When it comes to the diagnosis and management of peritonsillar abscess (PTA), telemedicine consultations are getting high marks, according to results from a study published in JAMA Otolaryngology-Head & Neck Surgery. Indeed, researchers concluded that these remote consults are efficient and cost-effective, with a high sensitivity, and that high-quality videos are easily achieved using standard smartphone cameras with little or no formal training.
“As our health care system moves toward alternative payment models in an effort to provide more cost-effective, high-quality care, telemedicine has emerged as a potential strategy. Within the field of otolaryngology, studies have suggested the potential of telemedicine, showing that it can be reliable and accurate while also leading to cost savings in both real time and delayed settings,” noted researchers led by Jonathan R. Mallen, of University of Connecticut Health, Farmington, CT.
“Telemedicine is appealing for treating patients with otolaryngologic pathologic conditions, as very few emergency departments or urgent care centers have access to an on-site otolaryngologist, particularly on nights and weekends,” they added.
PTAs are also relatively common, wrote Mallen and colleagues: “Within otolaryngology, one of the most common symptoms among patients presenting to an emergency department is odynophagia with concern for a peritonsillar abscess (PTA). Peritonsillar abscesses are the most common head and neck deep space infections, with an annual incidence of 30 to 37 per 100,000 in the general population and 125 per 100,000 in patients between 14 and 21 years of age.”
In light of these facts, they conducted this study to assess the reliability of telehealth in the diagnosis and triage of patients with suspected PTA by testing the accuracy of a telemedicine evaluation of suspected PTA in five attending otolaryngologists, who were given no additional history or exam findings, except for a report of odynophagia. Patient video recordings were carried out by two consulting otolaryngology resident physicians in both the ER and inpatient setting in 31 patients (mean age: 31.9 years; 51.6% women).
The five attending otolaryngologists were tasked with evaluation viewed telemedicine patient videos and rated each on whether they believed the patient had PTA and whether the patient needed a prompt otolaryngologic evaluation.
Criterion standard for the presence or absence of a PTA included drained purulence or identification of an abscess on CT scan. A diagnosis of PTA was considered negative if purulence was not expressed via formal incision and draining or needle aspiration and CT or MR results that were negative for PTA. In all, 51.6% patients had PTA.
Predictions from the five otolaryngologists regarding PTA according to standard criterion were consistent with these standards a full 81% of the time. Agreement among the five otolaryngologists was moderate, ranging from 0.49-0.81 (Fleiss к=0.57). Prediction based on majority prediction was high, with a sensitivity of 0.81 (95% CI: 0.54-0.96), a specificity of 1.00 (95% CI: 0.78-1.00), positive predictive value of 1.00 (95% DI: 0.75-1.00), and a negative predictive value of 0.83 (95% CI: 0.59-0.96).
When Mallen and fellow researchers evaluated the accuracy of the otolaryngologists’ recommendations for prompt in-person evaluation based on these videos with actual PTA status according to criterion standards, the mean diagnostic accuracy was also high (83%), as was mean sensitivity (90%). Agreement among otolaryngologists was again moderate, ranging from 0.55-0.74 (Fleiss к=0.60).
Predictions for prompt in-person evaluation based on the majority prediction had high diagnostic value, with a sensitivity of 1.00 (95% CI: 0.79-1.00), a specificity of 0.80 (95% CI: 0.52-0.96), a positive predictive value of 0.84 (95% CI: 0.60-0.97), and a negative predictive value of 1.00 (95% CI: 0.74-1.00).
Otolaryngologists also rated 99.4% of the videos to be of sufficiently high quality to make a diagnosis, and 82.6% to be of sufficiently high quality and include enough evidence to support a diagnosis. “Based on an independent, unanimous vote, all but 1 of the videos taken with a standard smartphone camera were deemed to be of sufficient quality to enable a diagnosis to be made remotely. This finding suggests that emergency and urgent care clinicians can use easy-to-take videos on readily available equipment to engage with otolaryngologists on clinical assessment and the need for intervention, including drainage, as well as potential patient transfer. The quality and capabilities of the video applications available on smartphones have consistently improved over time, supporting the expanded use of these applications for telemedicine in the future,” noted Mallen and colleagues.
Limitations of the study include limited enrollment and a sample skewed toward more acutely ill patients.
“Mallen et al performed an easily implemented telehealth method to improve patient care, decrease wait times for patient interventions, lessen the number of needless hospital transfers, reduce the use of unnecessary radiologic imaging, and, more topically, decrease both patient and clinician exposure to the Covid-19 pandemic,” wrote Arielle Thal, MD; Vikas Mehta, MD, MPH, both of Albert Einstein College of Medicine, Bronx, NY, in an accompanying editorial.
These results—especially during the Covid-19 pandemic and particularly in the specialty of otolaryngology—are of particular importance, they added.
“As the health care system adjusts to the effects of coronavirus disease 2019 (Covid-19), we have already seen a major shift toward telehealth in all settings, not just for patients or clinicians in remote locations. Telehealth has become particularly important in otolaryngology practices where many of the diagnostic procedures cause aerosolization of viral particles from the mucosal surfaces of the upper aerodigestive tract. This puts not only clinicians and staff but also other patients in close proximity at risk for contracting Covid-19. In many ways, the pandemic has laid bare the poor infection control practices in our clinics that we should be wary about readopting: crowded waiting rooms filled with sick patients, performing procedures without universally donning proper personal protective equipment, and consistent hand hygiene by all practitioners, to name a few,” concluded Thal and Mehta.
Telemedical consults for patients with suspected peritonsillar abscess (PTA) are viable and have a high sensitivity and cost-efficacy.
Smartphone telemedicine consults in the field of otolaryngology may be particularly useful as an infection control measure during the Covid-19 pandemic.
E.C. Meszaros, Contributing Writer, BreakingMED™
Mallen and Thal reported no disclosures.
Cat ID: 192
Topic ID: 86,192,730,192,925