key: cord-333003-t1lo5jpv
authors: Said, Mena; Ngo, Victoria; Hwang, Joshua; Hom, David B.
title: Navigating telemedicine for facial trauma during the COVID‐19 pandemic
date: 2020-07-09
journal: Laryngoscope Investig Otolaryngol
DOI: 10.1002/lio2.428
sha: 
doc_id: 333003
cord_uid: t1lo5jpv

IMPORTANCE: The COVID‐19 pandemic is changing how health care providers practice. As some telemedicine and telecommunication support tools have been incorporated into the otolaryngology practice in response to safety and access demands, it is essential to review how these tools and services can help facilitate facial trauma evaluation during a time when clinical resources are limited. OBJECTIVE: To review applications of telemedicine for the evaluation of facial trauma to better direct utilization of these methods and technologies during times of limited access to clinical resources such as the COVID‐19 pandemic. METHODS: A systematic review was conducted using PubMed, Embase, and Web of Science. RESULTS: After screening 158 titles and abstracts, we identified 16 eligible studies involving facial trauma evaluation using telemedicine. Telemedicine opportunities for facial trauma evaluation have the potential to be developed in the areas of multidisciplinary remote consultations, facial trauma triage, patient engagement, and postoperative follow‐up. CONCLUSION: The COVID‐19 pandemic is posing obstacles for both providers and patients in the delivery of health care at a time of limited clinical resources. Telemedicine may provide a potential useful tool in the evaluation and triage of facial injuries and patient engagement.

Facial trauma remains a significant morbidity of concern as patients continue to enter the emergency room from falls, assaults, or accidents. [6] [7] [8] Evaluation of acute facial injuries requires considerable provider-patient interaction as the thorough examination process guides successful treatment. Risk of cross infection increases during patient evaluations and head/neck surgeries, especially when clinicians come in close contact with the anatomical nasal and oral mucosa areas where the virus can thrive. 6 Opportunities for technology-based clinical evaluations are much needed.

Telemedicine, according to the Institute of Medicine (IOM), is the "use of electronic information and communications technologies to provide and support health care when distance separates participants." 9 Often used interchangeably with the broader Medicare term, telehealth, telemedicine has the potential to improve communication in otolaryngology, save time, and aid in diagnosis. 10 Other than routine telephone follow-up calls, few otolaryngologists utilized telemedicine in their practice 20 years ago. 11 As technologies developed and internet access improved over the years, however, some physicians envisioned telemedicine's practical potential for facilitating medical care, such as implementing tele-tools for consultation to the underserved, proctored surgery, treatment, education, and research. 11, 12 Early adoption in telemedicine for otolaryngology began in rural areas alongside the improvement of otologic image quality. 13 Today, in light of this unprecedented time during the COVID-19 pandemic, telemedicine has become more relevant to give patients the supportive care they need and at the same time reduce exposure risks to other patients and clinicians. With the increased adoption of telemedicine in otolaryngology practice and growing concern for subsequent "waves" of infection, we review the literature in regard to the applications of telemedicine in the evaluation of facial trauma.

A systematic review was conducted in PubMed, Embase, and Web of Science using the search terms: "telemedicine," "telehealth," "remote monitoring," "virtual visit," "virtual consultation," "facial trauma," "facial," "facial injury," "face trauma," and "face injury." Supplementary Appendix A: Search Strings. The search was limited by dates between June 1, 1997 and April 30, 2020. This review followed the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. 14 Titles, abstracts, and selected articles were independently assessed by three authors (M.S., J.H., and V.N.). The population of interest was patients who experienced facial trauma and received a clinical evaluation. We took into consideration all modalities of telemedicine or telehealth application, in addition to any medical tool that may potentially serve as a telemedicine application. We read original peer-reviewed research studies on the population of interest. Included were randomized controlled trials (RCT), non-RCTs, case-control studies, cohort studies, cross-sectional studies, case series, case reports, and qualitative research studies. We also added additional sources through reference review. Excluded were narrative reviews, articles without full-text access, and non-English language articles. We also excluded intervention studies that did not have a telemedicine approach. Disagreements and discrepancies between reviewers were discussed and resolved through consensus.

A total of 257 references were identified in the database search, of which 158 were considered eligible for inclusion based on the assessment of title and abstract. Upon full article review, 16 original peer reviewed research articles were selected for final inclusion ( Figure 1 ).

Due to the heterogeneity in research methodology and populations studied, formal meta-analysis was not conducted. Instead, we present a narrative synthesis of the results for the key domains of facial trauma evaluation using telemedicine. Table 1 shows the distribution of included articles across different domains of telemedicine.

This review found telemedicine technologies functioning as facilitators to facial trauma assessment, monitoring, treatment, and/or follow-up. The majority of articles (88%; 14/16) mentioned some form of assessment, which included using telemedicine tools to aid in diagnosis, triage, and referrals. Telemedicine technologies were described to be either store-and-forward, live interactive, remote monitoring, and/or mobile health application/device (Table 1 ).

Teleradiology was utilized in the evaluation of patients with facial trauma. [15] [16] [17] [18] [19] Brucoli et al 15 Out of 176 patients with "possible" surgical indications, 27 were offered surgery. Of note, the indication for surgical intervention for naso-orbital-ethmoid fractures was underestimated using teleradiology. Teleradiology allowed for accurate triaging of patients with orbitozygomatic maxillary complex, orbital wall, mandibular, maxillary, nasal, Le Fort, frontal sinus, and dentoalveolar fractures. 15 Jacobs et al. 16 highlighted the value of image quality through a prospective study comparing radiographic findings, diagnosis, confidence of read, and assessment of image quality of 20 facial plain radiographs. These preselected, plain radiographs, with and without mandibular and zygomatic fractures, were presented to eight oral maxillofacial surgery (OMFS) and eight emergency medicine (EM) physicians to interpret. OMFS physicians using plain radiographs had the highest sensitivity (100%) and specificity (84%) for diagnosis of fractures, followed by the EM physicians using plain radiographs (90% sensitivity, 77% specificity, respectively), then OMFS with telemedicine images (86% sensitivity, 80% specificity, respectively). Rates of diagnosis were similar between OMFS utilizing telemedicine and EM physicians utilizing plain radiographs. Telemedicine images were associated with lower image quality ratings, lower sensitivity, and lower confidence of diagnosis. Although a powerful adjunctive tool for the diagnosis of facial fractures, teleradiology must be used in conjunction with clinical information and with a strong emphasis on image quality. 16 In a case report, Millesi et al. 17 Telementoring shown with the Mitsuno et al. 18 study, was also highlighted in the Chiao et al. 19 case report describing a telemedicine demonstration where a comprehensive examination of the eye with ultrasound was conducted by minimally-trained crew members in space using reference cards, and real-time guidance from a remote radiologist. This remote guidance yielded ocular images of diagnostic quality that could guide remote decision-making-suggesting possible applications in craniofacial trauma patients with a remote expert guiding a responder in image acquisition. 19 

The evaluation of traumatic facial skin wounds was explored with telemedicine tools. [20] [21] [22] Van Dillen et al. 20 

Two studies explored the potential for using telemedicine tools to engage the patient in participating in their own facial trauma evaluation and follow up. 22, 28 Moumoulidis et al. 28 conducted a prospective single center study (n = 25) to assess the use of mobile phone photographs in diagnosing nasal fractures. Patients were asked in a questionnaire to judge their own perceived nasal shape change. They were also asked to take photographs of their nose and face with a mobile phone, to be reviewed by a clinician, to determine the presence of a fracture and indication for surgery. The same clinician then conducted an in-person clinical assessment to compare results. The camera assessment failed to identify 62% of nasal bone deviation cases determined by clinical examination. The patients' self-assessments were 100% sensitive whereas the image assessment had only a 38% sensitivity for detecting a deviated nose. It was determined that the use of photographs alone, without a telephone consultation or high resolution image, was considered unfeasible for diagnosis of nasal fractures. 28 The patients who refused to participate in the Moumoulidis et al. 28 believe that facial trauma is a unique injury with its own physical and psychological characteristics that require a specific focus on this topic of interest for providers.

During the COVID-19 pandemic, patients and health care providers alike will continue to face more safety and logistical obstacles during this time of uncertainty and limited clinical resources. Telemedicine in regards to facial injuries holds future potential for improved patient and provider safety, triage, speed of consultation, costs of care, follow-up, and extended geographic access to care. One must also realize the current limitations of telemedicine in regards to sensitivity and specificity in evaluating facial trauma as discussed in this article. With expected future disruptions from anticipated second waves of COVID-19, telemedicine will likely be a useful complementary tool in the clinical management of facial trauma.

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The authors declare no conflicts of interest.

https://orcid.org/0000-0001-9973-8379David B. Hom https://orcid.org/0000-0002-1000-3171