Telemedicine practices in otolaryngology: a single centre study

Introduction

Telemedicine (TM) refers to the use of real-time telephone or video technology to deliver healthcare (1). Most otorhinolaryngology outpatient clinics use telephone or video calls to access TM; however, adjuncts including virtual otoscopy and laryngoscopy have also been described in this setting (2,3). This is typically facilitated via a primary care provider or nurse practitioner and has been studied prior to the coronavirus disease 2019 (COVID-19) pandemic as a successful means of providing medical care to some of Australia’s remote and vulnerable populations (4). TM implementation is described as instantaneous patient assessment (synchronous), or delayed review of previously gathered clinical information (asynchronous) (5).

The uptake of TM in otorhinolaryngology outpatient clinics increased rapidly, by necessity, during the COVID-19 pandemic. Understandably, there are reservations from both patients and clinicians regarding this modality providing an appropriate assessment of patients in the absence of a physical exam (6,7). Many otorhinolaryngology conditions rely on examination findings to diagnose, exclude or monitor progression and treatment response. Some vulnerable patient groups, including those with a non-English speaking background (NESB), limited access to necessary infrastructure and technology skills or sensory impairments (such as hearing loss) may be disadvantaged by this method of care delivery (8,9). However, staged introduction and evaluation of this tool was challenging at the time of implementation in the midst of a global health crisis.

Despite these challenges, TM continues to be implemented beyond the period of the pandemic with increased frequency when compared to the pre-pandemic era (10,11). While the prevention of infection transmission was the initial precursor to drive an increase in the use of TM, other benefits are recognised including cost benefits, carbon footprint reduction and greater access to healthcare for a range of patient groups (12,13). This includes patients with limited mobility, financial barriers to treatment and geographic access issues. Given its ongoing use in the clinical context, a careful exploration of the outcomes of TM outpatient appointments in a local setting is required to inform optimal provision of this service.

Otolaryngology outpatient clinics encompass a vast array of clinical conditions and consideration of these patients on a subspecialty basis may help to better tailor TM use into the future. A review of this patient population in a general Ear, Nose, and Throat (ENT) clinic may assist in providing insight into the strengths and weaknesses of this mode of patient assessment. This study aims to evaluate outcomes of outpatient clinic appointments conducted both face-to-face (F2F) and using TM during the initial stages of the COVID-19 pandemic in Australia. We hypothesised that TM would demonstrate comparable attendance and discharge outcomes to F2F consultations but differ in follow-up patterns and intervention rates.

Methods

This retrospective observational cohort study was conducted in accordance with the Declaration of Helsinki and its subsequent amendments. The study was approved by the Eastern Health Office of Research and Ethics (QA20-131) and individual consent for this retrospective analysis was waived. The study is reported according to the STROBE reporting guidelines (available at https://www.theajo.com/article/view/10.21037/ajo-2025-1-84/rc).

All outpatient appointments at the Box Hill Hospital Ear Nose and Throat (ENT) Department from March to August 2020 were included in this review. This period encompassed the first 6 months of TM appointments at this centre and all were conducted via telephone by doctors in the ENT Unit. The scheduled appointments and appointment type (TM vs. F2F) were identified from the network database bookings list. Patients were allocated to appointment type following triage by an ENT registrar or consultant based on perceived clinical need for a timely physical examination. This was determined by clinician judgement as there were no set guidelines for this process. As such, allocation was non-random and subject to potential selection bias. Patients were excluded from the study if there were insufficient medical records to determine indication for and/or outcome of attended appointment.

Data extracted from the electronic medical record of our institution for each appointment included the following demographic information: patient age, sex, appointment type, modality, interpreter use and attendance. Patient appointments were then stratified into a subspeciality according to the type of otolaryngology presentation. This was identified as per the presenting complaint documented in the medical record and assigned to one of the following seven categories: head and neck, head and neck malignancy, paediatrics, otology, rhinology, laryngology, and other. Interventions that were ordered during the appointment were collected and categorized as none, advice, procedure, medication, investigation or referral.

Four appointment outcomes were collected: discharge from clinic, follow-up appointment F2F, follow-up with TM or booking to surgical waitlist. Time to planned follow-up appointment was recorded based on the documentation in the medical record. The outcome of this intended follow-up period was not included. Patients who did not attend appointments were recorded as such in the outcome of the appointment and included in the statistical analysis.

The primary outcome was appointment result for the F2F appointments compared with TM appointments. We also analysed time to follow-up, demographic differences, subspeciality presentation and attendance patterns between the two groups and the population as a whole.

Statistical analysis

The demographic data were summarised using descriptive statistics, including mean, median and standard deviation. Categorical variables were compared between groups using the Chi-squared test of independence or Fisher’s exact test. Continuous variables were analysed using analysis of variance (ANOVA) to compare means across groups and Mann-Whitney U testing was employed to compare median between groups.

To further explore associations between predictors and continuous outcomes, linear regression models were fitted. Both univariable and multivariable models were considered. Model fit was assessed using Akaike’s Information Criterion (AIC), and results are reported as regression coefficients with corresponding 95% confidence intervals (CIs). Confounding variables and interaction effects were addressed using multivariate analysis and parsimonious model selection. A P value <0.05 was considered statistically significant. Analyses were conducted in R (R Foundation for Statistical Computing, Vienna, Austria).

Results

Patient population

A total of 867 patients had 1,123 scheduled outpatient appointments at the ENT clinic during the study period. Five patients were excluded for insufficient documentation available in the medical record, with 1,118 appointments included in the study. The pertinent patient and appointment demographics are outlined in Table 1. The slight majority of the patients in this study were male (55.3%), with a median patient age of 38 years, ranging from 1 to 97 years [interquartile range (IQR), 9–61 years]. Paediatric patients accounted for 284 patients (341 appointments) and the remaining 578 were adult patients over 18 years old. F2F appointments constituted 41.3% of the appointments and 58.7% were conducted using TM. Only a small proportion of appointments (16.6%) were postoperative encounters.

Visit outcomes

In this general ENT outpatient clinic, appointments were relatively evenly distributed across the various subspecialities with paediatric presentations representing the most common presenting complaint at 26.1%. A detailed breakdown of the consult subspecialities and outcomes is displayed in Table 2. F2F follow-up was a slightly more frequent (32.0%) appointment outcome than discharge (30.1%) or TM follow-up (25.2%) without reaching statistical significance. Thirteen per cent of patients were booked for surgery from clinic during this period. Interpreters were used in 4.8% of outpatient appointments.

The most common intervention was ordering an investigation, which included radiology, pathology and audiograms. Median follow-up was longer for telehealth than F2F consultations, at 16 weeks (IQR, 8–26 weeks) vs. 10 weeks (IQR, 3–23.5 weeks), respectively (rank-biserial effect size =−0.27, P<0.001). Linear regression analysis demonstrated that follow-up duration was associated with review type, appointment modality, rhinology presentations and interpreter requirements. Review appointments and TM appointments were associated with an additional follow-up period of 2.6 (95% CI: 0.51–5.87, P<0.002) and 2.7 (95% CI: 0.70–4.64, P=0.007) weeks respectively. Rhinology-related conditions were also positively associated with a longer follow-up period of 3.8 additional weeks (95% CI: 0.08–7.49, P=0.04). Requiring interpreter services was associated with a shorter follow-up period by 4.3 weeks (95% CI: 0.42–8.12, P=0.03)

Comparison of TM and F2F appointments

When comparing F2F and TM appointments, there was no statistically significant difference in discharge rates observed between the two groups, although groups were not clinically equivalent due to triage-based allocation. Table 3 outlines the differences in appointment outcomes and intervention patterns between the two groups. There was a significant increase in TM follow-up in the TM group (30.2% of all TM appointments) when compared to F2F patients (18.2%, OR 1.95, 95% CI: 1.43–2.65, P<0.001). There was a significant increase in TM follow-up in the TM group (30.2% of all TM appointments) when compared to F2F patients (18.2%, OR 1.95, 95% CI: 1.43–2.65, P<0.001). Surgery was more commonly booked following F2F review than TM review, occurring in 22.5% vs. 5.8%, respectively (OR 0.21, 95% CI: 0.14–0.31, P<0.001). Patients in the TM group were more likely to have no intervention (47.3% vs. 26.4%, OR 2.50, 95% CI: 1.94–3.23, P<0.001). Advice, medication and referral were significantly more common following F2F review than TM review, occurring in 23.2% vs. 16.0% (OR 1.58, 95% CI: 1.17–2.12, P=0.003), 22.7% vs. 13.9% (OR 1.82, 95% CI: 1.34–2.47, P<0.001), and 7.6% vs. 3.5% (OR 2.26, 95% CI: 1.34–3.82, P=0.003), respectively. Investigation rates were not significantly different between groups despite being numerically higher in the TM group (24.7% vs. 20.6%, OR 1.27, 95% CI: 0.95–1.70, P=0.106).

Attendance patterns

The overall failure to attend rate was 13.0%, with 13.2% (n=61) in the F2F group and 12.8% (n=91) in the TM group, and no significant difference between the two groups was observed (OR 1.04, 95% CI: 0.73–1.48, P=0.845). A linear model for attendance did not show any association with sex, age, appointment type (new vs. review) or modality (TM vs. F2F). Increased attendance patterns were demonstrated for postoperative patients, otology, paediatrics, head and neck malignancy and laryngology patients. Telehealth patients were less likely to be new patients than F2F patients (25.9% vs. 41.8%). There was a significant association between consultation mode and New vs. Review status (OR 0.49, 95% CI: 0.38–0.63, P<0.001). This is demonstrated in Figure 1.

Figure 1 Attendance patterns by review type. ***, P<0.001. F2F, face-to-face; NS, not significant.

Discussion

In keeping with our hypothesis, our study shows that mode of appointment delivery did not impact attendance and discharge rates in a general otolaryngology clinic in the setting of an emergency pandemic. Anecdotal concerns that TM appointments have limited utility in general were not necessarily supported when considering that interventions were ordered in 52.7% of TM appointments and 28.8% of patients could be discharged using this modality. Similarly, failure-to-attend rates were not significantly different between the two groups (F2F and TM) despite the swift introduction of a new appointment modality. However, the ability to directly compare these two groups in detail was limited by the triaging process.

Furthermore, it is difficult to extrapolate the applicability of this data in the non-COVID era. Notably, the city of Melbourne was in lockdown for the majority of the study period with accompanying restrictions on clinical services including elective surgery. This may have resulted in a greater portion of patients with availability to participate in TM phone calls who may have otherwise been at work. Similar to our experience, in a retrospective review of 14,050 patients, Puyo et al. observed an increase in TM attendance compared to F2F during the period of the COVID-19 pandemic (14). Patients may have been unwilling to attend in person due to concerns of infection transmission and more willing to consider alternative treatment modalities with resultant high attendance in TM appointments and potentially elevated F2F failure to attend events.

The pandemic was a rapidly evolving situation with clinician uncertainty altering behaviour, including triage practices and thus limiting accurate conclusions regarding TM in current clinical practice. Indeed, the large portion of TM patients (58.7%) in our cohort represented a significant change from an outpatient department that previously did not have a formal TM service. Clinicians triaging and management decisions were likely impacted given the new appointment modality and unknown duration of reduced clinical activity. This element of our study precluded a true direct comparison between F2F and TM as they were not clinically equivalent. As suggested by O’Neil et al., there may have been a tendency in this period towards early rebooking of TM patients for F2F review and a hesitancy to waitlist for surgery without a F2F appointment and clinical examination prior (15). We observed that only 12.7% of patients during this period were waitlisted for surgery, with a much higher portion in the F2F group (22.5% vs. 5.8%). This may also be reflective of a selection bias from clinicians allocating appointments, potentially believing that the surgical consent process is better suited to the F2F modality.

In keeping with the findings of O’Neil et al., a greater portion of TM patients (65.4%) in our study were booked for follow-up (either TM or F2F) when compared to F2F patients (45.7%) (15). However, the follow-up period for TM patients was significantly longer in our study (16 weeks for TM vs. 10 weeks for F2F). This may indicate effective triaging of patients with conditions not requiring an urgent examination, rather than an inherent difference in outpatient modality. There is a slight increased portion of investigations in the TM patient population (24.7% vs. 20.6%), perhaps explained by the inability to examine patients via TM, which could contribute to the prolonged follow-up period to allow for return of results.

The considerable restriction on elective surgery during this period was another factor that likely altered attendance patterns and TM appointment outcomes. Only 4.8% of patients in our cohort were postoperative patients. TM has been reported in multiple studies as an effective tool for this patient cohort (16-18). Unfortunately, the study design and low portion of postoperative patients in our study meant that we were unable to evaluate TM sufficiently in this setting.

Our study identified several challenges associated with TM, some of which have been observed in other studies. In the 4.8% of patients documented to have required an interpreter, a significantly shorter period of follow-up of 4.3 weeks was found on linear regression analysis. This suggests potential communication challenges using TM in this patient population. On multivariate analysis, Miller et al. identified Medicare status and NESB to be associated with decreased uptake of TM in their retrospective review of 231,384 otolaryngology clinical visits (8). In our cohort, TM also appears to be less suited to new patients with only 25.9% new patients booked using this modality. A systematic review by Gupta et al. found 13–72% of new patients seen via TM were rebooked following their initial appointment, highlighting the variation of TM utility across the literature (19). Choi et al. reported that clinician satisfaction with TM to be lower in both these patient groups (NESB and new patients) when compared to F2F encounters (20). Of particular note in our study is the 47.3% of TM patients with no recorded intervention. Although 115 (37.1%) of these patients were discharged from the service, 111 patients (35.8%) were booked for F2F follow-up. This remains a sizeable group who may have been better suited to a F2F appointment instead; although this warrants closer evaluation.

There are additional benefits of TM beyond the reduction in infection transmission that are well recognised. TM has the potential to increase access to vulnerable patient groups. This includes the elderly, less mobile patients and patients from remote and rural areas that are often less well serviced by otolaryngologists (21,22). Ongoing utility of TM is further supported by the environmental and social considerations including reductions in carbon footprint and healthcare costs (23,24). There are also a number of examples of the use of TM as a triage tool to increase efficient allocation of outpatient clinic resources (25-27). Indeed, the Choi et al. study emphasized the role of increased rates of physician satisfaction when appropriately triaged patients are selective for TM (20).

The authors of this study recognise its limitations including the retrospective study design. Data collection during the early stages of the COVID-19 pandemic in Melbourne provided a large cohort of TM patients to study but also the earlier described challenges of applying this information following the pandemic. Significant advances in TM have occurred in the interim, including triaging protocols, software changes for TM platforms and use of video examination tools. As acknowledged above, the study period represented the introduction of a formal TM service in this department. This may have contributed to a lack of physician confidence and inconsistency in implementation TM, especially in the absence of any uniform guidelines.

A key limitation of this study is the non-random allocation of patients to TM or F2F appointments. Appointment modality was determined by clinician triage based on perceived clinical need, introducing potential selection bias and confounding by indication. Patients allocated to F2F review were likely to have more complex or examination-dependent conditions, whereas TM patients may have represented a lower-acuity cohort. As a result, direct comparisons between groups should be interpreted with caution, and observed similarities in outcomes such as discharge or attendance rates may reflect underlying differences in case mix rather than true equivalence between modalities

Additional research is required in order to elicit the relevance of these results in routine practice. A direct comparison of this patient population following the COVID-19 may help clarify ongoing patterns of TM use and include an increased number of postoperative patients. Furthermore, a larger study population would allow for a closer assessment of TM use in subspecialty groups. Another potential area of further research is an assessment of patient and clinician satisfaction with the service. This was not addressed in this study but could potentially assist in optimising the use of a TM service. There are multiple examples of high patient and clinician satisfaction with TM but limited literature available in the local environment (28,29).

Conclusions

This study showed no significant difference in discharge and clinic attendance rates when comparing TM to F2F outpatient appointments. It suggests that TM has a role within an otolaryngology outpatient setting in appropriately selected patients. Certain patient groups, including new patients and patients requiring interpreter services, may be better suited to a F2F appointment modality. Further investigation with a direct comparison in the current clinical setting would help to more clearly define this.

Acknowledgments

None.

Footnote

Reporting Checklist: The authors have completed the STROBE reporting checklist. Available at https://www.theajo.com/article/view/10.21037/ajo-2025-1-84/rc

Data Sharing Statement: Available at https://www.theajo.com/article/view/10.21037/ajo-2025-1-84/dss

Peer Review File: Available at https://www.theajo.com/article/view/10.21037/ajo-2025-1-84/prf

Funding: None.

Conflicts of Interest: All authors have completed the ICMJE uniform disclosure form (available at https://www.theajo.com/article/view/10.21037/ajo-2025-1-84/coif). The authors have no conflicts of interest to declare.

Ethical Statement: The authors are accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved. The study was conducted in accordance with the Declaration of Helsinki and its subsequent amendments. The study was approved by the Eastern Health Office of Research and Ethics (QA20-131) and individual consent for this retrospective analysis was waived.

Open Access Statement: This is an Open Access article distributed in accordance with the Creative Commons Attribution-NonCommercial-NoDerivs 4.0 International License (CC BY-NC-ND 4.0), which permits the non-commercial replication and distribution of the article with the strict proviso that no changes or edits are made and the original work is properly cited (including links to both the formal publication through the relevant DOI and the license). See: https://creativecommons.org/licenses/by-nc-nd/4.0/.

References

1. Fang CH, Smith RV. COVID-19 and the resurgence of telehealth in otolaryngology. Oper Tech Otolayngol Head Neck Surg 2022;33:158-64. [Crossref] [PubMed]
2. Bryson PC, Benninger MS, Band J, et al. Telemedicine in laryngology: Remote evaluation of voice disorders-setup and initial experience. Laryngoscope 2018;128:941-3. [Crossref] [PubMed]
3. Oremule B, Dempsey J, Veselinović T, et al. Designing a paediatric teleotology pilot in the UK: Outcomes from a scoping review of the literature, with insights from the Ear Portal pilot service in Perth, Western Australia. Int J Pediatr Otorhinolaryngol 2025;193:112343. [Crossref] [PubMed]
4. Habib AR, Crossland G, Sacks R, et al. Tele-otology for Aboriginal and Torres Strait Islander People Living in Rural and Remote Areas. Laryngoscope 2024;134:5096-102. [Crossref] [PubMed]
5. Manning LA, Gillespie CM. E-Health and Telemedicine in Otolaryngology: Risks and Rewards. Otolaryngol Clin North Am 2022;55:145-51. [Crossref] [PubMed]
6. Choi JS, Kim JH, Park S, et al. Telemedicine in Otolaryngology During COVID-19: Patient and Physician Satisfaction. Otolaryngol Head Neck Surg 2022;167:56-64. [Crossref] [PubMed]
7. Ohlstein JF, Ahmed OG, Garner J, et al. Telemedicine in Otolaryngology in the COVID-19 Era: A Year Out. Cureus 2021;13:e20794. [Crossref] [PubMed]
8. Miller LE, Xu L, Lorch AC, et al. Patient and Visit Characteristics Associated With Otolaryngology Telemedicine Care. Ann Otol Rhinol Laryngol 2023;132:1682-5. [Crossref] [PubMed]
9. Kemp M, Rising KL, Laynor G, et al. Barriers to telehealth uptake and use: a scoping review. JAMIA Open 2025;8:ooaf019. [Crossref] [PubMed]
10. Lorenz FJ, Heikel T, Tucker J, et al. Telemedicine in Otolaryngology in the Context of the End of the COVID-19 Public Health Emergency. Otolaryngol Head Neck Surg 2024;170:624-6. [Crossref] [PubMed]
11. MBS Review Advisory Committee. MBS Review Advisory Committee – Telehealth Post-Implementation Review – Final report. Australian Government Department of Health, Disability and Ageing; 2024.
12. Heffernan A, Lalande A, Chadha R, et al. Carbon savings potential of virtual care in obstructive sleep apnea and otitis media with effusion. Laryngoscope Investig Otolaryngol 2024;9:e1221. [Crossref] [PubMed]
13. Kellerman H, Mace JC, Detwiller KY, et al. Travel Costs and Carbon Savings Associated With Telemedicine in a Tertiary Care Rhinology Center. Int Forum Allergy Rhinol 2025;15:692-8. [Crossref] [PubMed]
14. Puyo EM, Salvati LR, Garg N, et al. The Impact of COVID-19 and Socioeconomic Determinants on Appointment Non-Attendance in an Urban Otolaryngology Clinic: A Retrospective Analysis From a Safety Net Hospital. Ann Otol Rhinol Laryngol 2025;134:117-24. [Crossref] [PubMed]
15. O'Neil LM, O'Neill M, Whelan F, et al. Novel ENT live telehealth and live video-otoscopy clinics in remote Australia: outcomes and comparisons to traditional clinic models. J Laryngol Otol 2024;138:253-7. [Crossref] [PubMed]
16. Smith AJ, Yoon JJ, Cofer SA, et al. Telehealth as an effective method of follow-up for pediatric post tonsillectomy patients. Am J Otolaryngol 2022;43:103639. [Crossref] [PubMed]
17. Boles RW, Zheng M, Kwon D. Expanded use of telemedicine for thyroid and parathyroid surgery in the COVID-19 era and beyond. Am J Otolaryngol 2022;43:103393. [Crossref] [PubMed]
18. Antezana LA, Xie KZ, Yin LX, et al. Performing parotidectomy postoperative follow-ups via telemedicine: Experience at a tertiary care, multiple-surgeon otolaryngology center. J Telemed Telecare 2024;30:739-46. [Crossref] [PubMed]
19. Gupta T, Gkiousias V, Bhutta MF. A systematic review of outcomes of remote consultation in ENT. Clin Otolaryngol 2021;46:699-719. [Crossref] [PubMed]
20. Choi JS, Lin M, Park S, et al. Physician satisfaction with telemedicine and in-person visits in otolaryngology. Am J Otolaryngol 2022;43:103596. [Crossref] [PubMed]
21. Spinos D, Coulson C, Beech T, et al. Advances in remote otology and rhinology service delivery: A scoping review. Am J Otolaryngol 2024;45:104399. [Crossref] [PubMed]
22. Bradford NK, Caffery LJ, Smith AC. Telehealth services in rural and remote Australia: a systematic review of models of care and factors influencing success and sustainability. Rural Remote Health 2016;16:3808.
23. Paczkowski F, Gandhi K, Dzioba A, et al. Economic, Environmental, and Social Value of Virtual Care in Otolaryngology: Sustainability in Quality Improvement Framework. Otolaryngol Head Neck Surg 2025;172:717-27. [Crossref] [PubMed]
24. De Ravin E, Armache M, Campbell F, et al. Feasibility and Cost of Telehealth Head and Neck Cancer Survivorship Care: A Systematic Review. Otolaryngol Head Neck Surg 2023;168:1312-23. [Crossref] [PubMed]
25. Hoerter JE, Debbaneh PM, Liu K, et al. A Comparison of In-Person and Telemedicine Triage in Otolaryngology. Perm J 2024;28:31-7. [Crossref] [PubMed]
26. Kaddour H, Jama GM, Stagnell S, et al. Remote triaging of urgent suspected head and neck cancer referrals: our experience during the first wave of the COVID-19 pandemic. Eur Arch Otorhinolaryngol 2022;279:1111-5. [Crossref] [PubMed]
27. Metcalfe C, Oh S, Glazzard N, et al. A novel remote assessment pathway to streamline the management of two-week-wait suspected head and neck cancer referrals: a prospective analysis of 660 patients. J Laryngol Otol 2024;138:667-71. [Crossref] [PubMed]
28. Hoi KK, Brazina SA, Kolar-Anderson R, et al. A Longitudinal Comparison of Telemedicine Versus In-Person Otolaryngology Clinic Efficiency and Patient Satisfaction During COVID-19. Ann Otol Rhinol Laryngol 2022;131:1177-84. [Crossref] [PubMed]
29. Rimmer RA, Christopher V, Falck A, et al. Telemedicine in otolaryngology outpatient setting-single Center Head and Neck Surgery experience. Laryngoscope 2018;128:2072-5. [Crossref] [PubMed]