Cell phones in telehealth and otolaryngology.

The worldwide prevalence of mobile phones makes them a powerful platform for providing individualized health care delivered at the patient's convenience. They have the potential to extend the health care interaction from a brief office visit to a continuous monitoring via body sensors of either a specific healthcare parameter or with multiple sensors in wireless body area networks. Remote data collection by way of mobile phones in underserved areas allows for better management of public health and provides the opportunity for timely intervention. Published data showing benefits specific to otolaryngology are primarily in remote consultation, body sensors specific to balance, and appointment compliance.

Emerging technology in head and neck ultrasonography.

Increased use of ultrasonography of the head and neck by clinicians has resulted from more compact, higher resolution ultrasound machines that can be more readily used in the office setting. Palm-sized machines are already used for vascular access and bladder assessment. As the resolution of these machines becomes adequate for head and neck assessment, ultrasonography is likely to become a routine adjunct to the office physical examination. Further techniques to reduce artifact beyond spatial compounding, second harmonics, and broadband inversion techniques are likely to be developed to improve ultrasound images. Manual palpation using the ultrasound transducer or "sound palpation," using sound to recreate vibration provides information on tissue "stiffness," which has been successfully used to distinguish between benign and malignant lesions in the head and neck (particularly thyroid nodules). Microbubble contrast-enhanced ultrasound provides improved resolution of ultrasound images. Three- and four-dimensional ultrasonography provides for more accurate diagnosis. The ability of microbubbles with ligands affixed to their outer surface to target specific tissue makes them excellent delivery vehicles. DNA plasmids, chemotherapy agents, and therapeutic drugs can be released at a specific anatomic site. The motion of microbubbles stimulated by ultrasound can be used to increase drug penetration through tissues and has been shown to be effective in breaking up clots in stroke patients (without increased risk). High-intensity focused ultrasound can be used to create coagulation necrosis without significant damage to adjacent tissue. It has been effectively used in neurosurgery and urology, but its effectiveness in the head and neck is still being determined. A prototype for surgical navigation with ultrasound has been developed for the head and neck, which allows real-time imaging of anatomic surgical changes.

Pneumosinus dilatans.

Pneumosinus dilatans refers to an abnormally large aerated sinus; two other characteristic features of this disease are that the bony walls of the sinus are of normal thickness and there is no evidence of erosion. Most cases occur in the frontal sinuses. We describe a new case of pneumosinus dilatans in a 21-year-old woman. She required no treatment.

Radiofrequency excision versus monopolar electrosurgical excision for tonsillectomy.

OBJECTIVE: We previously compared radiofrequency (Evac) tonsillotomy with monopolar electrosurgical (Bovie) tonsillectomy and showed significantly less pain with the Evac. Tonsillotomy leaves a cuff of tonsil behind, the significance of which is unknown. We hypothesize that Evac tonsillectomy also is less painful than Bovie tonsillectomy. STUDY DESIGN AND SETTING: We compared Evac (ENTec Evac 70; ArthroCare, Sunnyvale, CA) and Bovie tonsillectomy in a prospective, blinded fashion. Each participant had 1 tonsil removed by each device. We recorded, by side, the surgical time, blood loss, operative difficulty, pain (postoperative days 1, 3, 5, 7, 10, and 14), and the side that each patient preferred. RESULTS: Data were analyzed for 17 patients. They reported significantly less pain with the Evac (P < 0.036, F = 5.87). The Evac was preferred by 12 of 14 patients. CONCLUSION: Evac tonsillectomy is significantly less painful than Bovie tonsillectomy. Patients blinded to treatment preferred the Evac technique. SIGNIFICANCE: The Evac device decreases postoperative pain.

Radiofrequency ablation versus electrocautery in tonsillectomy.

OBJECTIVES: The objective of this study was to compare the safety, difficulty of removal, and postoperative pain profile of radiofrequency ablation versus standard electrocautery removal of tonsils. STUDY DESIGN AND SETTING: A prospective, blinded study was designed to remove 1 tonsil with each of the 2 methods. Time of operation, estimated blood loss, difficulty of operation, postoperative pain, rate of postoperative hemorrhage, and the patient's preferred technique were evaluated. RESULTS: The operating time was significantly longer (P < 0.007) and the patients reported significantly less pain (P < 0.001) with radiofrequency ablation. There were no differences in blood loss, difficulty of operation, or postoperative hemorrhage rates. The patients preferred the radiofrequency ablation technique (P < 0.001). CONCLUSION: Radiofrequency ablation is a viable method to remove tonsillar tissue. Operating time for this procedure will likely decrease with experience. There was significantly less pain reported with radiofrequency ablation compared with standard electrocautery.

An analysis of 3599 midfacial and 1141 orbital blowout fractures among 4426 United States Army Soldiers, 1980-2000.

OBJECTIVE: We sought to present the epidemiology associated with 3599 midfacial and 1141 orbital blowout fractures. STUDY DESIGN AND SETTING: We conducted a multicenter, 20-year retrospective analysis of hospitalization data on U.S. Army active duty soldiers. RESULTS: Men composed 96% of the patients, with men aged 20 to 29 years the most affected. Of midfacial and blowout fractures, 54.8% and 70.2% occurred with concomitant injury, with 36.2% and 50.9% sustaining other facial fractures, respectively. Three hundred forty orbital blowout fractures (29.8%) had an associated eye injury. Common mechanisms included fighting and motor vehicle accidents. CONCLUSIONS: Young men comprised the most susceptible population, and assault was the predominant mechanism. A high incidence of concomitant injury in midfacial and orbital blowout fractures, particularly ocular and intracranial injury, emphasizes the importance of a thorough physical examination. SIGNIFICANCE: We report the results from one of the largest series of midfacial and orbital floor blowout fractures from a population that crosses urban, rural, and foreign boundaries.

Telehealth: voice therapy using telecommunications technology.

Telehealth offers the potential to meet the needs of underserved populations in remote regions. The purpose of this study was a proof-of-concept to determine whether voice therapy can be delivered effectively remotely. Treatment outcomes were evaluated for a vocal rehabilitation protocol delivered under 2 conditions: with the patient and clinician interacting within the same room (conventional group) and with the patient and clinician in separate rooms, interacting in real time via a hard-wired video camera and monitor (video teleconference group). Seventy-two patients with voice disorders served as participants. Based on evaluation by otolaryngologists, 31 participants were diagnosed with vocal nodules, 29 were diagnosed with edema, 9 were diagnosed with unilateral vocal fold paralysis, and 3 presented with vocal hyperfunction with no laryngeal pathology. Fifty-one participants (71%) completed the vocal rehabilitation protocol. Outcome measures included perceptual judgments of voice quality, acoustic analyses of voice, patient satisfaction ratings, and fiber-optic laryngoscopy. There were no differences in outcome measures between the conventional group and the remote video teleconference group. Participants in both groups showed positive changes on all outcome measures after completing the vocal rehabilitation protocol. Reasons for participants discontinuing therapy prematurely provided support for the telehealth model of service delivery.

Telemedicine: teleproctored endoscopic sinus surgery.

OBJECTIVE/HYPOTHESIS: Teleproctored surgery projects a surgeon's expertise to remote locations. The objective of the present study was to evaluate the safety and feasibility of this technique as compared with the current standard of care. STUDY DESIGN: Prospective. METHODS: A study was conducted in a residency training program comparing conventionally proctored endoscopic sinus surgery cases with teleproctored cases, with the faculty surgeon supervising through audiovisual teleconferencing (VTC) in a control room 15 seconds from the operating room. RESULTS: Forty-two control patients (83 sides) and 45 teleproctored patients (83 sides) were evaluated. There were no internal differences between groups regarding extent of polypoid disease, revision status, procedures per case, degree of difficulty, general or local anesthesia, or microdebrider use. There were no cases of visual disturbance, orbital ecchymosis or hematoma, or cerebrospinal fluid leak. Orbital fat herniation and blood loss were equal between groups. Three teleproctored cases required faculty intervention: two for surgical difficulty, one for VTC problems. Teleproctored cases took 3.87 minutes longer per side (28.54 vs. 24.67 min, P <.024), a 16% increase. This was thought to be a result of nuances of VTC proctoring. Residents had a positive learning experience, with nearly full control of the operating suite combined with remote supervision through telepresence. Faculty thought such supervision was safe but had concerns regarding personal skills maintenance. CONCLUSIONS: Teleproctored endoscopic sinus surgery can be safely performed on selected cases with an acceptable increase in time. Teleproctored surgery with remote sites may continue to be safely investigated. Incorporating remote supervision through telepresence into the curriculum of surgical residency training requires further study.

Telemedicine in otolaryngology.

More research is needed in otolaryngology telemedicine, but it would be a mistake to stop at only determining if telemedicine is as good as an in-person exam. The digital image recorded in a telemedicine encounter can be manipulated to increase diagnostic information not currently available. Radiologists currently take a chest radiograph in which a chest mass or the tip of an nasogastric tube is difficult to visualize, and by inverting the gray scale or viewing other digital manipulations of that image, the mass or tube tip becomes obvious. Examples in otolaryngology might include images of the larynx manipulated to better demonstrate the inflamed tissue of reflux, or images of the tympanic membrane manipulated to better demonstrate early retraction. Despite dramatic and likely continued decreases, equipment cost is still an issue. Current research points to good consumer acceptance, and certainly with each new generation the technology is more readily accepted. As Nesbitt [4] points out, it is certainly not difficult to look to the future and see ubiquitous broadband with video as common as telephone, or even extreme broadband enabling robotics and virtual reality TV with three-dimensional touch. Robotics and genomics will eventually play a greater role in telemedicine and our lives in general. Applications for remote diagnosis in biologic warfare defense and homeland security are currently raising interest in telemedicine. Telemedicine will be combined with new technological advances such as virtual "fly-through" computerized axial tomography examinations. Instead of performing an exploratory tympanotomy, surgeons will use computer programs to "fly through" and examine all aspects of a patient's middle or even inner ear. Spectral imaging of the eardrum, larynx, or oropharynx will immediately identify bacteria without cultures, or gram stain, and potential malignancy without biopsy. By measuring fluorescence emitted from an oropharynx illuminated with a specific visible or nonvisible light spectrum, spectral imaging will be able to provide instant identification of bacteria or evidence of malignant changes. The underlying principles of a successful business model must continue to be applied, with the most critical ingredient for telemedicine's success being the filling of specific health care needs. As long as the need is there, telemedicine in otolaryngology will advance.