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:
  1. 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.
  2. 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.
  3. 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.
  4. 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.
  5. Patient clothing: Patients should avoid clothing that obscures or covers the neck in order to reduce obstruction of the physician’s view.
  6. 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:
  1. 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.
  2. 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.
  3. Subsite exam: highlighted in section below
  4. 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).
  5. 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.