Professionalism should be maintained throughout the virtual visits.
Physicians should use a high-resolution camera, such as one from a
laptop or an external webcam, and dress professionally. Furthermore,
physicians should ensure their face is clearly seen in their video and
that there is ample lighting. It may be advisable for physicians to have
the materials recommended for patients easily available, such as a
flashlight and napkins, in order to demonstrate aspects of the exam on
themselves if patients are having difficulty. Having access to a
high-quality wi-fi or network signal is also critical.
Patients :
It is imperative for physicians to obtain a clear and unobscured view of
their patient’s head and neck during a virtual examination. To help
ensure this, physicians can communicate certain baseline expectations to
patients using the handout in Figure 1 and have the
nursing/administrative staff discuss this with the patient prior to the
visit.
A. General Setup:
- Patient positioning: Ideally, patients should be sitting on a dining
room chair or equivalent. This allows them to sit erect and permits a
second person to stand behind the patient to perform a neck exam.
Patients should also choose a room in the house that has ample
lighting and avoid having light sources, including windows, positioned
behind their back, as this can cause underexposure of the subject and
a silhouette effect.
- Equipment: If patients have access to a laptop or a computer with a
large screen, they should be encouraged to use that over their
cellphone. Additionally, a high resolution camera and wi-fi signal is
important.
- Camera positioning: The camera positioned at eye-level helps provide
physicians with a clear, properly angled view of the patient’s face
and neck. Ideally, the camera, whether it is on the laptop or phone,
should be propped up, such that patients have both hands free and
unoccupied in order to perform basic physical exam tasks.
- Second person present during the visit: If possible, patients should
be encouraged to have a family member or friend present during the
visit, so that they can assist with certain tasks if needed. This is
preferable for many aspects of the virtual physical exam; for example,
it allows patients to maintain an optimal camera angle for the
physician while a third person carries out the basic examination.
- Patient clothing: Patients should avoid clothing that obscures or
covers the neck in order to reduce obstruction of the physician’s
view.
- Extra light source: Patients should have a flashlight or another light
source to enhance visualization during the physical exam. In such
situations, light should be focused as much as possible on the target
of interest, while minimizing illumination of surrounding structures.
As stated previously, having an additional person aid in this task can
help maximize the physician’s view through the camera and reduce
multitasking required by the patient.
B. Physical exam:
- Vital signs: If able, patients should be asked to take their blood
pressure, temperature and weight before the visit with
self-purchased BP cuffs, thermometer and weighing scale.
- Exam: Since physicians cannot perform the physical exams, they will
need to rely on the patient’s own ability to perform their own
physical exam. These are highlighted in Figure 1.
- Subsite exam: highlighted in section below
- Neck exam: If a second person is present during the visit and able
to do the exam, they should be encouraged to participate. Ideally,
they should be asked to stand behind the patient to perform the
exam. As highlighted in Figure 1, it is ideal if they palpate the
patient’s neck in a directional manner (from superior to inferior,
then medial to lateral).
- Cranial nerve exam: most frequently tested cranial nerves are
highlighted in Figure 1
Subsite specific guidelines :
These subsite specific guidelines and tips are provided as a guide to
optimize the telemedicine visit. It is by no means intended to serve as
an all-inclusive list of questions and physical examination maneuvers
for each subsite. Rather, the purpose is to provide some structure and
thoughts on how to best navigate surveillance and examination of these
subsites.
Oral cavity :
Subjective: In addition to the routine questions, physicians can ask
patients if they note the following symptoms: new sore in the mouth,
unresolving pain in the mouth, trismus, dysphagia, odynophagia, ear
pain, difficulty with tongue mobility, tongue numbness, pain or
difficulty with mastication, loosening of teeth, any new lumps, weight
loss, and constant bad breath.
Physical exam: Patient history of these symptoms are of particular
importance during the virtual oral cavity examination. Upon first
glance, a self-performed, abbreviated oral cavity physical exam may seem
straightforward due to the ease of access to the oral cavity. However,
this exam may be quite challenging for patients based on their level of
expertise in being able to properly position their camera or external
light source (flashlight). As discussed in the general guidelines, the
presence of an additional individual to properly angle the light source
for the patient can be extremely beneficial and make a critical
difference. Additionally, in order to ensure patients do not obstruct
the physician’s view of the oral cavity subsite, physicians may find it
useful to demonstrate optimal examination technique on themselves. For
example, this could involve grasping the tip of the tongue with a napkin
using the fingertips in order to maximize its view (see Figure 1).
Oropharynx :
Subjective: Since the virtual physical examination of the oropharynx is
limited, the physician is more reliant on the patient’s reported
symptoms. Symptoms are similar to those highlighted for the oral cavity
examination.
Physical examination: Attempts can be made to have the patients use a
spoon as a tongue depressor to evaluate and view the soft palate and
tonsils.
Larynx :
Subjective: Once again, due to limitations of a virtual physical
examination, physicians must largely rely on patient reports of salient
symptoms, including dysphagia, odynophagia, hoarseness or voice changes,
ear pain, breathing difficulty, constant sore throat, or new neck mass.
Physical exam: Patients can phonate a few different sounds, and attempts
can be made to hear breaks in voice or changes in voice quality.
Physicians can have patients feel for laryngeal crepitus to obtain
clinical signs of mass in the retrolaryngeal space or
hypopharynx.11 If there are concerns with airway
patency, patients can be asked to breath with an open mouth, which could
reveal concerns for an obstructive mass or stenosis.
Salivary glands :
Subjective: Symptoms to ascertain from patients include presence of a
new mass or swelling, facial nerve weakness, pain in the region of a
salivary gland, numbness in a part of the face, pain with mastication,
and trismus.
Physical exam: Attempts can be made to determine subtle changes or
asymmetry in the salivary glands. To facilitate this, patients can be
asked to first look straight at the camera, then turn their body 45
degrees from the midline in either direction, and then look upwards. If
there are concerns for changes in skin morphology in the area overlying
the lesion, patients can be asked to gently run their fingers over the
lesion and to assess for skin mobility. The cranial nerve exam and neck
exam are of particular importance for clinical assessment of salivary
gland pathology.