key: cord-0753852-a86g6p2d authors: Yang, Alex; Lewis, Robert J.; Watson, Nora; Riley, Charles A.; Tolisano, Anthony M. title: The cell phone vibration test: A telemedicine substitute for the tuning fork test date: 2021-09-25 journal: Laryngoscope Investig Otolaryngol DOI: 10.1002/lio2.665 sha: 0000b6da665726420ab8ac9246d526f2f44d5943 doc_id: 753852 cord_uid: a86g6p2d OBJECTIVE: An at home‐test for differentiating between conductive and sensorineural hearing loss remains elusive. Our goal was to validate the novel cell‐phone vibration test (CPVT) against the Weber tuning fork test (WTFT) and to assess if the CPVT can be self‐administered by patients reliably. STUDY DESIGN: Cross‐sectional. METHODS: The CPVT involves placement of a vibrating cellphone on the center of the forehead to determine which ear perceives the sound louder. 40 consecutive adult patients with an audiogram within 6 months and no report of recent hearing changes were recruited. Group 1 consisted of 20 patients who were examined by the provider with the CPVT and WTFT using various tuning forks (256, 512, and 1024 Hz). Group 2 consisted of an additional 20 patients who received instructions on self‐administering the CPVT. Kappa statistics were calculated to assess the strength of concordance between the CPVT, WTFT, and audiometric findings for group 1 and between patient self‐administered and provider administered CPVT and WTFT for group 2. RESULTS: Concordance between CPVT and WTFT in the entire cohort was substantial (Kappa coefficient: 0.81 for 256 Hz, 0.73 for 512 Hz, and 0.62 for 1024 Hz) with similar concordances between actual and expected results based on audiogram (Kappa coefficient: 0.52 for CPVT and 0.52 for WTFT). Concordance between patient‐administered and provider‐administered CPVT showed almost perfect agreement (Kappa coefficient: 0.92). CONCLUSIONS: The CPVT provides consistent results when compared to a formal WTFT and can be reliably self‐administered by patients with appropriate instructions. Level of evidence: 4 As a consequence of the global COVID-19 pandemic, an acceleration in the implementation of telemedicine occurred in order to better triage patients while maintaining medical resources and promoting social distancing. Concurrent improvements in video conferencing technology and the convenience afforded by telemedicine have allowed virtual health practices to persist even after many clinics have begun returning to in-person practice. Nevertheless, a primary disadvantage of telemedicine remains its relative inability to perform a complete physical examination, at least not in the same manner one would in clinic. In particular, an effective otologic exam remains elusive. The ability to rapidly and effectively identify sudden sensorineural hearing loss (SSNHL) is essential. SSNHL-with an incidence in the United States of 5 to 27 per 100 000 people 1 -is one of the few true otologic emergencies requiring expedited evaluation. Current guidelines recommend the initiation of oral or intratympanic steroids within 14 days of symptom onset. 2, 3 Although 32% to 65% of SSNHL cases recover spontaneously, 4 delay in management may lead to residual tinnitus, vertigo, and permanent hearing loss as well as significant negative impacts on quality of life. 2, 5, 6 Audiometry is the gold standard for diagnosing SSNHL; however, this requires appropriately trained staff and equipment which may not be readily available. Thus, the first step in evaluating a patient with suspected SSNHL begins with a history and physical examination to exclude conductive hearing loss (CHL). 2, 3 Tuning fork tests remain a fundamental part of the otologic examination. Lateralization of the Weber turning fork test (WTFT) to the affected ear has historically differentiated CHL from SNHL. 7 Alternatives to the WTFT such as the hum test and the bandage scratch test have been proposed, but neither of these methods have been appropriately validated for general otology patients. The overall clinical data base studying these alternative tests is thin and external validity was limited as they were performed on patients with normal hearing with simulated CHL or solely on postoperative patients. 8, 9 Given the ubiquity of cellphones, utilization of the native vibration function of a mobile phone as a surrogate for a tuning fork is a newer proposed alternative. One study demonstrated the use of smartphone vibration as a replacement to the WTFT on an inpatient ward, but the external validity of this study was limited as it was performed only on patients with a simulated CHL. 10 Another study performed on 60 consecutive patients presenting to the emergency department with unilateral sudden hearing loss found smartphone vibration as an adequate substitute when a provider may not have access to a tuning fork. 11 Further demonstrating the cell phone vibration test's (CPVT) utility for effective and accurate patient self-administration at home would dramatically enhance the telemedicine encounter for patients with SSNHL. Not only would it reduce COVID-19 exposure risk, but it may also assist clinicians in resource scarce settings triage which patients will need expedited, in-person care. The aim of this study, therefore, is to validate the CPVT as an adequate replacement to the WTFT on actual otology patients. An audiogram was used as the gold standard against which to compare accuracy for both the CPVT and the WTFT. Furthermore, we assessed whether patients could accurately self-administer the CPVT when given appropriate instructions. 15 Otolaryngology practices are at a higher theoretical risk of transmission since a complete evaluation involves the upper aerodigestive tract and aerosol generating procedures such as nasal endoscopy and flexible fiberoptic laryngoscopy are frequently performed in office. 16, 17 Otolaryngologists have continued to embraced telemedicine in accordance with ongoing recommendations made by the American Academy of Otolaryngology. Tele-otolaryngology was already of particular interest to the military, given the need to provide tertiary level care to patients in austere or remote locations. Retrospective studies performed at the Vermont Veteran Affairs Medical Center and Naval Medical Center San Diego found up to 62% of otolaryngology encounters would be eligible for telemedicine visits and that 64% of telemedicine patients were able to receive a preliminary diagnosis and plan, respectively. 19, 20 More recent studies found high levels of both patient and provider satisfaction with respect to tele-otolaryngology, though there remains some concern regarding the lack of physical examination. 21 Virtual physical examination maneuvers help address this practice gap, but the most apparent barrier is the ability and confidence of the patient to perform a maneuver on themselves. The CPVT breaks down this major challenge to oto-telemedicine and confers several significant advantages relative to the WTFT for at home use. First, nearly all patients have access to a cellular phone with vibration function. Second, the continuous vibration setting of cell phones is consistent, whereas proper technique is more important when utilizing a tuning fork to avoid the generation of nonfundamental sound frequencies that are produced when the fork is struck incorrectly, a fact that may confound patient interpretation. 22 The primary disadvantage to this, or any at home physical exam maneuver that requires patient cooperation, is that patients must follow instructions correctly. Emphasis on the need to firmly press the smartphone onto the center of the forehead, for example, is impor- Only 19% of patients were prescribed oral steroids by their PCM or the ED, which means a significant number of patients were not adequately treated within the ideal 14-day window recommended by the SSNHL clinical practice guideline. 24 Although it does not replace gold standard audiometry, the CPVT clearly provides clinicians performing virtual health examinations an additional tool to assist in the prompt recognition and diagnosis of SSNHL. The diagnostic accuracy of the CPVT and WTFTs as compared to a formal audiogram appears less than optimal and is somewhat expected given the controversy behind WTFT accuracy. Sensitivity and specificity vary widely amongst a handful of heterogenous studies, and the Weber has been shown to lateralize even with modest hearing asymmetries (2.5-4 dB) lower than our defined 10 dB threshold, which may explain the low accuracy amongst the SNHL patient cohort. 25 The CPVT is a virtual physical exam maneuver similar to a WTFT that can be self-administered by patients to help differentiate CHL and SNHL. The addition of this at home physical exam maneuver to the telemedicine encounter has the capacity to expedite care for those patients most at need for additional testing. The authors declare no conflict of interest. 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