General Otolaryngology Clinic Research Articles

Effects of Language, Age, and Hearing Loss on Health-Related Quality of Life.

To understand the effect of age on health-related quality of life (HRQoL) in patients with hearing loss and determine how primary language mediates this relationship. Cross-sectional study. General otolaryngology clinic in Los Angeles. Demographics, medical records, and HRQoL data of adult patients presenting with otology symptoms were reviewed. HRQoL was measured using the Short-Form 6-Dimensionutility index. All patients underwent audiological testing. A path analysis was performed to generate a moderated path analysis with HRQoL as the primary outcome. This study included 255 patients (mean age = 54 years; 55% female; 27.8% did not speak English as a primary language). Age had a positive direct association with HRQoL (p < .001). However, the direction of this association was reversed by hearing loss. Older patients exhibited significantly worse hearing (p < .001), which was negatively associated with HRQoL (p < .05). Primary language moderated the relationship between age and hearing loss. Specifically, patients who did not speak English as a primary language had significantly worse hearing (p < .001) and therefore worse HRQoL (p < .01) than patients who spoke English as a primary language with hearing loss. Increasing age was associated with bilateral hearing loss compared to unilateral hearing loss(p < .001) and subsequently lower HRQoL (p < .001). Polypharmacy (p < .01) and female gender (p < .01) were significantly associated with lower HRQoL. Among otolaryngology patients with otology symptoms, older age and not speaking English as a primary language were associated with worse hearing and subsequently lower HRQoL.

Impact of Age and Gender on Quality of Life Among General Otolaryngology Patients.

The combined effects of age and gender on health-related quality of life (HRQoL) in otolaryngology patients are unclear. This study tested the hypothesis that the effect of age on HRQoL differs by gender in otolaryngology patients. Patients seen in a general otolaryngology clinic were included in this retrospective chart review. HRQoL was measured by the SF-6D score. Patient characteristics, including demographics and category of chief otolaryngology complaint, were extracted from medical records. A multivariable linear regression analysis was used to analyze the combined effect of age and gender on HRQoL. The model was adjusted for race, ethnicity, number of complaint categories, and number of medications. The study included 728 patients (age mean=52, SD=18; 48% male). Multivariable linear regression models found a significant interaction effect between age and gender (β= 0.213, p < 0.05). For younger patients, female gender was protective; however, at age greater than 35 years, female gender was a risk factor for decreased HRQoL. Compared to Black patients, Asian and other race patients reported significantly greater HRQoL (β= 0.207, p < 0.05 for Asian; β= 0.126, p < 0.05 for other races). Additionally, an antagonistic interaction effect was found between age and number of category of otolaryngology complaints in moderating HRQoL (β= 0.468, p < 0.001). Age affects HRQoL differently in men than in women. Among otolaryngology patients, women experience a greater decrease in HRQoL as they age. 4 Laryngoscope, 133:801-806, 2023.

Treatment decision-making among Asian Americans with chronic rhinosinusitis.

Treatment decision-making among Asian Americans with chronic rhinosinusitis.

Screening for Eustachian Tube Dysfunction in Clinical Practice Using the Eustachian Tube Dysfunction Questionnaire-7.

To evaluate the ability of the Eustachian Tube Dysfunction Questionnaire-7 (ETDQ-7) to discriminate between patients with Eustachian tube dysfunction (ETD) and Non-ETD diagnoses, and identify symptom information to improve ability to discriminate these groups. Cohort study. Pilot retrospective study with consecutive adult patients presenting to otology clinics and one general otolaryngology clinic in an academic health system. Patients were administered ETDQ-7 with eight additional symptom items. Electronic health records were reviewed for demographic and diagnostic information. Patients were grouped into diagnosis categories: 1) True ETD, 2) experiencing ear fullness (EF) not due to ETD, and 3) Control patients without ETD-related disorders or EF. ETDQ-7 and symptom item scores were compared by the diagnosis group. Receiver-operative characteristics curves and area under the curve (AUC) were generated for each ETD diagnosis group based on ETDQ-7 and symptom scores. Of the 108 patients included in this study 74 (68.5%) were diagnosed with ETD. Patients with ETD had higher (indicating worse symptom burden) overall ETDQ-7 scores than Control group (Median [Q1, Q3] 3.0, [1.7, 4.1]; versus 1.5 [1.0, 3.4] P=.008). There was no statistically significant difference between overall ETDQ-7 scores for ETD and Non-ETD EF patients (P=.389). The AUC for the ETDQ-7 in discriminating ETD from other conditions that cause EF was 0.569; the addition of 8 symptom questions to the ETDQ-7 improved AUC to 0.801. Additional patient-reported symptom information may improve the ability to discriminate ETD from other similarly presenting diagnoses when using ETDQ-7. 3 Laryngoscope, 132:2217-2223, 2022.

Patient Awareness of Head and Neck Cancer Risk Factors: Assessment of the General Otolaryngology Population

Objective: The general public’s knowledge of the risk factors for head and neck cancer is insufficient. The level of awareness of such risk factors amongst the otolaryngology clinic patient population has not yet been elucidated in the literature. Method: This individual cohort study took place at a tertiary academic center. A survey was designed and administered to all patients who presented to otolaryngology clinic from 2017 to 2018 to assess knowledge of head and neck cancer risk factors. The main outcome measures were percentage of correct responses for each cancer risk factor and comparison of percent correct between cancer and non-cancer patients. Results: A total of 510 patients were enrolled in the study including 69 patients (13.5%) with a history of head and neck cancer. The most well recognized risk factors by all patients were cigarettes (83.7%) and chewing tobacco (77.5%). Twenty-nine percent of patients correctly identified alcohol as a risk factor. Additional risk factors were poorly recognized. Cancer patients had a similar or better correct response rate than non-cancer patients except for chewing tobacco (68.1% vs 78.9% respectively). Conclusion: The general otolaryngology clinic population, especially patients with a history of head and neck cancer, demonstrated improved knowledge of some risk factors for head and neck cancer, but insufficient awareness of alcohol and HPV transmissible behaviors.

Rapid telehealth implementation into an otolaryngology practice during the COVID-19 pandemic.

ObjectiveReport outcomes of rapid implementation of telehealth across an academic otolaryngology‐head and neck surgery department during the COVID‐19 pandemic.MethodsThis is a retrospective, single‐institution study of rapid deployment of telehealth during the COVID‐19 pandemic. Characteristics of patients were compared between those who agreed and those who declined telehealth care. Reasons for declining telehealth visits were ascertained. Characteristics of telehealth visits were collected and patients were asked to complete a post‐visit satisfaction survey.ResultsThere was a 68% acceptance rate for telehealth visits. In multivariable analysis, patients were more likely to accept telehealth if they were being seen in the facial plastics subspecialty clinic (odds ratio [OR] 59.55, 95% confidence interval [CI] 2.21‐1607.52; P = .015) compared to the general otolaryngology clinic. Patients with Medicare (compared to commercial insurance) as their primary insurance were less likely to accept telehealth visits (OR 0.10, 95% CI 0.01‐0.77; P = .027). Two hundred and thirty one patients underwent telehealth visits; most visits (69%) were for established patients and residents were involved in 38% of visits. There was an 85% response rate to the post‐visit survey. On a scale of one to ten, the median satisfaction score was 10 and 99% of patients gave a score of 8 or higher. Satisfaction scores were higher for new patient visits than established patient visits (P = .020).ConclusionRapid implementation of telehealth in an academic otolaryngology‐head and neck surgery department is feasible. There was high acceptance of and satisfaction scores with telehealth.Level of Evidence3.

Persistent Obstructive Sleep Apnea Burden on Family Finances and Quality of Life.

We previously found that financial concerns negatively affect the quality of life of families of children with persistent obstructive sleep apnea (OSA) after tonsillectomy. The goal is to quantify the financial impact on families of children with persistent OSA and assess contributing factors. Cross-sectional survey study with comparison group. Upper airway center at a tertiary pediatric hospital. Participants included consecutive children with persistent OSA from September to October 2017. Healthy children seen in a general otolaryngology clinic served as controls. Families of both groups completed the Family Impact Questionnaire and the modified Comprehensive Score for Financial Toxicity (COST). Families of the 50 patients (25 study and 25 control) completed the surveys: the mean age was 6.4 years (95% CI, 5.0-7.8), and 19 (38%) were female. There were no differences in age, sex, race, or insurance status between groups (P > .05). The mean apnea-hypopnea index for the study group was 7.9 events/h (range, 5.5-10.3), and 40% (10/25) had Down syndrome. Positive airway pressure and/or oxygen were used by 72% (18/25). The Comprehensive Score for Financial Toxicity for study patients (21.9; 95% CI, 14.8-26.0) was significantly lower than for controls (30.2; 95% CI, 26.6-30.8; P = .003), reflecting elevated financial toxicity. Study families reported greater financial impact on the Family Impact Questionnaire (8.4; 95% CI, 6.1-10.7) versus controls (3.6; 95% CI, 1.8-5.4; P = .002); concerns regarding missed days of work and school were common (30.7%). Families of children with persistent OSA reported a high financial burden related to their children's disease and were more likely to report financial toxicity than families of controls. Concern regarding missed work and school associated with appointments and treatment was a significant factor.

A SINGLE CASE STUDY ON EFFECT OF LAKSHADI CHOORNA KARNADOOPANA IN OTOMYCOSIS ASSOCIATED WITH OTITIS MEDIA

Otomycosis is a common condition encountered in a general otolaryngology clinic setting and has typically been described as fungal infection of the external auditory canal with frequent complications involving the middle ear. Although rarely life threatening, the disease is a challenging and frustrating entity for both pa-tients and otolaryngologists as it frequently requires long-term treatment and follow-up. Despite this, there could be recurrences. Karnasrava is a disease mentioned by Acharya Sushruta in the chapter of Karnaroga Vigyaniya under twenty-eight Karnarogas. Karnasrava is the condition characterized by discharge from Karna and occurs mainly due to Avarana of Vata Dosha. Otomycosis being one of the causes of Karnasrava was selected for the study. Treatment of Karnasrava is explained by Sushruta i.e. Karnadoopana, Karnapoorana, Prakshaalana etc. Case Study: This is a case report of 50-year-old female patient who had complains of pain in right ear since 1 month associated with watery discharge from right ear. The subject is a known case of diabetic mellitus since 1year. The Otoscopic examination of bilateral ear, confirmed that, diagnosis of right ear was Otomycosis associated with otitis media. Materials and Method: The subject who approached Shalakya tantra OPD of GAMC with symptoms of right ear pain associated with on and off watery discharge was systematically reviewed. Intervention was planned for Doshic component involved in Karnasrava. Result: The subject showed considerable improvement in right ear. Discussion: Karnasrava is the condition characterized by Srava from Karna and occurs mainly due to Av-arana of Vata Dosha. Otomycosis is a fungal infection of external auditory canal and one of the causes for Karnasrava. This study sheds light on holistic treatment like Karnadoopana told in the Ayurvedic clas-sics.

CLINICO-MYCOLOGICAL STUDY OF OTOMYCOSIS

Otomycosis Is a common condition encountered in a general otolaryngology clinic setting so, We conducted a study with an aim to determine the frequency, common presenting symptoms, predisposing factors and spectra of fungi. Where we found that Patient with Otomycosis presents with nonspecific symptoms like pruritis, discomfort and pain in the ear, aural fullness, tinnitus, hearing impairment, and sometimes discharge, and also recurrence was seen in some cases which is very frustrating for both the patient and doctor as it frequently requires long-term treatment and follow-up. Mainstay of treatment involves removal of debris, thorough toileting of the external ear and the use of antimycotic agents. Summary: Otomycosis is a very frustrating clinical entity for both the otolaryngologist as well as for patient. So educating people about the predisposing factors, risks, cause and care is an important concern to be addressed.

Cost savings associated with an outpatient otolaryngology telemedicine clinic.

ObjectiveTo test the null hypothesis that there is no difference in patient cost savings between the telemedicine and traditional face‐to‐face approach. The second objective was to assess the financial impact on the peripheral healthcare system, as compared with staffing a conventional clinic with “on‐site” otolaryngologist.MethodsTwenty‐one patients were enrolled. To assess “patient‐benefit” cost savings, a model was formulated that would utilize a certified nurse practitioner (CNP) to conduct a general otolaryngology clinic at the peripheral site, as compared with having to travel to the tertiary referral center. A “peripheral site‐benefit” cost analysis was performed to assess costs of initiating and operating a telemedicine clinic at the peripheral site, compared with having an on‐site otolaryngologist.ResultsThe total patient‐benefit cost savings would be $182.09 per patient per encounter and $333.22 per patient annually. The fixed cost to the peripheral site to initiate the telemedicine system was $9,895. Two hundred sixty telemedicine encounters would be needed to offset the initial cost, and 537 encounters would be needed to surpass revenue of the conventional clinic.ConclusionA real‐time telemedicine otolaryngology clinic provides significant cost savings for both patients and the peripheral healthcare system. This pilot study supports telemedicine as a cost‐effective approach to providing general otolaryngology care to rural patients.Level of Evidence4

Patient preferences regarding the communication of biopsy results in the general otolaryngology clinic

ObjectivesTo determine the preferred methods of communicating biopsy results for patients in our comprehensive otolaryngology clinic, and to examine factors associated with preferring remote vs. in-person communication of results. Study designCross-sectional study. SettingAcademic comprehensive otolaryngology clinic. Subjects and methodsA survey instrument was administered to 107 consecutive adult otolaryngology patients undergoing head and neck fine needle aspiration biopsy from March 1, 2017 to April 30, 2018 assessing their health literacy using the Brief Health Literacy Score and their preferred method of notification of biopsy results (in-person vs. remote). Results69% of patients preferred remote notification of their biopsy results (either by telephone or via an online portal). 54% of patients prioritized clear explanation of the results as the most important factor when communicating a malignant result. Adequate health literacy was associated with lower odds of preferring in-person notification (adjusted odds ratio 0.11, 95% CI 0.03 to 0.39). Patients who prioritized clear explanation of the results were more likely to prefer in-person notification (adjusted OR 4.13, 95% CI 1.31 to 14.88). ConclusionsA significant proportion of patients in our comprehensive otolaryngology clinic undergoing fine needle aspiration biopsy preferred remote communication of their biopsy results. Patients most valued clear explanations from the provider and prompt receipt of the result when communicating malignant results. This highlights the need for individualized results communication plans, for patients undergoing biopsy.

Mobile Technology-Based Real-Time Teleotolaryngology Care Facilitated by a Nonotolaryngologist Physician in an Adult Population.

Telehealth can improve access to specialist care. Very few reports of the use of smartphones for teleotolaryngology exist. The objective of this study is to evaluate the use of mobile teleotolaryngology facilitated by a nonotolaryngologist physician. A prospective study in adult patients attending a general otolaryngology outpatient clinic. The telehealth encounter with a remote otolaryngologist was facilitated by a final-year medical student simulating a general physician prior to the scheduled visit. The patient and the remote otolaryngologist rated their satisfaction with the encounter. The remote otolaryngologist formulated a diagnosis and rated the level of certainty of this diagnosis. Diagnoses from the telehealth encounter and the face-to-face encounter were compared. Forty-eight patients with an average age of 42.5 years participated in this study. In 79.2% of the consultations, there was concordance between the diagnoses. The average patient and remote otolaryngologist satisfaction with the encounter was 9.5 ± 0.9 and 8.7 ± 1.3, respectively. Twenty-four of the 48 visits (50%) were defined as unnecessary. In the otology group, concordance rates and rates of preventable visits were highest. Synchronous telehealth consultations, facilitated by a general physician, can be an alternative to visiting a general otolaryngology clinic, especially for otologic patients.

Determining Patient Preferences for Indeterminate Thyroid Nodules: Observation, Surgery or Molecular Tests.

Gene-expression classifiers (GEC) and genetic mutation panels (GMP) have been shown to improve preoperative diagnostic evaluations of indeterminate thyroid nodules. Despite the improvement, uncertainty regarding the proper management exists. Patient preferences may better inform the management of these indeterminate thyroid nodules. Hypothetical scenarios were administered to two groups of patients: those with previous FNA-confirmed indeterminate thyroid nodules (Group A, n=50) and those presenting to a general otolaryngology clinic for other reasons (Group B, n=50). We evaluated patient preferences for surgery, observation and the use of molecular tests while varying the risk of malignancy, cost and diagnostic properties of the tests. The mean threshold for choosing surgery over observation was a 38.6% risk of malignancy on FNA. When offered either GEC, GMP or both (with their inherent imperfect diagnostic properties) in addition to the indeterminate FNA, 85.0% of respondents picked at least one of the molecular tests over either observation or surgery if the test(s) were free of charge. However, only 51.7% of respondents chose at least one of the tests when asked to pay the current cost of the test(s) (p<0.001). On multivariable analysis, sex, the presence of an indeterminate FNA diagnosis and income level significantly predicted the desire to proceed with a molecular test above standard management. Patient preferences for thyroid nodule management are dependent on the risk of malignancy, prognosis of cancer and costs. Patients prefer molecular tests over standard management with indeterminate thyroid nodules, but the costs of the test(s) reduce the desire.

The use of complementary and alternative medicine by patients attending a general otolaryngology clinic: can we afford to ignore it?

Background There is growing interest in use of complementary and alternative medicine (CAM) among the general population. Little information is available, however, on CAM use in adults attending an otolaryngology outpatient clinic in the UK. Objective The purpose of this article is to study the prevalence and pattern of CAM use among adult patients attending the ear, nose, and throat (ENT) clinic in a UK teaching hospital. Study design A cross-sectional study was used. Subjects and methods All patients on their primary visit to an ENT clinic were asked to complete an anonymous questionnaire for a 14-week period from October 2005 to January 2006. Results Based on 1366 completed questionnaires, 53% (728/1366) were female and 47% (638/1366) were male. Twenty-nine percent (395/1366) were older than 60 years, and 56% (763/1366) were married. Twenty percent (275/1366) had a university education. Sixty-one percent (833/1366) had used CAM, almost 36% in the preceding 12 months. The popular remedies were cod liver oil (368/833), garlic (197/833), cranberry (181/833), aloe vera (176/833), primrose oil (174/833), and Echinacea (163/833). Nonherbal therapies included massage (230/833), acupuncture (186/833), aromatherapy (135/833), chiropractic (121/833), reflexology (119/833), and homeopathy (110/833). Seventeen percent (143/833) used CAM for their current illness. Only 8% (64/833) found CAM ineffective; yet, 57% (473/833) would recommend CAM to others. Fifty-one percent (421/833) failed to inform their primary physician of their CAM use. Conclusion Despite concerns over CAM efficacy, safety, and cost effectiveness, use of CAM is popular among patients attending an ENT clinic. Their use is not generally related to their presenting illness. Otolaryngologists should be aware of current trends in CAM use when managing patients, including possible interactions with other medication.

Prevalence of Vitamin D Deficiency among Patients Attending a General Otolaryngology Clinic in South Auckland

We performed a prospective observational study to estimate the prevalence of vitamin D deficiency in patients attending a general otolaryngology clinic in South Auckland, New Zealand. From July 21,2008, to August 7, 2008, all new patients presenting to otolaryngology clinics at which one of the authors (D.R.) was present had their vitamin D status assessed by measurement of their plasma 25-hydroxyvitamin D [25(OH)D] level. Of 48 patients, 2% had 25(OH)D levels of 17.5 nmol/L or less (a level associated with osteomalacia), 58% had 25(OH)D levels of 50 nmol/L or less (a level associated with vitamin D deficiency), and 100% had 25(OH)D levels of 80 nmol/L or less. Most of the patients attending a general otolaryngology clinic in South Auckland are vitamin D-deficient. It is unclear whether low vitamin D levels are associated more directly with otolaryngological disorders or skin type, because the small size of this study and the broad range of conditions seen precluded a meaningful statistical analysis. Further research into the relationship of vitamin D to specific otolaryngological presentations is required.

Identification of predictors and development of a screening protocol for cerebello‐pontine lesions in patients presenting with audio‐vestibular dysfunction

Magnetic resonance imaging (MRI) scanning in the investigation of cerebellopontine angle lesions represents a finite resource, the use of which needs to be carefully rationalised. Our aim was to identify predictive factors that can distinguish between patients with and without cerebellopontine angle lesions, and develop a screening protocol which could be useful in the clinical setting as an aid to clinical judgment. Case-control study. Secondary care. Audio-vestibular features were collated on 136 patients (M : F 1.39 : 1) and 288 controls (M : F 1 : 1.1). Diagnostic by analysis of symptoms and audiometric data using logistic regression, receiver-operator characteristic curves and backwards elimination. Development of a predictive algorithm comprising those factors which are most strongly predictive of the presence of a cerebellopontine angle lesion. Positive predictors of a cerebellopontine angle lesion include the interaural threshold difference at 1 (P = 0.044) and 4 kHz (P = 0.034). The threshold in the better hearing ear at 0.25 kHz exerts a negative predictive (i.e. protective) effect (P = 0.005). The presence of tinnitus does not appear to influence the outcome on logistic regression. Although vertigo does exert an influence on the overall model, its impact is highly equivocal. We have identified audiometric factors which exert a positive and negative predictive influence on the presence of a cerebellopontine angle lesion, and audiovestibular symptoms which appear to exert little effect on the model. Our predictive equation represents a user-friendly standardised method of risk-stratification of patients within a general otolaryngology clinic.

Quality of Life in patients with vestibular schwannomas managed conservatively

Since the era of magnetic resonance imaging (MRI) scanning, vestibular schwannomas are being diagnosed earlier, growth has been shown to be static in up to 70% of cases and patients have admitted to a reduced quality of life following acoustic neuroma surgery. The aim of this study was to assess the quality of life in patients with vestibular schwannomas managed conservatively. Fifty patients with a vestibular schwannoma were identified who were being managed by interval MRI scanning. Fifty patients attending the general otolaryngology clinic with similar symptoms were prospectively recruited. Each group was assessed using the short form 36 (SF-36) health survey. Both groups were adequately age and sex matched and the SF-36 scores were comparable across all eight health domains.

Reading skills of otolaryngology outpatients: implications for information provision.

The aim of this prospective observational study was to estimate the proportion of otolaryngology patients with poor reading skills, as a guide to information provision. The subjects were a consecutive series of 50 adult outpatients attending a general otolaryngology clinic at the Victoria Infirmary, Glasgow, and whose first language was English. Reading skills were estimated using the Rapid Estimate of Adult Literacy in Medicine. For comparison, the SMOG readability formula was used to estimate the reading skills required to understand the Department's 35 information leaflets, the standard elective admission notification letter and the surgical consent form. Fourteen (28 per cent) patients were found to have poor reading skills (8th grade or less). The surgical consent from required 11th grade reading ability, as did the standard admission letter, and the leaflets required 9th to 15th grade (graduate) reading ability (median 11th grade). Many patients could be expected to have difficulty understanding these written materials. Information must be written in plain English to be suitable for a wide range of patients, including those with poor reading skills.

How uncomfortable are the various positions recommended for the instillation of nose drops?

Nose drops are widely used in the topical treatment of nasal disorders. Their efficacy has previously been shown to depend on the position of the head adopted during instillation. All three of the commonly recommended head positions (head back, praying-to-Mecca, Mygind's) are uncomfortable, and this may affect patient compliance. As yet, no assessment has been made of the discomfort encountered by patients. Twenty adults from a general otolaryngology clinic were asked to adopt each of three positions and then rate the discomfort experienced on a 10 cm visual analogue scale. The results show that although Mygind's position is well tolerated, the praying-to-Mecca position was significantly more uncomfortable than any other. In the absence of any evidence that the praying-to-Mecca position is clinically more efficacious than Mygind's, it seems inappropriate to continue to advocate its use.

Model for optimal space and staff efficiency in an otolaryngology clinic

Maximizing efficiency of staff and resources is one method of reducing costs without affecting quality. Using a methodology similar to that used to maximize efficiency of airline-gate use, we developed a model with which to evaluate nursing support staff and clinical examining-room resources in a general otolaryngology clinic. For 144 patients over 7 consecutive clinic days, with four otolaryngologists and various combinations of support staff and examining rooms, we measured space and staff resource use, including total clinic time, number of patients seen, patient waiting time, physician and nurse productivity, and examining-room use. A simulation model was used as the medium of analysis to define parameters of the patient encounter. We identified optimal efficiency when there were three examining rooms and one and one-half nursing staff per physician or five examining rooms and three nursing staff for two simultaneously practicing physicians. Compared with a model of two rooms and one nursing staff member, our ideal model increased the percentage of the physicians’ time spent in direct contact with patients from 84% to 92%. Visit length decreased from 81 minutes to 57 minutes, the average time from check-in to examination decreased from 47 to 16 minutes, and it became possible for three additional patients to be seen each day. Additional rooms and support staff, in comparison with the optimally efficient distribution, did not significantly affect these parameters. Maximizing efficiency with the use of this methodology can decrease waiting times for patients, resulting in greater patient satisfaction, improved physician productivity, total number of patients seen, and increased total contact time between physicians and patients. (Otolaryngol Head Neck Surg 1998;119:394-7.)