato per un        S, Tel A, et al. Clinical signs, telemedicine
teleconsulto. I requisiti standard per la TM includono un computer associato a una foto-           and online consultations in head and neck
camera digitale, in alternativa uno smartphone o un tablet. La piattaforma TM si basa sul          diseases during the SARS CoV-2 pandemic:
software Lifesize™, che può essere scaricato liberamente.                                          an Italian experience. Acta Otorhinolaryngol
Risultati. Il numero di teleconsulti eseguiti è stato di 178: 163 (91,5%) gestiti a domicilio;     Ital 2022;42(SUPPL.1):S36-S45. https://doi.
15 (8,5%) invitati a una visita in presenza. Il numero di pazienti provenienti da medici ge-       org/10.14639/0392-100X-suppl.1-42-2022-04
nerici è stato 98 (55,1%), da unità spoke 52 (29,2%), i pazienti prontamente stabilizzati in
                                                                                                 © Società Italiana di Otorinolaringoiatria
unità spoke e ulteriormente trasferiti al centro hub 20 (11,2%), mentre 8 (4,5%) sono stati      e Chirurgia Cervico-Facciale
immediatamente inviati all’unità spoke dopo un teleconsulto multiprofessionale.
Conclusioni. La telemedicina migliora i modelli organizzativi e fornisce una soluzione mo-
                                                                                                                OPEN ACCESS
dulabile per superare i problemi di sovraffollamento, di risorse e tempo. Se questi sviluppi
dovessero continuare, potremmo trovarci di fronte a una transizione graduale verso un            This is an open access article distributed in accordance with
                                                                                                 the CC-BY-NC-ND (Creative Commons Attribution-Non-
sistema sanitario più digitale ed efficiente.                                                    Commercial-NoDerivatives 4.0 International) license. The
PAROLE CHIAVE: malattie testa e collo, COVID-19, telemedicina                                    article can be used by giving appropriate credit and mentio-
                                                                                                 ning the license, but only for non-commercial purposes and
                                                                                                 only in the original version. For further information: https://
                                                                                                 creativecommons.org/licenses/by-nc-nd/4.0/deed.en




S36
                                                                      Telemedicine in head and neck diseases during SARS CoV-2 pandemic




Introduction                                                      The second and most common type is the “asynchronous
                                                                  form”, in which the information and results of the patient’s
Telemedicine (TM) has been described in various forms             clinical examination are presented to the physician as a
since the invention of the telegraph and the telephone, and       medical record, and therefore there is no direct interview
the first time that it was mentioned in scientific publication    with the patient. This type of consultation is the most wide-
was in the 1920s 1. The transmission of radiologic images         ly used among healthcare professionals 7,8.
was feasible since 1950, but only with the diffusion of in-       In the third type, the real-time or “synchronous form”, the
ternet 2 was its application enhanced, initially to improve       visit takes place in real time through videoconferencing,
the provision of care, especially in rural areas, and by fa-      and is a live interaction between the health care provider
cilitating access to specialist advice 3.                         and the patient.
Because of the catastrophic impact of Coronavirus Disease         The suitable conditions for asynchronous care are inher-
2019 (COVID-19) pandemic, many health services were               ently non-emergent. The use of such techniques with the
altered, and thus innovative solutions such as TM have            assistance of a licensed health care technician has already
been created resulting in a transformation of health care         been shown to be useful in head and neck oncology consul-
and in an opportunity to see the role that TM can play in         tations, remote otologic and audiologic evaluation, coch-
daily clinical management of patients 2.                          lear implantation and hearing aid management, laryngeal
Initially, in most otolaryngology services, in-hospital visits    ultrasound, nasofibroscopy and tomography review in rhi-
were suspended, except for urgent cases 4. As many coun-          nosinusal diseases 9.
tries have alternated periods of lockdown, which posed            A recent study has reported that 62% of ear nose and throat
severe restriction in mobility to citizens, the delivery of       (ENT) examinations do not require specialist procedures
health care services underwent a complete redesign, privi-        and could possibly be performed with the help of a health
leging solutions based on remote assistance, and focusing         technician, who would communicate the data obtained to
on the dimension of the territory. In this scenario, the use of   the physician 5. Moreover, other publications mention that,
TM was introduced to try to cope with the new difficulties        in specific situations, the direct consultation of the patient
that the pandemic has brought in terms of care 2.                 with the physician, with the aid of common technologies, is
COVID-19 is a highly transmissible respiratory infec-             already available to the general population 5.
tion and otolaryngologists and all head and neck surgeons         In this paper we describe the implementation of a synchro-
(HNS) are the physicians at the highest risk of infection 5       nous telemedicine model designed to deliver care during
and their offices a place that can foster transmission within     the pandemic, presenting its technical components, settings
the community.                                                    of application and potentialities, focusing our attention on
In this setting, the figure of the clinician plays a central      the possible clinical signs, which can be captured by a re-
role, as they must help patients, examine the severity of         mote examinator using available technology. We emphasise
symptoms and decide for hospitalisation or home care.             the clinical examination of the patient with suspect upper
Head and neck surgeons (HNS), like otolaryngologists and          respiratory trait infection using TM, focusing on history as-
maxillofacial surgeons, are called upon to address several        sessment, description of symptoms and clinical signs, and
questions raised by general practitioners, and TM paves the       present our preliminary results.
way for interdisciplinary consultations and provides a plat-
form to remotely discuss cases, even in the absence of in-
person examination of patients. In this way, patients with        Materials and methods
COVID-19 could safely be cared for via TM.                        Patient selection and creation of the protocol
Finally, an estimated 41-42% of the population had delayed        During the pandemic, in the Maxillofacial Surgery Depart-
or avoided seeking care during the pandemic because of            ment of the University of Udine, Italy, a crucial decision
concerns about COVID-19.                                          was taken in order to modulate the flow of outpatient clin-
There are three types of TM:                                      ics, and to decrease the number of patients needing physical
1. remote monitoring;                                             consultations in the hospital. The first step was to identify
2. store and forwards or asynchronous 6;                          the types of patients eligible for tele-examination: urgent
3. real-time interactive visit or synchronous 4,5.                cases were deferred to in-presence evaluation, limiting on-
The first type includes self-testing and self-monitoring,         line examination to non-urgent cases with mild symptoms.
relying upon a range of technologies to monitor patients          A professional, identified within the health care person-
remotely, and is mainly indicated to manage chronic diseases,     nel, commonly a nurse performing a telephone triage, to
such as asthma, diabetes mellitus and other similar diseases.     select the appropriate patients, assessed this. Mild, flu-like



                                                                                                                                  S37
M. Robiony et al.




symptomatology represents the characteristic of the typi-       access code. Once the patient entered the given code, they
cal patient who can be the candidate for tele-examination.      were admitted to the virtual space. Specific frames of the
This organisation offers the possibility to keep potentially    examinations were taken in form of screenshots or short
infectious patients, both for COVID or non-COVID infec-         video frames, which were stored for each examination to
tion, outside from the hospital, to limit the spread of the     provide documentation of clinical findings. The clinical da-
virus, especially in the hospital environment where frag-       tabase was compiled as if a physical examination was per-
ile patients are at high risk of complications. Several signs   formed, and another appointment date was communicated
reported during the telephone triage ascertained the need       to the patient if follow-up was needed.
for in-person consultation. These included neck swelling,
persistence of sore throat for more than 3 days with fever      Networks between Hub Unit - Spoke Unit -
beyond 38°C and difficulty to swallow or breathe, since         general practitioners
these symptoms may be associated with a severe laryngeal        TM becomes an essential resource and support in order to
disease or local complication like a tonsillar abscess.         provide a communication between the main hospital (hub
                                                                unit) and minor hospitals (Spoke units) (Fig. 1). Territorial
Technical components of the telemedicine platform               healthcare (general practitioners) can fast-track a request
developed at our institution                                    for a specialist evaluation from a spoke unit to its hub body
The standard requirements for telemedicine include a            and rapidly make a correct diagnosis and a shared decision
computer associated with a digital camera, alternatively        on where, when and how to treat a patient with upper
a smartphone or tablet. The latest generation devices are       respiratory tract infections (e.g., transfer the patient for
equipped with high-resolution cameras with sensitive light      more intensive care, need for laboratory analysis, therapies,
detection and powerful microphones.                             or observation). Tele-consultation and tele-examination are
Before scheduling the videoconference examination, we           the most appropriate TM modalities to enable this process,
asked the patient for his/her availability of technological     based on a remote cooperation between the hub specialist,
devices, which type, and, especially for elderly people, the    spoke emergency doctors and general practitioners who are
presence of a caregiver or a relative who can provide tech-     offered the opportunity of teleconsulting. The specialist
nological assistance.                                           can guide the doctor to perform evaluations through
Moreover, we also asked the patient to obtain a flashlight      telesemeiology, as defined later in this paper, by using a
or a torch to create the appropriate lighting conditions for    virtual environment.
complete examination of the oral cavity.
The TM platform is based on the Lifesize™ software 10.          Clinical application
Both the clinician and the patient were required to install     Upper airways are examined based on a simple schemati-
a copy of the software, which can be freely downloaded.         sation within three areas, which are affected by infections
The software is available for multiple operating systems,       and offer different possibilities and limitations for remote
including Windows and Mac, as well as for mobile devices        examination:
(iOS and Android).                                              • nasal, or superior compartment;
This software was adopted by our institution, and it allows     • oral cavity and oropharynx, or middle compartment;
to create a virtual agenda, wherein management is assigned      • laryngeal, or inferior compartment.
to the case manager of our clinic. Appointments for ex-         The nasal compartment can be only externally visualised
aminations were scheduled every 40 minutes, including a         during tele-examination, thus offering the possibility to as-
15-minute window allowing both the patient and clinician        sess the presence of secretions. Anamnesis plays a crucial
to correctly configure the platform and devices. In this way,   role and allows to investigate the presence of symptoms
a virtual meeting space is created in which a virtual room      related to infections, including most commonly secretions,
environment (VRE) hosts the tele-examination. In our ex-        and nasal obstruction. In case of sinusitis, a common find-
perience, this resulted in the creation of a “Maxillofacial     ing is cacosmia and the patient often refers the presence of
Surgery Clinic Examination Office”, which was the modal-        postnasal drip. Most importantly, the clinician should in-
ity it appeared on the patient’s screen.                        vestigate the absence or presence of smell, which is more
After receiving the confirmation of reservation for a tele-     specific for COVID-19 infections.
examination, we sent to the patient a portable document         The oral cavity is eligible to direct inspection with the aid
file (PDF) containing the instructions for the meeting, the     of a smartphone camera and appropriate lighting, and can
consent details for registering and storing images and video    be examined up to the palatopharyngeal arch, in the pres-
frames and the download links for Lifesize as well as the       ence of a collaborating patient. The patient is invited to



S38
                                                                                          Telemedicine in head and neck diseases during SARS CoV-2 pandemic




Figure 1. Schematic illustration of the hub – spoke hospital network within the University Hospital of Friuli Centrale. Contacts prior to centralisation of patients
are mediated by teleconsultations, which also provide clinicians from spoke units with the possibility to discuss clinical cases and define whether patients should
be treated at the spoke unit or centralised to the hub centre (Udine).


open the mouth, lower the tongue and at the same time                               using a smartphone-based examination, as it would require
pronounce the sound “A” exposing the posterior oro-                                 flexible optics to inspect the laryngeal opening, which are
pharyngeal wall. Findings related to upper airway infec-                            available only in a specialist setting.
tion include mucosal hyperemia, tonsil enlargement and                              At the end of the procedure, records were registered in an
the presence of plaques. As seen for the nasal compart-                             electronic archive, and a formal description of the examina-
ment, even for the oral cavity anamnesis plays an impor-                            tion was reported. Moreover, at the end of each tele-exami-
tant role, since patients usually complain of sore throat,
                                                                                    nation, a questionnaire was filled in by the responsible phy-
which exacerbates during swallowing. A specific element
                                                                                    sician which included six categories of items describing the
to investigate to focus attention on a possible COVID-19
                                                                                    overall fluidity of the examination, quality of visualization,
infection is the absence of taste, which is often associated
with the absence of smell 11.                                                       model of device used, visual signs captured by clinical in-
The laryngeal compartment can be investigated with an-                              spection, referred symptoms and the programme for further
amnesis and sound. The most common symptom is cough                                 care and follow-up. Clinicians from hub, spoke centers and
and a lower, croaking voice, as well as noisy breath, pos-                          general practitioners reported a considerably high satisfac-
sibly due to vocal fold inflammation but also to early glot-                        tion score, and deemed tele-examination a useful and rapid
tic cancer. The laryngeal compartment cannot be examined                            ally for both urgent and non-urgent situations.



                                                                                                                                                              S39
M. Robiony et al.




The rise of “telesemeiology”                                                      all patients. The specialist prepared a synthetic checklist
As part of their training, all clinicians were instructed to                      to collect all the necessary information intuitable from
perform a complete on-line anamnesis and to evaluate vis-                         the teleexamination. This “telesemeiology checklist” was
ual signs associable to upper airway infections. We created                       based on the aforementioned aspects, with particular at-
the term ‘telesemiology’ 12, a novel expression coined to                         tention on recent anamnesis reported by the patient and
define the group of signs and symptoms detectable through                         signs visible in an on-line consultation. Many clinical signs
remote clinical inspection performed using technological                          were attributable to simple manifestations of infections, in-
devices. The reliability of such signs is strongly dependent                      cluding sore throat, rhinorrhoea, cough and mild fever. In
upon patient collaboration, since they are requested to per-                      COVID-19 patients, a higher frequency of smell and taste
form specific tasks in front of the camera, with appropri-                        reduction was observed, although the same symptoms were
ate lighting and following the instructions of the clinician                      also common in patients affected by seasonal flu or cold.
(Fig. 2). When the consultation is performed in presence                          The overall number of teleconsultations performed was
of a physician such as in case of connection between hub
                                                                                  178, of which 163 (91.5%) were managed at home with
unit, spoke units and general practitioners, the examination
                                                                                  medical therapy or observation, while 15 (8.5%) were invit-
is more reliable.
                                                                                  ed to an in-presence examination. In such cases, the clinical
                                                                                  signs related with the history of the patient posed the threat
Results                                                                           of possible worsening of clinical conditions, in fact some
Teleconsultation for upper respiratory infection started                          patients were hospitalised with the following diagnoses:
in April 2020, after pressure exerted by the pandemic on                          tonsillar abscess (4 patients), odontogenic abscess (2 pa-
the Italian health care system forced the adoption of novel                       tients), acute sinusitis (2 patients) and 3 had neck masses
organisational designs. During this period and using the                          which required further investigation. In particular, one of
appropriate technological devices and a suitable internet                         the patients requiring immediate teleconsultation was re-
connection, examinations were successfully conducted for                          ferred to our attention by the general practitioner, as he had




Figure 2. An overview of possibilities offered by telesemeiology with remote inspection in patients undergoing oral cancer resection and reconstruction with
free flaps. Panel A illustrates complete wound healing after 6 months; panel B shows tongue movement and functional integrity of hypoglossal nerve after neck
dissection; panel C shows mouth opening, with a complete restoration of mandible excursion; panel D shows healing of the donor site (radial forearm free flap).



S40
                                                                     Telemedicine in head and neck diseases during SARS CoV-2 pandemic




presented with suggestive symptoms of neck abscess, in-          technician, who can perform the clinical examination and
cluding fever beyond 39°C, respiratory tirage and fatigue,       transmit the data in real time to the specialist, was used
sensation of airway compression and loss of consciousness,       mostly for ear diagnoses (52.6%). The remaining diagno-
and was rapidly admitted to the intensive care unit.             ses included throat problems (14.1%) and nasal disorders
Concerning organisation and networks, the results also in-       (13.3%), earwax plug (9.2%), chronic otitis externa (8.1%)
clude evaluation of the number of patients coming from           and otitis media (8.1%) 15. The same authors noted that a
general practitioners (98-55.1%), from spoke units (52-          specialised procedure was not required to diagnose and
29.2%), and patients promptly stabilized in spoke units and      treat 51% of cases; therefore, they were considered suitable
further transferred to the hub centre (20 patients-11.2%).       for TM, but the eligibility varied depending on the anatomic
Eight (4.5%) patients were immediately fast-tracked in the       site. In the remaining 49% of cases, specialised procedures
spoke unit after prompt multi-professional tele-consulta-        were performed in the clinic by a health care technician
tion between spoke and hub units.                                under the supervision of an otolaryngologist via telemoni-
                                                                 tor. The most common procedures were cerumen removal
Discussion                                                       and endoscopic examinations of the larynx and nose. Other
                                                                 procedures included removal of foreign bodies, reposition-
Already in the pre-COVID era, the topic of TM was stud-          ing manoeuvers and topical treatments 15.
ied mainly to enable care for patients in rural areas of the     In otology, a study with asynchronous video-otoscopy (us-
United States. In fact, McCool & Davies were studying            ing an appropriately licensed health care technician) has
the eligibility of different anatomical sites in 2017 that re-   reported a diagnostic capability equivalent to physician-
sulted from 92% in inner ear diseases to 39% in laryngeal        directed otoscopy 5,9.
disorders. In addition, their data show that otology is par-     The diagnosis of otologic diseases is mostly noninvasive.
ticularly well suited for this type of propaedeutic approach.    The initial diagnosis usually involves a detailed history
Diagnostic concordance rates ranged from 79 to 85% 13.           and physical examination by otoscopy. The problem with
Other authors have reported high diagnostic reliability in       TM in the field of otology is clinical examination. Con-
patients with various ENT conditions, including otologic         ventional otoscopy is not expensive, but raw images cannot
conditions, rhinosinusitis, peritonsillar abscess, and nasal     be shared online. In recent years, smartphone otoscopy is
fracture 14. The diagnostic accuracy and effectiveness of        being developed, which seems to have demonstrated good
empiric therapy provided during TM visits are of particular      reliability, and is promising in terms of TM. In addition,
interest in determining the feasibility of its use in the ef-    these tools are increasingly accessible to the population,
fective management of patients 14. A limitation to this type     thus offering the patient the ability to contact physicians
of approach is the need for an adequately trained health         directly for advice 5.
care technician to perform diagnostic and minor therapeu-        Indeed, in recent work, carried out in a tertiary centre
tic procedures 13,15.                                            where the spectrum of disease was broad, most middle ear
During this pandemic, considering the pressure and load          diseases were diagnosed using patient-reported symptoma-
on healthcare system, reorganisation and flexibility have        tology and use of smartphone otoendoscopy, with a high
played and continue to play a key role across all levels.        degree of accuracy 5.
Similarly, this pandemic offers the opportunity to study         The limitations observed are mainly due to the resolution
and develop innovative solutions to overcome the problem         or contrast of the images, or to the instrument being too
of crowding within closed spaces, and isolation of positive      large for narrow ear canals 5,9. Subtle findings such as a
COVID-19 patients, or in those with suspicion of infection.      mild retraction pocket, atelectasis, pinhole perforation, or
Indeed, in the last two years the number of original and re-     small cholesteatoma may not be evident in low-quality im-
view papers has multiplied, and it is now possible to know       ages 9.
the experience of different services worldwide.                  Similarly, other authors cite that the effective use of tele-
Even if the TM is of interest, it also has some limitations:     medicine in otolaryngology consultations is highly depend-
one of the greatest is the unique head and neck anatomy,         ent on the ability to transmit clinical images of adequate
which requires palpation and specific tools to examine.          quality for remote diagnosis 9,16.
Moreover, remote lighting of the structures in the ear nose      In addition, image quality may be affected not only by the
and throat is, at the moment, not an easily and widely avail-    technology used, but also by the skill level of the health
able technology, thus limiting the eligibility of a large num-   care technician. Further research is needed to evaluate the
ber of ENT visit that could be performed with TM 2.              distinction between image acquisition by a trained special-
Wu et al. found that the use of TM with the help of a health     ist and by a general practitioner or health care technician,



                                                                                                                                 S41
M. Robiony et al.




as the purpose of TM is to provide specialised services         crisis situations such as the COVID-19 pandemic, simple
when an ENT specialist is not physically present 16.            initial telephone consultation has high concordance with
Nevertheless, other authors note that the quality of video-     the final treatment plan despite some limitations in diag-
otoscopy recordings was acceptable or better in 87% of          nostic concordance due to the inability to perform physical
cases 9. Facial palsies and tumors of the outer ear have        examination 17.
obvious symptoms and signs, which can be diagnosed on           Similarly, Choi et al. examined the concordance in diag-
photographs with almost 100% accuracy 5. The diagnostic         nosis and management between the initial TM visit and
accuracy of vertigo, when not using a health care techni-       subsequent laryngoscopic examination in an outpatient ter-
cian, appears to be relatively low, given the inability to      tiary care centre; the overall concordance rates were high:
perform additional physical examinations and the fact that      86.0 and 93.6% for diagnosis and management, respec-
eye cameras are not currently accessible to most patients.      tively. They emphasised that although TM should not re-
Certainly, when an eye-tracking camera or device will be-       place in-person physical examination and laryngoscopy for
come widely available, the feasibility of diagnosing vertigo    laryngology-related disorders, it can be effectively used to
of peripheral origin can be reassessed and the overall ac-      provide a preliminary diagnosis, appropriate management
curacy of asynchronous TM will likely improve 5.                plan and triage during the current pandemic 14.
TM has also been applied to tinnitus rehabilitation and         It has been proposed that, in institutions with multiple
cochlear implant candidacy, fitting, programming and            otolaryngology team members able to perform laryngos-
maintenance, as well as hearing aid evaluation and pro-         copy examination, a single examiner can capture the im-
gramming. It appears that cochlear implant threshold,           age while the others could review the information remotely.
comfort and impedance levels are easily obtained via TM         This would limit the number of personnel undergoing a
and are not significantly different to those achieved by in-    procedure that generates aerosol 18. Some authors strongly
person sessions 9.                                              recommend the application of TM to voice therapy, as it
Although some works have evaluated the use of TM in sinus       meets standards of care with increased physician and pa-
nasal and laryngology pathologies, it seems that, in those      tient satisfaction 9,19.
districts, the diagnostic concordance is lower than the re-     Concerning management concordance rates for complaints
sults found for otological pathologies. Indeed, Kwok et al.     related to swallowing and general throat complaints (i.e.,
confirm these data. Direct examination of the nasal cavity      pharyngodynia, discomfort, or throat knot feeling), TM
and larynx requires specialised skills and equipment; these     with video can provide useful preliminary information
have been particularly challenging during the COVID-19          such as overall swallowing function and change in voice
pandemic because of the potential production of aerosols        quality/aspiration symptoms after swallowing 14.
(which promote contamination) in examinations such as           According to the work of Choi et al., the diagnostic and
nasoendoscopy 17.                                               management concordance rate for airway complaints was
Nevertheless, in sinus nasal pathologies telephone con-         95%. Detailed history collection, including previous history
sultation presents a good diagnostic concordance with the       of trauma, intubation, tracheostomy and major surgery, can
diagnosis of the referring physician, thus allowing an ap-      guide clinicians towards accurate diagnosis before laryngo-
propriate triage of physical appointments and adequate ini-     scopy. In these cases, TM can be used for appropriate triage
tiation of medical treatment 17.                                during the pandemic, recognising urgent issues that need
In cases of nosebleeds, telemedicine can help identify trig-    rapid follow-up (i.e., symptomatic airway obstruction, as-
gers, risk factors and can help manage mild bleeding. Of        piration, severe dysphagia, suspicion of malignancy, etc.).
course, failure to control bleeding with conservative meas-     Of course, it is important to note that the small percentage
ures should prompt an in-person evaluation 9.                   of cases with misdiagnosis or mismanagement may result
Alternatives within TM include increased use of radiologi-      in critical morbidity in these patients 14.
cal investigations for sinus disease and laryngeal pathol-      TM seems to be easily applicable to facial reconstructive
ogy, with limitations for small mucosal lesions. Other alter-   surgery given that the assessment of facial soft tissue re-
natives described are voice recordings and speech analysis      lationships and defects is already heavily based on digital
systems for speech pathology, although access to these          photographic documentation and analysis 9,18. Facial trauma
investigations is still limited 9,18. However, some authors     may also be particularly amenable to remote assessment. In
have pointed out that the exclusive use of radiologic inves-    fact, high concordance has been reported between evalua-
tigations for diagnosis is a deviation from the standard of     tion of patients with facial trauma during a traditional visit
care and may have medicolegal implications 14. Kwok et al.      and evaluation performed via videoconferencing with re-
showed that in resource-limited settings and particularly in    view of radiologic images. Again, a remote approach can



S42
                                                                     Telemedicine in head and neck diseases during SARS CoV-2 pandemic




be used for triage, avoiding unnecessary transfers for pa-       Especially in such difficult times, the challenge for a mod-
tients who do not require intervention 9,19.                     ern health care institution is to maintain a high quality of
The limitation in the full adoption of TM for facial trauma      care, at the same time safeguarding both patients and cli-
assessment is image quality. Low-quality images do not al-       nicians by reducing the number of physical consultations.
low for assessment of clinical evidence of septal hemato-        Because of the rapid spread of SARS-CoV-2 infection, and
ma, intraoral malocclusion and facial contour asymmetries.       especially more contagious variants, including the omicron
In addition, because one cannot palpate the face, one can-       strain, we have seen an increasing flow of patients saturat-
not assess the mobility and stability of the facial fracture,    ing hospital departments.
differentiate between oedema and haematoma, and assess           It is worth mentioning that the role of TM was also to pre-
the degree of sensitivity. With the inability to smell dur-      vent overcrowding of hospitals, and especially emergency
ing physical examination, one cannot identify odours that        departments for respiratory infections, which become fre-
would indicate an infection 19.                                  quent during winter and are self-resolving in many cases.
Regarding the indication for tonsillectomy with or with-         TM is particularly useful for such cases, which would eas-
out adenoidectomy, it appears that telephone consultations       ily saturate general practitioners’ offices or hospitals, but
were concordant with the results of physical examination         which can also be managed by home care using medical
(90.4% diagnostic concordance with the referring general         therapies and observation. In contrast, tele-examinations
practitioner and 99.1% concordance of the diagnosis and          allow to ascertain the potential severity of cases which need
treatment plan with the physical appointment). This obser-       hospitalisation, filtering and limiting hospital accesses to
vation seems to be true especially for paediatric patients 17.   conditions that strictly require more intensive management.
TM can also be successfully used in clinical care of patients    Especially for head and neck specialists, exposure to poten-
with cleft lip and palate. However, patients undergoing          tial infectious contacts is not negligible; therefore, TM is a
cleft lip and palate repair usually require comprehensive,       valuable strategy to decrease unessential contacts with pa-
multidisciplinary care over an extended period of time 18.       tients, together with the aim of maintaining clinicians safe.
In the management of the head and neck cancer patient,           This is particularly helpful in a time in which depletion of
should any change in symptoms occur, TM can facilitate           personnel both for overworking and for infections between
contact between the patient and their physician, without the     health workers has put the system into an unprecedented
need for high-risk face-to-face contact. The MD Anderson         crisis.
Head and Neck Surgery Consortium has created guidelines          Telesemeiology is defined as the evaluation of the complex
for management of head and neck cancer by subsite, and           and composite signs of patients’ face or other body parts
TM is incorporated as an essential tool that should be used      using a detector technology from remote, via a telecom-
judiciously whenever possible 18.                                munications infrastructure and performed through coop-
The ability to contact the physician may represent a re-         eration between clinicians. As mentioned, a variety of head
duction in emotional burden for the patient, improve their       and neck regions can be examined through telesemeiology
quality of life and reduce the discomfort of symptoms that       to ascertain several conditions, such as inspecting the oral
patients face. Indeed, it would appear that patients with        cavity and visualising tonsils and the posterior oropharynx.
head and neck cancer who were monitored through TM in-           Telesemeiology continues to provide a valuable informa-
tervention reported significantly better quality of life and     tional library of recorded data on signs and symptoms of
lower symptom burden after treatment than patients who           disease, contributing to implement a rapidly growing ar-
received routine cancer care 18.                                 chive of medical information that is being translated into
Encouraged by the success obtained by several authors, and       big data and artificial intelligence technology. Therefore,
especially in the current difficult situation, we organised      telesemeiology data will be collected and analysed to con-
a TM service in our region. Our region is organised ac-          tinuously improve clinical practice in emergency situations
cording to a hub and spoke model within a circumscribed          and provide solid data.
healthcare environment, the University Hospital of Friuli        Moreover, improving knowledge in the novel field of tel-
Centrale (UHFC) composed of one hub (University Hospi-           esemeiology further corroborates the relationship between
tal of Udine) and 4 spoke units (Hospital of Latisana, Hos-      hub specialists and spoke clinicians during the pandemic,
pital of Palmanova; Hospital of San Daniele and Hospital         contributing to the diffusion of new clinical and scientific
of Tolmezzo). Considering the pre-existing organisational        knowledge, and increasing overall experience in the field.
health care design and a relatively small region, which also     On the other hand, a clinician should be always aware that
includes mountain territory, which is notably remote to ac-      tele-examination is mediated by technological devices and
cess, we planned a TM network according to these features.       provides an incomplete assessment of the patient compared



                                                                                                                                 S43
M. Robiony et al.




with in-presence evaluation. Only inspection is possible,         and belief is that such developments will continue, acceler-
and is further limited by factors including inadequate com-       ating the transition to a more digital and efficient healthcare
pliance, low resolution cameras and unstable internet con-        system.
nection. Oral cavity visualisation might be biased by inap-
propriate compliance of patients, in particular the depth of      Conflict of interest statement
the mouth is not easily visible without appropriate lighting.     The authors declare no conflict of interest.
Moreover, many spaces are not visible without appropri-
ate technological instrumentation, such as nasal cavities,        Funding
deep throat and larynx. In the future, novel devices might        This research did not receive any specific grant from fund-
be developed to improve visualisation of such spaces, for         ing agencies in the public, commercial, or not-for-profit
instance portable endoscopes and optical cameras which            sectors.
would allow to explore such regions when a spoke unit
physician wants to share results of clinical examination          Authors’ contributions
with the hub centre referent. However, such devices would         SS, AT, EO and MR: conceptualization; MR and CM: su-
not be usable directly by patients, thus maintaining this         pervision and coordination; SS, AT, JKA and MG: writing;
limitation.                                                       AT: images; CM: management.
Some authors, in a prospective work, verified that patients’
overall satisfaction with TM consultation was excellent,          Ethical consideration
with 87% satisfied or very satisfied. Factors that were un-       This study reports results of a novel organizational design.
pleasant to patients were the absence of physical examina-        No experimental treatment was applied on patients, there-
tion and poor audio and video quality 3,17,20. Morisada et        fore ethical commitee was not required.
al. 21 studied the satisfaction of patients with TM performed
synchronously in rhinologic examinations and found no             References
significant difference between TM and undergoing tradi-           1
                                                                      Eikelboom RH. The telegraph and the beginnings of telemedicine in
tional consultations, despite the inability to perform clini-         Australia. Stud Health Technol Inform 2012;182:67-72. https://doi.
cal examination and rigid rhinoscopy.                                 org/10.3233/978-1-61499-152-6-67
In addition, the ability for frequent video- or image-based       2
                                                                      Manning LA, Gillespie CM. E-Health and telemedicine in otolaryn-
communication between patient and physician may im-                   gology risks and rewards. Otolaryngol Clin North Am 2022;55:145-
                                                                      151. https://doi.org/10.1016/j.otc.2021.07.011
prove patient satisfaction by facilitating closer postopera-      3
                                                                      Fieux M, Duret S, Bawazeer N, et al. Telemedicine for ENT: effect on
tive follow-up and wound care. For evaluation of nonemer-             quality of care during COVID-19 pandemic. Eur Ann Otorhinolaryn-
gent conditions such as skin injuries and wound care, 83%             gol Head Neck Dis 2020;137:257-261. https://doi.org/10.1016/j.
of patients reported that they would prefer TM to tradition-          anorl.2020.06.014
al evaluation for similar future visits 9.                        4
                                                                      Lee AKF, Cho RHW, Lau EHL, et al. Mitigation of head and
                                                                      neck cancer service disruption during COVID-19 in Hong Kong
We foresee that telesemiology, which arose during the                 through telehealth and multi-institutional collaboration. Head Neck
COVID-19 pandemic, will profoundly influence the future               2020;42:1454-1459. https://doi.org/10.1002/hed.26226
of clinical examinations together with the education of           5
                                                                      Cha D, Shin SH, Kim J, et al. Feasibility of asynchronous and
young physicians. In particular, for university institutions          automated telemedicine in otolaryngology: prospective cross-
                                                                      sectional study. JMIR Med Inform 2020;8:e23680. https://doi.
TM can provide valuable resources allowing the possibil-              org/10.2196/23680
ity to transmit live clinical examinations on streaming plat-     6
                                                                      Kokesh J, Ferguson AS, Patricoski C. The Alaska experience using
forms, while students observe and learn.                              store-and-forward telemedicine for ENT care in Alaska. Otolaryn-
                                                                      gol Clin North Am 2011;44:1359-1374. https://doi.org/10.1016/j.
                                                                      otc.2011.08.010
Conclusions                                                       7
                                                                      Huang VW, Imam SA, Nguyen SA. Telehealth in the times of SARS-
The pandemic allowed to design and implement, in the                  CoV-2 infection for the otolaryngologist. World J Otorhinolaryngol
                                                                      Head Neck Surg 2020;6 (Suppl 1):S49-S53. https://doi.org/10.1016/j.
form of scientific small-scale pilot projects, innovative             wjorl.2020.04.008
possibilities to evaluate patients with upper respiratory trait   8
                                                                      Ohlstein JF, Garner J, Takashima M. Telemedicine in otolaryngol-
infections, through fluid cooperation among hub and spoke             ogy in the COVID-19 era: initial lessons learned. Laryngoscope
units, general practitioners and head and neck surgeons.              2020;130:2568-2573. https://doi.org/10.1002/lary.29030
We foresee that TM will improve organisational models,
                                                                  9
                                                                      Singh AK, Kasle DA, Jiang R, et al. A review of telemedicine
                                                                      applications in otorhinolaryngology: considerations during the
providing a scalable solution to overcome problems of                 Coronavirus disease of 2019 pandemic. Laryngoscope 2021;131:744-
overcrowding, depletion of resources and time. Our hope               759. https://doi.org/10.1002/lary.29131




S44
                                                                                      Telemedicine in head and neck diseases during SARS CoV-2 pandemic




10
     Lifesize-Cloud contact center and video meeting solutions. Lifesize       16
                                                                                    Ning AY, Cabrera CI, D’Anza B. Telemedicine in otolaryngol-
     https://www.lifesize.com/en/. Accessed: February 4, 2022.                      ogy: a systematic review of image quality, diagnostic concordance,
11
     Xydakis MS, Dehgani-Mobaraki P, Holbrook EH, et al. Smell and                  and patient and provider satisfaction. Ann Otol Rhinol Laryngol
                                                                                    2021;130:195-204. https://doi.org/10.1177/0003489420939590
     taste dysfunction in patients with COVID-19. Lancet Infect Dis
     2020;20:1015-1016. https://doi.org/10.1016/S1473-3099(20)30293-0
                                                                               17
                                                                                    Kwok M, Hunn S, Tan H, et al. Diagnostic concordance of telemedi-
                                                                                    cine for otolaryngology, head and neck surgery in regional Australia.
12
     Robiony M, Bocin E, Sembronio S, et al. Redesigning the paradigms
                                                                                    ANZ J Surg 2021;91:1668-1672. https://doi.org/10.1111/ans.16881
     of clinical practice for oral and maxillofacial surgery in the era of
     lockdown for COVID-19: from tradition to telesemeiology. Int J
                                                                               18
                                                                                    Samarrai R, Riccardi AC, Tessema B, et al. Continuation of telemedi-
     Environ Res Public Health 2020;17:6622. https://doi.org/10.3390/               cine in otolaryngology post-COVID-19: applications by subspe-
                                                                                    cialty. Am J Otolaryngol 2021;42:102928. https://doi.org/10.1016/j.
     ijerph17186622
                                                                                    amjoto.2021.102928
13
     McCool RR, Davies L. Where does telemedicine fit into otolaryngol-        19
                                                                                    Said M, Ngo V, Hwang J, et al. Navigating telemedicine for facial
     ogy? An assessment of telemedicine eligibility among otolaryngology
                                                                                    trauma during the COVID-19 pandemic. Laryngoscope Investig Oto-
     diagnoses. Otolaryngol Head Neck Surg 2018;158:641-644. https://               laryngol 2020;5:649-656. https://doi.org/10.1002/lio2.428
     doi.org/10.1177/0194599818757724                                          20
                                                                                    Layfield E, Triantafillou V, Prasad A, et al. Telemedicine for head
14
     Choi JS, Yin V, Wu F, et al. Utility of telemedicine for diagnosis and         and neck ambulatory visits during COVID-19: evaluating usability
     management of laryngology-related complaints during COVID-19.                  and patient satisfaction. Head Neck 2020;42:1681-1689. https://doi.
     Laryngoscope 2022;132:831-837. https://doi.org/10.1002/lary.29838              org/10.1002/hed.26285
15
     Wu CN, Luo SD, Lin HC, et al. Eligibility for live, interactive otolar-   21
                                                                                    Morisada M V, Hwang J, Gill AS, et al. Telemedicine, pa-
     yngology telemedicine: 19-month experience before and during the               tient satisfaction, and chronic rhinosinusitis care in the era of
     COVID-19 pandemic in Taiwan. Biomed J 2021;44:582-588. https://                COVID-19. Am J Rhinol Allergy 2021;35:494-499. https://doi.
     doi.org/10.1016/j.bj.2021.07.012                                               org/10.1177/1945892420970460




                                                                                                                                                   S45
