Ear visualisation equipment is a vital tool of the trade for audiologists, ENT surgeons, audiometrists and ear health nurses. HPA delves into advances and trends.
Ear examination and access have come a long way since French physician Dr Guy de Chauliac first described and illustrated an aural speculum in 1363 and English surgeon Dr John Bruton devised the inaugural otoscope in 1862 combining an ear speculum with a perforated mirror and a magnifying glass.
Today’s otoscopes are advanced pieces of equipment which enable precise assessment of the ear’s internal structures for inflammation, abnormalities, fluid, wax and other issues.
Likewise, surgical microscopes, endoscopes and exoscopes (robotic microscopes) enable incredible visualisation and access. They include AI-supported systems which feature digital imaging for neurotological interventions such as acoustic neuroma, and advanced visualisation systems for middle ear procedures and cochlear implant surgeries.
University of Melbourne lecturer, audiologist Mr Dominic Power, has taught ear examination skills to audiology students since 2001 and is lead audiologist at its Melbourne Hearing Care Clinic, where audiologists deliver care to patients while training students.
Additionally, he teaches cerumen removal assisted by the VoroTek O Scope, invented in Australia specifically for ENT and audiological work. Power uses it as a teaching and in-practice tool for wax removal and deep canal procedures as it combines LED illumination with a unique optical pathway for looking in ear cavities.
Power says the main change in otoscopes in the past two decades has been LED bulbs which are brighter, drain the battery less and are more reliable. “In the old days audiologists would be mid-way through a session using an otoscope and the bulb would go without warning,” he says. “You’d have to scramble to find a new one.”
LED bulbs don’t colour the ear as much as incandescent bulbs, he adds. “If you’re looking in the ear, you want to make sure wax looks like wax, skin looks like skin, blood looks like blood, and if you’re trying to differentiate one from the other, having a good neutral light source means it doesn’t all look white or brown,” Power says.
Benefits of video otoscopes
Video otoscopes have also changed ear visualisation displaying what’s happening inside the ear on a screen during examination for practitioner and patient to see. Melbourne Hearing Care Clinic has 12 video otoscopes, Power says, adding they’re a worthwhile investment for audiology clinics.
“They’re $3,000 to $4,000 each but we use quality ones which have really good light,” he says. “They’re easy to handle, have good attachments that are easily cleanable and are much better compared to video otoscopes released a dozen years ago which were clunkier, needed a separate light source, and were more cumbersome.”
Video otoscopes provide digital images of the patient’s ear which are easily stored in their clinical record for future comparison and consultation with other audiologists or ENT surgeons. “We can email them the picture and ask for a second opinion which is really helpful,” Power says.
“Patients love to see inside their ear and it’s a great educational tool. If they’re cotton bud users, we can take photos of the damage they’ve done and show them. We can also show them if there’s fluid, or why a bit of wax in the ear is good.”
Another tool, Bebird video otoscopes available on Amazon for about $80, connect to a phone via WiFi and an app. They have a bright light and camera to pop in the ear and are more for consumers than practitioners. “Our audiologists and students have taken them to Cambodia and Thailand to provide advice on ear conditions in remote areas but they’re also helpful for clients with ear conditions who need ongoing monitoring,” Power says.
“Clients can take pictures at home and send images to their doctor or audiologist who can advise if they need to seek urgent attention or it’s par for the course.”
Video otoscopes can guide students on properly orienting light and focus towards the area of interest. “One skill students have difficulty with is finding the eardrum and doing thorough otoscopic examination, so as a training tool, it’s very good to show what they need to be looking for,” Power says.
Audiologists who fit Lyric invisible hearing aids use an operating microscope to provide clear illumination and visualisation up to the eardrum, providing gold standard visualisation, he adds.
The newest kid on the block in Australia is the WaxScope from the UK which is connected to a phone, and Power believes will complement existing technology. He says the WaxScope has an “additional brilliant light source”, and a nice set of optics to focus at any depth along the ear canal at the swipe of a screen.
Future predictions
Brightness is constantly increasing such as fibre optic light sources in Bebirds, the WaxScope, and from LED globes, Power says. He predicts otoscopes will become brighter, smaller and more affordable.
Audiologist of 33 years, Ms Alison Chiam, says “ear visualisation is the foundation of what we do”. “It gives us information about the canal, the eardrum, the middle ear, and integrated with a good audiogram, can tell us an enormous amount about health or pathology in an ear,” she adds.
Chiam started her career at Latrobe Regional Hospital before working for Hearing Australia when it was the National Acoustic Laboratories (NAL) in Gippsland, Victoria. She worked seven years for NAL as a paediatric and adult specialist before opening her own practice, Jervis Bay Hearing Centre, NSW, in 2002.
She says otoscopy and tympanometry remain her foundations. “I have an otoscope that looks the same as when I first started but viewing the ear and eardrum has expanded using existing mediums in a new way; with greater magnification or adding digitalisation including image capture through video onto a screen as a still or moving image, binocular, sound (immittance), pressure, microscopic or electronic detection mediums,” she says.
“Otoscopes are still essentially a light source guided down the ear canal by a funnel shaped tip helping us visualise and examine the condition of the canal and eardrum. “Audiology clinics have embraced some or all of these technologies and many integrate them with other digital technologies to send, save, record and communicate images.”
Detecting pathology
Projecting something tiny that’s not illuminated onto a screen helps practitioners see markers and points. “You become better at diagnosing pathology, especially pathologies that need to be managed, like cholesteatoma,” Chiam says.
“Video otoscopes are fantastic in powering up our ability to detect pathology early, train colleagues and patients, and bring in expertise and communication”.
Digitalisation means audiologists can share what they see and measure across teams and borders. “I can communicate with my surgeons, share videos and images, ask for advice, and discuss cases with specialist interest groups or a university on the other side of the world and that’s huge.
“Conversely, an expert can sit in front of a global audience and show and tell, this is what a cholesteatoma looks like, or what an eardrum looks like when it’s oscillating with a tiny tonic tensor tympani or stapedial tendon response.”
She’s currently discussing cases with ENT specialists in Germany and Belgium.
“What is most important though is empowerment and education of patients. When a patient sees a giant blob of wax or a hole in the eardrum, they’re motivated and understand why we’re sending them for that medical appointment,” she adds. “The fascination of seeing inside a part of their anatomy they never ordinarily see adds understanding and personalisation to the diagnostic and rehab process.”
Chiam uses different technologies for different purposes. “My VoroTek Voroscope I love for wax removal. The narrow visual axis and binocular view help me move with finesse and accuracy in a small, deep space.
“I also use it in ears where I need that extra bit of clarity and depth to help grasp what’s happening especially when trying to understand audiograms with possible middle ear pathology such as cholesteatoma.
“Additional diagnostic power and confidence in these tricky cases can help early detection and diagnosis.”
Capturing images has expanded into manufacturing through digital scanning. If Chiam does an ear scan using a 3D ear scanner to provide an impression for a hearing aid or custom earplug, it’s emailed to a manufacturer immediately, reducing turnaround. Scans are saved on her database for a quick replacement if a patient loses a device.
Using pressure is another way to visualise movement of the eardrum. Chiam’s liaising with a university professor in France to provide data assisting in standardising and tuning a pressure sensor for objectively measuring movement of middle ear tendons.
Adding machine learning to imagery also scales up diagnostic skills through apps that help visualisation. For example, the University of Pittsburgh free iPhone app – Pitt CMU iTM – uses AI to accurately diagnose acute otitis media. It assesses a video of the eardrum captured by connecting an otoscope to a smartphone camera.
Similarly, in Australia, DrumBeat.ai leverages advanced AI algorithms to analyse and classify ear disease from otoscopic images in remote areas. Healthcare workers use a digital video otoscope to capture images which the app analyses and triages.
Difference between deafness and hearing
In Chiam’s clinic, recent cases highlight the importance of visualisation technology – and an ability to act on what’s discovered.
She recently saw a patient with profound sudden sensorineural hearing loss. “Six months ago, his GP treated him for otitis media and flu and didn’t organise audiology. It’s possible AI imagery recognition could have helped this GP and with more accurate diagnosis, this patient may have received steroid treatment within the window needed for possible recovery,” Chiam says.
“Now it’s total hearing loss and I’m referring him for surgery for a cochlear implant or bone-anchored hearing aid so the difference in outcome is huge.”
She was recently in theatre during a cochlear implant for a patient with total hearing loss and a tumour entwined around the auditory nerve in his better ear. His dead ear was implanted, and an excellent outcome was needed, knowing he would go deaf in the other ear.
“With the Cochlear SmartNav navigation tool we could watch on an iPad screen and guide in real time the implant being slowly inserted so there’s less trauma, and we could see each electrode’s response being activated and tested,” she says.
“I could send myself results for each electrode I measured during surgery, ready for the patient to attend ‘switch on’ in my clinic. He’s performing exceptionally well very early on. For compromised patients, every little bit counts, and this visualisation technology played a role.”
Trends in ENT surgery
In ear, nose and throat (ENT) surgery, exoscopes, also called robotic microscopes, are making headway. An exoscope is a digital, high-definition camera system that provides a high-resolution, magnified view of the surgical field to external monitors, offering an alternative to traditional operating microscopes.
The exoscope’s optical scope sits outside the patient’s body, not requiring the surgeon to look through eyepieces, allowing for a broader field of view and better ergonomics. This reduces the need for surgeons to maintain uncomfortable positions for extended periods.
The team can see the procedure on large screens as the camera captures the surgical field and transmits images to high-resolution monitors. Many exoscopes offer 3D capabilities, providing a realistic representation of depth and anatomy.
The system is often mounted on a robotic arm and controlled by the surgeon with a foot pedal, offering hands-free navigation. It can also be worn as a VR type headset. Improved visualisation is enabled through a broader and brighter image, allowing surgeons to navigate and see structures around the corner.
Sydney ENT surgeon Professor Payal Mukherjee says it’s an exciting time with changing technology. She’s a big advocate for exoscopes and is pushing for hospitals to fund them due to healthcare workers, particularly surgeons, having the highest rates of work-related musculoskeletal injuries. This is because they look down for extended periods through standard surgical microscopes, causing neck and back strain.
The public health system spends a decade in costs and skills to train a medical graduate to become a surgeon, yet their careers are often cut short due to these injuries, she adds.
“Ear surgeons and other microsurgeons use microscopes for long periods causing injury to their necks and backs as they’re hunched over for hours,” she says. “This impacts patient safety – if a surgeon operating on you is in pain and distracted, they’re not going to be able to do the best surgery.
“Many senior surgeons need back and spine surgery due to operating; hospitals have a duty of care to patients but also to doctors.” Prof Mukherjee says to get funding approved for very expensive equipment at hospitals for your specialty is a barrier. “But this activity is limiting the life of the surgical workforce. Funding this equipment is in the best interests of surgeons, hospitals and patients,” she adds.
With colleagues, ENT registrar Dr Ankit Ajmera and physiotherapist-turned-ENT surgeon Associate Professor Raewyn Campbell, Prof Mukherjee performed a study at Sydney Adventist Hospital in 2025.
They compared a new 3D head-mounted exoscope with a standard fixed operating microscope and found the exoscope resulted in less musculoskeletal strain, reducing the risk of musculoskeletal injury from high to moderate.
“Visualisation was equivalent to the operating microscope but immediately, we were sitting neutral, were more comfortable and not in as much pain,” she says. “The VR-type headset meant a lot of eye control with your eyes looking up or down controlling zoom, magnification and focus.”
A lighter headpiece would improve comfort, she adds. Other things that could help include hand rests for surgical chairs to rest elbows and arms on, reducing fingertip tremor, important for operating in the ear’s tiny space.
Prof Mukherjee says surgical equipment was traditionally made for men, but more women are surgeons now who tend to have smaller hands and be shorter. Women’s bodies must fit into men’s surgical equipment which doesn’t consider changes with pregnancy or menopause, she adds.
“Different microscopes have different pluses and minuses and we’re running a workshop in February at Sydney Adventist Hospital with Advanced Bionics, for female cochlear implant surgeons in Asia Pacific to look at different exoscopes and microscopes,” she says.
“There are numerous exoscopic systems. The one we studied was a robotic system but others have lighter goggles which are the same idea and disconnect the head from the visualisation field.
“There’s lots happening in this space and even in the past 12 months, we’ve seen other companies bring out different varieties of the same concept. Device companies that look at visualisation are really exploring this as an unmet need.”
Prof Mukherjee says other systems incorporate augmented reality which overlays 3D anatomy in the visual field so you can see critical structures appearing.
Teleaudiology advances
Telehealth is another advance making inroads into ear visualisation especially in remote areas, says Ear Science Institute Australia research manager, Adjunct Associate Professor Rob Eikelboom. He initially worked at Lions Eye Institute in image processing and analysis of the retina and optic disc via telehealth before moving to Ear Science in 2001.
Most of his work for the past 24 years has been in hearing outreach and epidemiology in East Pilbara, looking at the health of the population, association of hearing loss and tinnitus with other health conditions like mental health, and device use.
Video otoscopes have been useful in remote areas, he says. “Parents, carers, kids and their classmates can see what’s happening inside their ears which is great because it takes away the fear factor,” he says.
“It’s a great educational tool for showing wax or a hole in their eardrum compared with their other healthy ear; here’s a sign that you used to have a bad ear infection and it’s healed or here’s wax we can’t see through, so we need to have it cleaned.”
Images have been shared with nurses and ENT surgeons in Perth and elsewhere to ensure correct diagnosis and treatment. Adj/Assoc Prof Eikelboom imagines ear visualisation via telehealth – where a health worker onsite uses a video otoscope remotely and sends images to a specialist elsewhere – will grow.
While the technology’s great, it’s the people that make the system work, he says. “I’ve seen equipment sitting in a cupboard because nobody knows what to do so it’s all about people’s willingness to pick it up and have a go,” he adds.
Ear Science also has a Zeiss operating microscope and a VoroTek O Scope in the Pilbara to boost visualisation especially for wax removal.
Adj/Assoc Prof Eikelboom would love future technology to look through the eardrum and into the middle ear. AI or machine learning to detail what an image is would also be beneficial, he says.
“Computer aided diagnosis of what the picture is showing, answering if there is disease, wax, an eardrum hole and how big it is, or if there’s scarring, could be complemented by what audiologists measure using tympanometry to build a picture of what’s happening,” he says.
“I think more people should use video otoscopes in clinics because they’re a fantastic teaching tool for patients.”
Adj/Assoc Prof Eikelboom is also an advocate for more GP training in otoscopy especially video otoscopes as they’re user friendly and not “in the patient’s face as much”. “Seeing an image on a screen is a distraction for a wriggling one-year-old,” he adds.
Is OCT the new frontier?
Also on the horizon to improve ear visualisation is OCT (optical coherence tomography), a non-invasive imaging tool used in ophthalmology and optometry to produce 3D images of the back of the eye.
In 2024 University of Southern California researchers including ENT surgeon, Professor John Oghalai and Professor of Otolaryngology – Head and Neck Surgery Brian Applegate, developed a hand-held portable device integrating high-resolution OCT with a traditional otoscope. This allowed clinicians to view the surface and deeper structures of the tympanic membrane and middle ear.
OCT uses light waves to scan tissue and create 3D images, similar to how ultrasound produces images using sound waves. But it produces higher-resolution images than ultrasound, making it a safe option with no risk to hearing or balance.
The researchers claim it is a significant step forward in imaging technology for ear health and could readily fit into the hearing clinic workflow, providing relevant new information for diagnosing and managing tympanic membrane and middle ear disease.
Tests on more than 100 patients in a clinical trial demonstrated its ability to reveal pathological features previously invisible using standard otoscopy. Clinical applications included monitoring myringitis, tympanic membrane perforation healing, retraction pockets, and subsurface scarring air pockets.
In 2025 the team fitted an OCT device onto an operating microscope to take images during surgery of tissues and cells in the inner ear through the dense bone that surrounds it. It reliably detected fluid imbalance in the inner ear, correlated with hearing loss severity.
“These findings are exciting because hearing loss can happen suddenly, and we often don’t know why. OCT offers a way to explore the underlying cause and potentially guide treatment,” Prof Oghalai says. He hopes it will lead to better understanding of pathology of Menière’s disease, sudden sensorineural hearing loss, cochlear hydrops, autoimmune inner ear disease, and vestibular schwannoma tumours.
