The rapid expansion of telehealth during COVID-19 provided an unexpected opportunity for providers and patients across medical specialties to test the benefits of a technology that saw limited use prior to COVID-19. Like many specialties, pediatric otolaryngology shifted almost overnight to using telehealth for most if not all clinical appointments.
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February 2023Now, nearly three years since this rapid shift, pediatric otolaryngologists are again seeing patients in the clinic. But telehealth isn’t going away. Recent surveys of pediatric otolaryngologists show that many see the utility of telehealth in a variety of situations, such as postoperative evaluation or history taking, particularly for patients and families who live far from the clinic (World J Pediatr Surg. 2022;5:e000440). Surveys of patients and families also show their support for telehealth (Ann Otol Rhinol Laryngol. 2021;130:788–795).
Pediatric otolaryngologists who are asked to comment on their experiences echo these results. “Early in response to the pandemic, we learned quickly that many patients with otolaryngologic conditions can be managed via telemedicine,” said Mark Gerber, MD, division chief of otolaryngology–head and neck surgery at Phoenix Children’s Hospital. Although the total volume of telemedicine visits has declined, he said that the technology is still being used by families who live far from Phoenix.
Our experience is that, frankly, telehealth can be used, at a minimum, as a triage visit for many patients and families. —Julie Wei, MD
Describing the rapid shift of over 2,800 outpatient appointments to telehealth during the early days of the pandemic at her institution, Julie Wei, MD, a professor of otolaryngology–head and neck surgery and chair of otolaryngology education at the University of Central Florida College of Medicine in Orlando and current president of the American Society of Pediatric Otolaryngology, described the shift as “humbling and eye-opening” as it “challenged our assumption of what pediatric ENTs can assess using telehealth,” she said. “Our experience is that, frankly, telehealth can be used, at a minimum, as a triage visit for many patients and families.”
These experts and others also emphasize the need for further advances in the technology to overcome some of its limitations in pediatric otolaryngology. Among the most critical is the difficulty of virtually conducting a thorough physical exam that, as one expert noted, requires looking into small, dark holes.
Going forward, questions will continue to evolve around the best uses for telehealth in pediatric otolaryngology, its current limitations, and expected future advances in technology that will help to overcome these limitations. This article provides a picture to date of how pediatric otolaryngologists view telehealth and their experience with it, as well as data on patient and family perceptions that offer useful insight into how to incorporate telehealth into clinical care to best meet their needs.
Best Uses and Limitations of Telehealth
Telehealth is seen as favorable for several regular pediatric otolaryngology situations, including taking a history, conducting postoperative evaluations, and reviewing imaging. For patients and families who live in rural areas or far from their clinic or hospital, telehealth is particularly helpful.
“The easiest and most appropriate patients are those who are reviewing some type of study, such as a sleep study or imaging, often in plans for surgery,” said Patrick C. Barth, MD, a pediatric oncologist and enterprise medical director for telehealth specialty care at Nemours Children’s Health in Wilmington, Del. “Telehealth is also popular in the postsurgical realm, specifically when photos or direct visualization with a camera can be used,” he said.
The easiest and most appropriate patients are those who are reviewing some type of study, such as a sleep study or imaging, often in plans for surgery. —Patrick C. Barth, MD
Dr. Wei and her colleagues learned that telehealth was adequate for the initial assessment for snoring, obstructive sleep apnea, and sleep-disordered breathing based on the ability to virtually get a great targeted history and combine that with a visual of the tonsils obtained by asking the caregiver to open the child’s mouth and have them say, “Ahhhh.” “Often, we can order a sleep study and/or a lateral neck X-ray to assess adenoid size as needed based on using a telehealth visit, or even make referrals to other subspecialists,” she said. She also noted that she was able to easily offer nonsurgical recommendations for common complains such as epistaxis, runny nose, cough, and chronic nasal congestion via telehealth, despite the inability to perform a great exam.
Carla Giannoni, MD, a professor of otolaryngology at the Baylor College of Medicine and chief medical information officer at Texas Children’s Hospital in Houston, agreed and added that telemedicine provides a good way to share follow-up imaging studies with patients and families after an in-person clinical visit or hospitalization, particularly for patients for whom coming to the clinic or hospital is difficult because of distance or medical conditions.
Overall, Dr. Giannoni said there are more things otolaryngologists could be doing using telehealth than are currently being done, such as follow-up exams for sinus infections after an in-person evaluation. “I have a lot of families who think it is wonderful for follow-up sinus evaluation,” she said, adding that reviewing imaging, for example, is not only effective, but many families prefer it.
Another potential use is for presurgical discussions, said John Carter, MD, a pediatric otolaryngologist at Ochsner Health in New Orleans. For caregivers facing a long drive to the clinic to talk about whether their child is a good candidate for an airway surgery, tonsillectomy, or ear drum repair, for example, he said that telehealth can be useful tool to explain the indications for surgery, the risks and benefits, and other presurgical issues.
Data from a recent survey support this, but with a caveat (J Pediatr Otorhinolaryngol. 2022;153:111014). Sent to a sample of caregivers of patients (up to 26 years old) to assess their satisfaction with otolaryngology outpatient visits, the survey included questions, among others, on whether the caregiver’s child was given a surgery recommendation during the visit and whether the caregiver agreed with the surgical recommendation. The survey found that nearly all caregivers (98.6%) agreed with the surgical recommendation; however, if surgery was not recommended during the appointment, caregivers were 11 times more likely to disagree with the surgical recommendation. This was the finding regardless of whether the patient and/or family met in person with the provider or via telehealth.
The survey also shed light on improving patient and family satisfaction when using telemedicine compared to in-patient visits. In the survey, outpatient visits were sorted into three groups: 1) in-person visits six weeks before telemedicine was implemented, 2) telemedicine visits during the first six weeks of implementation, and 3) in-person visits during telemedicine implementation (IDTM). Questions in the survey included the ability to communicate with the physician, the ability to understand clinical recommendations from the physician, the courtesy of the physician and staff, the physician’s knowledge, and the overall experience. Responses to the survey showed that patients and families in group 1 responded more positively to the ability to communicate with the physician and the overall patient experience than those in group 2. No significant differences were found for the other statements.
Dr. Gerber underscored the need for providers to take extra time to connect with the child and family when using telehealth, given that communication is more challenging compared to in-person visits. “That connection is still possible; it’s just not as easily accomplished as when the child and their family are with you in the office,” he said.
Dr. Wei said that the greatest concern she hears from physicians and advanced practice providers about using telehealth is whether they will be able to examine the child thoroughly enough. Data from surveys support this concern. In one survey, pediatric otolaryngology providers at a tertiary care, freestanding children’s hospital were sent a survey to assess their perception of the effectiveness of telemedicine visits compared to in-person visits (World J Pediatr Surg. 2022;5:e000440). The survey asked providers how they perceive the effectiveness of telehealth for four clinical tasks: history collection, physical examination, medical decision-making, and patient counselling. Physical examination was rated consistently less favorably compared to the other three tasks.
Another survey of pediatric otolaryngologists at Vanderbilt University Medical Center found that limited physical exams were cited as the primary concern with using telehealth (Ann Otol Rhinol Laryngol. 2021;130:788-795). Of the 16 pediatric otolaryngologists completing the survey, only two said they were able to visualize the oropharynx/tonsils adequately more than 50% of the time via telehealth; six were able to visualize it between 25% and 50% of the time, and eight were able to visualize it less than 25% of the time. None were able to visualize the tympanic membrane via caregivers’ use of an otoscope or by taking pictures. Respondents also said that ear-related complaints and breathing concerns (such as noisy breathing or stridor) would be among the most difficult of diagnoses to triage over telehealth because of the inability to do a physical exam with an otoscope, the inability to look into the ear canal, the lack of audiologic evaluation, and the inability to perform a nasolaryngoscopy.
Current technology provides some help in conducting physical exams via telehealth, such as over-the-counter devices (small cameras) that caregivers can use to capture images. Experts offer some tips regarding things that providers can ask caregivers to do during the telehealth visit to improve clinical assessment, particularly when dealing with young children (Table 1).
