Download Mobile Applications in Otolaryngology– Head and Neck Surgery

State of the Art Review
Mobile Applications in Otolaryngology–
Head and Neck Surgery
Matthew C. Wong1, and Kevin Fung, MD, FRCS(C)1
No sponsorships or competing interests have been disclosed for this article.
Abstract
Objectives. To study the current selection of mobile applications (apps) relating to otolaryngology–head and neck surgery (OtoHNS). To conduct a review of the apps available in
OtoHNS.
Data Sources. App Store, Google Play, BlackBerry World,
Windows Store.
Methods. The Apple, Google, Windows, and Blackberry
mobile app stores were searched for apps relating to
OtoHNS. App information was analyzed based on in-store
descriptions, and apps were downloaded and reviewed.
Conclusions and Implications for Practice. There is a rapidly
expanding collection of apps with a wide variety of functions
available in OtoHNS. There are several high-quality apps for
education and clinical use, which have been highlighted in
our review. Mobile apps have the potential to become
widely incorporated into OtoHNS, although there is a need
for appropriate guidance from the specialty to ensure app
quality and accuracy of content.
Otolaryngology–
Head and Neck Surgery
2015, Vol. 152(4) 638–643
Ó American Academy of
Otolaryngology—Head and Neck
Surgery Foundation 2015
Reprints and permission:
sagepub.com/journalsPermissions.nav
DOI: 10.1177/0194599815568946
http://otojournal.org
Mobile devices and apps are widely used by physicians,
residents, and medical students and have become commonplace in hospitals, clinics, and medical classrooms. Recent
studies have found that 83% of attendings, 88% of residents,
and 85% of medical students use a smartphone.2,3 One
study found that 56% of residents and attendings use medical apps in clinical practice.3 Medical apps have a broad
range of functions, including finding drug interaction
resources, performing medical calculations, and acting as
tools for medical education.
Recent studies have examined the apps available in different specialties, including orthopedic surgery, infectious
disease, colorectal disease, dermatology, pain management,
radiology, neurosurgery, anesthesiology, urology, and plastic surgery.4-15 There has been very limited research conducted on apps in otolaryngology–head and neck surgery
(OtoHNS). In 2010, an editorial by Pope et al described
apps that may be useful for practicing otolaryngologists.16
Since then, the mobile app landscape has drastically changed. The purpose of this study is to provide an up-to-date
review of the current selection of apps in OtoHNS and to
provide a useful resource to help guide physicians and trainees through the apps available in the specialty.
Methods
Keywords
mobile applications, medical education, smartphones, apps
Received September 14, 2014; revised December 29, 2014; accepted
January 2, 2015.
Introduction
Mobile devices have become ubiquitous in all aspects of
today’s society, including medicine. Mobile devices are
small, handheld computing devices and include smartphones and tablets. Currently, the most popular smartphones worldwide are Apple’s iPhone and Samsung’s
Galaxy, while the most popular tablets are Apple’s iPad
and Samsung’s Galaxy Tab.1 Mobile devices allow users
to perform a variety of functions through third-party applications (apps), which can be downloaded from online app
stores. The largest app stores are Apple’s App Store (iOS),
Google Play (Android), Windows Store, and BlackBerry
World.1
The Apple (iOS App Store), Google (Google Play), Windows
(Windows Phone Store), and BlackBerry (BlackBerry World)
app stores were searched for apps relating to OtoHNS. The
following search terms were used: otolaryngology–head and
neck surgery, otolaryngology, ear nose throat, ENT, ear,
nose, throat, otology, rhinology, laryngology, head and neck,
facial plastics. Apps were selected based on app store
descriptions. Apps were included if they related to the
1
Department of Otolaryngology–Head and Neck Surgery, Schulich School
of Medicine and Dentistry, Western University, London, Ontario, Canada
This article was presented at the 4th Canadian Society of Otolaryngology–
Head and Neck Surgery Conference on Undergraduate Medical Education;
November 8, 2014; Montreal, Quebec, Canada.
Corresponding Author:
Kevin Fung, MD, FRCS(C), Associate Professor, Department of
Otolaryngology–Head and Neck Surgery, Schulich School of Medicine and
Dentistry, Western University, 800 Commissioners Road East, London
Health Sciences Center, Victoria Hospital, Room B3-427, London, Ontario,
Canada.
Email: [email protected]
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Wong and Fung
639
Search was conducted of the Apple, Google, Windows,
BlackBerry app stores using multiple search queries
relating to otolaryngology – head and neck surgery
24%
n = 18
Search returned 421
unique apps
41%
n = 31
75 appsrelating to
otolaryngology – head and neck
surgery included
Journal / Conference
Clinical
16%
n = 12
346 apps with no relation to
otolaryngology – head and neck
surgery or not written in English
excluded
Educaon
For Paents
19%
n = 14
Figure 2. Categories of applications (apps) based on app function.
- 62 in the Apple store
- 26 in the Google store
- 4 in the BlackBerry store
- 1 in the Windows store
Figure 1. Flow diagram for applications (apps) found in app
stores.
specialty of OtoHNS and the app store description was written in English. Apps were excluded if they had no relation to
the specialty (Figure 1). Data were collected based on store
descriptions, including app name, function, price, date published, frequency of updates, intended audience, user ratings,
number of user reviews, and developer information. The top
10 user-rated apps were determined based on in-store user
ratings, out of apps with at least 5 user ratings.
Results
The search of the app stores was carried out in January
2014. Seventy-five unique apps that met the inclusion criteria were identified. Sixty-two (83%) of all apps were
available in the Apple store, 26 (35%) in the Google store,
4 (5%) in the BlackBerry store, and 1 (1%) in the Windows
store. Seventeen (23%) of the apps were available in multiple stores. One (1%) of the apps was published in 2008, 5
(7%) in 2009, 7 (9%) in 2010, 13 (17%) in 2011, 19 (25%)
in 2012, and 30 (40%) in 2013.
The average app price was $4.81, with a range of $ 0 to
$67.49; 40 (53%) of the apps were free. The average price
of paid apps was $10.46, with a range of $ 0.99 to $67.49.
There were several payment methods for paid apps. Most
commonly, apps required full payment before downloading
the app. Other apps had free trials available, whereby users
can download and test limited content for free before deciding whether to pay to access full content. Although uncommon, some apps required monthly or yearly subscriptions to
access content.
Developer Information
Developer information was collected based on store descriptions and in-app information. There were 62 unique developers for the 75 apps. Thirty-nine (52%) apps stated that
physicians were involved in development. The remaining 36
(48%) apps had no clear statements of physician involvement. Only 7 (9%) apps contained references for in-app
content.
Categories
Apps were organized into categories according to subspecialty: 51 (68%) of the apps related to general OtoHNS, 9
(12%) to otology, 7 (9%) to head and neck oncology, 3
(4%) to rhinology, 3 (4%) to laryngology, 1 (1%) to facial
plastics, and 1 (1%) to allergy.
The apps were also organized into categories corresponding to app function (Figure 2). Apps in the education category are aimed at educating medical students, residents,
physicians, and other health care professionals (n = 31,
41%). This category includes question banks, reference
texts, and anatomy pictures and atlases. Apps containing
abstracts and articles for journals and apps designed for conferences and meetings were placed into the journal/conference category (n = 14, 19%). Apps designed for use in
clinical settings by physicians and other health care professionals were placed into the clinical category (n = 12, 16%).
Apps in this category include clinical reference guides,
cancer staging tools, and apps intended to aid in procedures.
Apps designed for patient use were placed into the for
patients category (n = 18, 24%). This category features specific clinic and hospital information, auditory tests, and
apps designed for educating patients.
User Ratings/Reviews
The majority of apps had no user ratings (63%). Nine apps
(12%) had 1 to 5 ratings, 6 (8%) had 6 to 10 ratings, and 13
(17%) had greater than 10 ratings. For the apps that had at
least 1 rating, the average user rating was 3.2 out of 5, with
a range of 0 to 5. The majority of apps also had no written
user reviews (84%). Ten apps (13%) had 1 to 5 reviews, 1
(1%) had 6 to 10, and 1 (1%) had greater than 10 reviews.
Table 1 displays the top 10 user-rated apps, out of apps
with at least 5 ratings. The top-rated journal/conference app was
Otolaryngology–Head and Neck Surgery, which is the app for
the journal of the same name. The app allows subscribers to
access abstracts and full-text articles from recent issues from
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640
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4.99
Apple
Android
Apple
Clinical
Clinical
TNM Head and Neck
1.99
Free
b
Top 10 applications (apps) based on in-store user ratings, out of apps with at least 5 ratings.
Available Only for iPad devices.
c
Free trial available. Price is for full content.
a
Free
Apple
For patients
Headache Diary
(EcoHeadache)
ENT Handbook
Apple
Journal/conference
Laryngoscope
Free
Apple
For patients
4.5
49.99c
Apple
Education
AcademyQ: Otolaryngology
Knowledge Self-assessment
Tool
Advent MD
4.5
Free
Android
Appleb
Clinical
drawMD
Free
Android
Apple
4
4
4
4.5
4.5
5
5
4.99
Android
Apple
Clinical
Education
ENT for Students
5
User Rating,
out of 5
Free
Price, $
Apple
Platform
ENT Surgery Handbook
Journal/conference
Category
Otolaryngology–Head
and Neck Surgery
App Name
Table 1. Top 10 User-Rated Otolaryngology–Head and Neck Surgery Apps.a
5
6
51
5
12
22
85
12
7
19
No. of
User Ratings
No
Yes
No
Yes
No
Yes
Yes
Yes
Yes
Yes
Physician Involvement
with App Development
Yes
No
No
Yes
No
Yes
No
No
No
Yes
References for
Content
TNM staging tool for head and
neck cancers
Illustrate and modify medical
images to communicate with
and educate patients
Hundreds of study questions
separated into subspecialty
areas
Helps patients and families
understand impact of hearing
loss, snoring, sinusitis
Access abstracts and full-text
articles for the journal The
Laryngoscope
Helps patients track headache
pain
A management guide for
common conditions seen in
hospital
Clinical guide for
otolaryngology–head and neck
surgery basics and
emergencies
Quiz questions directed for
medical student learning
Access to abstracts, articles,
podcasts for the journal
Otolaryngology-Head and Neck
Surgery
Description
Wong and Fung
641
their mobile devices. The app also allows users to quickly
access links, including author guidelines and reviewer guidelines, and to listen to AAO-HNSF podcasts. The Laryngoscope
is another top-rated journal/conference app and is the official
app of the journal of the same name. The app allows subscribers
to access abstracts and full-text articles. This app enables users
to easily jump to figures or tables, search articles, and e-mail
articles or citations.
Two of the top user-rated apps were education apps.
ENT for Students is an app designed to educate medical students and residents through text and multiple-choice questions. The questions are organized by category, with a small
number of questions per category. After answering, the correct
answer is displayed, although there are no explanations or
references provided. AcademyQ: Otolaryngology Knowledge
Self-assessment Tool was developed by the American
Academy of Otolaryngology—Head and Neck Surgery
Foundation and is a self-assessment and learning tool designed
for residents and physicians. The app is a paid question bank
that contains more than 400 questions with answers, explanations, and references for further reading. The user can save
favorite questions and make in-app text or audio notes.
Several of the top-rated apps were in the clinical category. ENT Surgery Handbook was developed by a group
from the East Lancashire Hospitals NHS Trust and is
intended to be used as a clinical guide for the management
of common emergencies seen in OtoHNS. The content is
in point form and focuses on management but also
includes pictures, etiologies, and other considerations. The
app also contains doses for commonly used medications
and a section titled ‘‘ENT Consent Aide Memoire,’’ which
contains complications for common surgeries. drawMD
ENT is an iPad-only app that aims to enhance physicianpatient communication by allowing clinicians to illustrate
and modify medical images to share with patients. The app
provides anatomical images that a physician can modify to
indicate pathologies or describe surgical procedures.
Images can be saved and e-mailed to patients. ENT
Handbook was developed by a group of physicians from
Royal Melbourne Hospital and is intended to be an inhospital guide for residents. The app has sections on
airway concerns, resident duties, common operations, and
common emergencies. The content is in bullet form and
focuses on management. TNM Head and Neck is a cancer
staging app based on the seventh edition of the American
Joint Committee on Cancer Staging Manual. The app provides a quick TNM staging tool with explanations for
many head and neck cancers.
Two of the top apps were designed for patient use.
Advent MD aims to help patients and family members
understand sinus conditions, snoring, and hearing loss. The
app contains a hearing test, a snoring simulator, and a section that simulates noises as heard by individuals with hearing loss. Headache Diary (EcoHeadache) helps patients
track ‘‘headache, migraine, and ENT pain.’’ It enables
patients to create a log of information about pain, including
onset, duration, quality, severity, and treatment used. This
information can be graphed, and the app encourages patients
to present the information to a physician.
Discussion
The advent of mobile technology has allowed access to virtually unlimited amount of information at our fingertips.
Mobile devices and apps have already become widespread in
medicine and are expected to become more prevalent in the
future.17,18 Despite the extensive use of mobile devices and
apps in medicine, there has been limited research on apps in
the specialty of OtoHNS. In our study, we analyze and
review the current selection of apps available in OtoHNS.
Seventy-five unique apps relating to OtoHNS were found
at the time the search was conducted. This number is comparable to other specialties, with recent studies finding 39
apps in neurosurgery, 79 in dermatology, 108 in pain management, 66 in orthopedic surgery, and 63 relating to colorectal disease.6,7,10-12 The number of apps published per year
in OtoHNS has increased each year, which is consistent
with the continuing expansion of the mobile app market.
The app market is projected to continue growing in the near
future, and as a result, it seems likely that the number of
apps in OtoHNS will continue to grow as well.1
The majority of apps were available in the Apple App
Store (83%), followed by the Google store (35%), with the
BlackBerry and Windows stores having a very limited
selection. All of the top 10 user-rated apps were available in
the Apple Store, 4 in the Google store, and none in the
Windows or BlackBerry stores. Apple is the most popular
platform for apps in OtoHNS, and it is the most popular
platform among physicians and trainees. One study found
that 83% of smartphones owned by physicians, residents,
and medical students were iPhones.2 Interestingly, this is
not reflective of the current US smartphone market, where
Google (Android) owns a 53% market share followed by
Apple at 42%.19
There are several high-quality apps that could potentially
be integrated into everyday clinical use. Several useful clinical guides and handbooks were highlighted in Table 1 in
the top user-rated apps. These apps provide a quick reference for management of conditions or cancer staging,
among other functions. One particular clinical app that
stands out is drawMD ENT, which allows physicians to
interact with patients in a new and unique way. It is feasible
that surgeons could modify and edit a patient’s own computed tomography or magnetic resonance imaging scan to
describe a surgery or use this app to describe and obtain
consent for surgery from patients. There are also apps emerging that allow smartphones to function as high-definition
cameras for endoscopy with the use of an adapter. There are
already multiple apps that can be integrated into clinical
use, and apps have the potential to significantly change clinical practice in OtoHNS in the future.
There are also useful apps for education in OtoHNS.
AcademyQ and ENT for Students were outlined and provide
question banks that students can use for learning on the go.
Another notable app is learnENT, an interactive educational
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642
Otolaryngology–Head and Neck Surgery 152(4)
app for medical students that contains text, images, videos,
and quizzes. The app was developed by the Canadian Society
of Otolaryngology–Head and Neck Surgery Undergraduate
Medical Education Working Group and contains references
for content. Although these apps provide information that can
be found in textbooks or online, the value of mobile apps is
in portability, ease of access, and the combination of text,
multimedia, and interactive interface that are unique to
mobile apps.
The majority of the apps in our study had no in-store user
ratings or user reviews. This provides difficulty for users
trying to assess the quality of apps in stores. There are several external resources that can aid users in determining app
quality. iMedicalApps.com is an independent Web site run
by physicians and health care professionals. The Web site
provides analysis and commentary on mobile technology in
medicine and includes in-depth reviews for many medical
apps.20MedicalAppJournal.com is another useful Web site
that aims to provide a database of unbiased reviews for medical apps.21
Only 52% of the apps stated that physicians were
involved in development. This low level of physician involvement in app development raises quality assurance issues
and concerns regarding the accuracy of app content.
Furthermore, the vast majority of apps did not have in-app
references for content. These issues are not unique to
OtoHNS, as studies have raised similar concerns about unregulated app content in other specialties.7,10,22-24 These quality assurance issues make it difficult to determine the
accuracy of app content and provide barriers to apps becoming incorporated into clinical use and medical education.
We believe that steps should be taken to regulate app development and to ensure quality and accuracy of content. In
the short term, we envision a peer-review process whereby
a body of physicians reviews apps and creates a bank of
‘‘approved apps.’’ Ultimately, we believe a review process
is required that involves physician evaluation of apps during
app development. Apps would have to be approved before
being classified as a ‘‘medical app.’’ As apps become more
prevalent in OtoHNS, guidance from otolaryngologists is
required to assess app quality, validity, and effectiveness
before they can be fully incorporated into clinical practice
and medical education.25
This study had some limitations. Our study includes apps
specific to OtoHNS; many general medical apps that may
be useful for otolaryngologists were omitted due to the
search criteria used. Other studies have outlined general
medical apps that physicians and trainees in otolaryngology
may find useful.1,26 We were also limited by the information available in the app stores. We were unable to determine the most downloaded OtoHNS apps as several of the
stores do not make these data available. Although new apps
and devices will soon emerge as technology continues to
rapidly evolve, our study provides an up-to-date review of
the apps currently available in OtoHNS.
Conclusion
Our study reviewed the current selection of apps available
in OtoHNS. We found a rapidly expanding collection of
apps with a wide variety of functions. Several high-quality,
affordable apps for education and everyday clinical use
have been highlighted in our review. Mobile apps have the
potential to be widely incorporated into OtoHNS, although
there is a need for appropriate guidance from the specialty
to ensure app quality and accuracy of content.
Author Contributions
Matthew C. Wong, study conception and design, acquisition and
analysis of data, drafting the manuscript; Kevin Fung, study conception and design, drafting the manuscript, critical revision of
manuscript
Disclosures
Competing interests: None.
Sponsorships: None.
Funding source: None.
References
1. ABI research’s smartphone and handsets market research.
http://bit.ly/1tvVs3i. Updated July 7, 2014. Accessed July 10,
2014.
2. Wallace S, Clark M, White J. ‘‘It’s on my iPhone’’: attitudes
to the use of mobile computing devices in medical education,
a mixed-methods study. BMJ Open. 2012;2(4):e001099.
3. Franko O, Tirrell T. Smartphone app use among medical providers in ACGME training programs. J Med Syst. 2012;36:
3135-3139.
4. Abboudi H, Amin K. Smartphone applications for the urology
trainee. BJU Int. 2011;108:1371-1375.
5. Amin K. Smartphone applications for the plastic surgery trainee. J Plast Reconstr Aesthet Surg. 2011;64:1255-1257.
6. Franko O. Smartphone apps for orthopaedic surgeons. Clin
Orthop Relat Res. 2011;469:2042-2048.
7. Hamilton A, Brady R. Medical professional involvement in smartphone ‘‘apps’’ in dermatology. Br J Dermatol. 2012;167:220-221.
8. Kraidin J, Ginsberg S, Solina A. Anesthesia apps: overview of current technology and intelligent search techniques. J Cardiothorac
Vasc Anesth. 2012;26:322-326.
9. Oehler R, Smith K, Toney J. Infectious diseases resources for
the iPhone. Clin Infect Dis. 2010;50:1268-1274.
10. O’Neill S, Brady RR. Colorectal smartphone apps: opportunities and risks. Colorectal Dis. 2012;14:530-534.
11. Rosser B, Eccleston C. Smartphone applications for pain management. J Telemed Telecare. 2011;17:308.
12. Tseng J. Review of neurosurgical smartphone applications.
Journal MTM. 2012;1:4-10.
13. Al-Hadithy N, Ghosh S. Smartphones and the plastic surgeon.
J Plast Reconstr Aesthet Surg. 2013;66:e155-e161.
14. Szekely A, Talano R, Bagyi P. Smartphones, tablets and mobile
applications for radiology. Eur J Radiol. 2013;82:829-836.
Downloaded from oto.sagepub.com at SOCIEDADE BRASILEIRA DE CIRUR on April 6, 2015
Wong and Fung
643
15. Mohan A, Branford O. iGuide to plastic surgery: iPhone apps,
the plastic surgeon, and the health care environment. Aesthet
Surg J. 2012;32:653-658.
16. Pope L, Silva P, Almeyda R. iPhone applications for the
modern day otolaryngologist. Clin Otolaryngol. 2010;35:
350-354.
17. Ezdalga E, Ozdalga A, Ahuja N. The smartphone in medicine:
a review of current and potential use among physicians and
students. J Med Internet Res. 2012;14:128.
18. Mosa AS, Yoo I, Sheets L. A systematic review of healthcare
applications for smartphones. BMC Med Inform Decis Mak.
2012;12:67.
19. comScore reports April 2014 U.S. smartphone subscriber market
share. http://bit.ly/VG1YIe. Updated June 3, 2014. Accessed July
10, 2014.
20. iMedicalApps Web site. http://www.imedicalapps.com. Accessed
July 11, 2014.
21. Medical app journal peer review for medical apps Web site.
http://medicalappjournal.com. Accessed July 11, 2014.
22. Wolf J, Moreau J, Akilov O. Diagnostic inaccuracy of smartphone applications for melanoma detection. JAMA Dermatol.
2013;149:422-426.
23. Misra S, Lewis TL, Aungst TD. Medical application use and the
need for further research and assessment for clinical practice: creation and integration of standards for best practice to alleviate
poor application design. JAMA Dermatol. 2013;149:661-662.
24. Kulendran M, Lim M, Laws G, et al. Surgical smartphones
applications across different platforms: their evolution, uses
and users. Surg Innov. 2014;21:427-440.
25. Fung K. Otolaryngology–head and neck surgery in undergraduate
medical education: advances and innovations. Laryngoscope. In
press.
26. Dala-Ali B, Lloyd M, Al-abed Y. The uses of the iPhone for
surgeons. Surgeon. 2011;9:44-48.
Downloaded from oto.sagepub.com at SOCIEDADE BRASILEIRA DE CIRUR on April 6, 2015