key: cord-0854556-c78144c3 authors: Bhutta, Mahmood F.; Swanepoel, De Wet; Fagan, Johan title: ENT from afar: Opportunities for remote patient assessment, clinical management, teaching and learning date: 2021-05-05 journal: Clin Otolaryngol DOI: 10.1111/coa.13784 sha: 641fd07bb32e7d303cb3ab3b18cc4d7c58619844 doc_id: 854556 cord_uid: c78144c3 Remote communication in ENT has been expanding, spurred by the COVID‐19 pandemic. Conferences and teaching have moved online, enabling easier participation and reducing financial and environmental costs. Online multi‐disciplinary meetings have recently been instigated in Africa to discuss management of cases in head and neck cancer, or cochlear implantation, expanding access and enhancing patient care. Remote patient consultation has also seen an explosion, but existing literature suggests some caution, particularly because many patients in ENT need an examination to enable definitive diagnosis. Ongoing experience will help us to better understand how remote communication will fit into our future working lives, and also where face‐to‐face interaction may still be preferable. • Most teaching and conferences have moved online and are now seeing record numbers of attendees. • Recently instigated online multi-disciplinary meetings increase availability of services, can enhance standards of care and offer platforms for learning. • Remote patient consultation has seen an explosion, but may not be appropriate for many ENT patients because often they need to be examined. • Future experience will better define how to best integrate remote communication into our working lives. This enthusiasm and opportunity should be balanced with some caveats. Reliable Internet is not available in all countries or regions worldwide, and data can be expensive in many low-and middleincome countries, limiting universal and easy access to such educational resources. Acquisition of manual skills such as those required for surgery may be better practised in-person rather than virtually. And of course, we should not underestimate the social aspects of inperson courses and conferences, which often add value that cannot be fully realised through online or asynchronous interaction. Of course, during the pandemic many of us have also seen an explosion in the use of remote consultation for patient care. And there are potential huge advantages to patients in terms of costs to their time, purse and carbon footprint. With remote consultation often the question is how little information, we as clinicians feel comfortable with to make a decision. Perhaps, our patients can help us here: In our previous issue, Mughal et al found that a telephone call asking people with a recent nasal injury to self-assess for cosmetic deformity halved the number of in-person consultations required. 6 Guidance from NHS England suggests remote consultation is most suitable for people who do not need a physical examination, 5 but in an initial consultation, many ENT patients do need to be examined. In this issue, Gupta et al report a systematic review of remote consultation in ENT 7 where they found that up to 72% of patients required a follow-up appointment. We really need to better investigate and define where remote consultation is appropriate and effective, such that it provides definitive care. Key to that success will be our ability to capture and send more high-quality information to the person making the diagnosis. That opportunity has already been explored and developed, particularly for disorders of the ear and hearing, and applied in regions like sub-Saharan Africa where there are very few ENT surgeons or audiologists, and task shifting to community health workers supported by mobile phone or other technologies has been found to improve access and affordability. Remote diagnosis of ear disease from captured images or video has been validated | 691 in a number of studies, 8-10 but nevertheless, human resource scarcity remains a barrier because specialists' time is still required to interpret the data transmitted. In an attempt to circumnavigate that problem, in our previous issue Schuster-Bruce et al reported a study exploring performance of non-specialist diagnosis of ear disorders, or of a prediction model based on patient history, and compared those with expert onsite or tele-diagnosis. 11 Models not utilising an expert were found to be inaccurate, and so we do need to further improve data capture or its analysis. Recent advances in artificial intelligence (AI) diagnosis of images of the tympanic membrane are showing promise, 12, 13 with the first clinically available AI classification system released last year as a beta version. 14 Pure tone audiometry conducted from a mobile phone using automated protocols and calibrated headphones has also demonstrated accurate results, and in combination, these technologies are paving the way for decentralised ear and hearing care through simple userinterfaces that enable digital inclusion and incorporate quality control and remote support. 15 But again, although promising, we must remember these technological developments come with caveats. Patients and community members from the most remote or socio-economically disadvantaged circumstances may not have easy access to technological platforms, 16 and so we need to be cognisant that we keep use of remote consultation equitable. And we will all be aware of the difficulties our patients with hearing loss may have with communication that is not face-to-face, or indeed our laryngectomees. Doing things remotely has been forced upon us, and proven the power of online platforms to increase access to education, conferences, case discussions and patient consultations. But, it is true that forced isolation has also made many of us realise the importance of face-to-face social interactions, which may offer opportunities for a deeper bonding with our colleagues, and with our patients. Remote working is definitely here to stay, but let us not be afraid to use our growing experience, and our instinct, to say when and where it does not quite work. https://orcid.org/0000-0002-4688-1670 COVID-19, climate change, and the american thoracic society a shared responsibility Exploring perceptions, barriers, and enablers for delivery of primary ear and hearing care by community health workers: A photovoice study in Mukono District, Uganda African head and neck fellowships: A model for a sustainable impact on head and neck cancer care in developing countries Telepathology in low resource African settings. Front Public Health Clinical guide for the management of remote consultations and remote working in secondary care during the coronavirus pandemic Telephone triage is effective in identifying nasal fractures that require manipulation A systematic review of outcomes of remote consultation in ENT Video-Otoscopy recordings for diagnosis of childhood ear disease using telehealth at primary health care level Diagnostic accuracy of a general practitioner with video-otoscopy collected by a health care facilitator compared to traditional otoscopy A cross-sectional evaluation of the validity of a smartphone otoscopy device in screening for ear disease in Nepal Comparative performance of prediction model, nonexpert and telediagnosis of common external and middle ear disease using a patient cohort from Cambodia that included one hundred and thirty-eight ears Building an Otoscopic screening prototype tool using deep learning Otitis media diagnosis for developing countries using tympanic membrane image-analysis Digital otoscopy with AI diagnostic support: making diagnosis of ear disease more accessible. ENT & Audiology News EHealth technologies enable more accessible hearing care COVID-19 and the digital divide in the UK ENT from afar: Opportunities for remote patient assessment, clinical management, teaching and learning