The external ear is the gateway to the sense of hearing. In the profession of audiology, clinical details of visual examination of the pinna, concha, external auditory canal (EAC) and tympanic membrane (TM) have received significantly less attention than functional assessment of auditory capacity using psychoacoustic, electro-acoustic and electro-physiological techniques. Recent cost-effective developments in endoscopic optics and miniature video camera technology have made video endoscopic otoscopy or VIDEO OTOSCOPY (VO) accessible to audiologists in a practical way. VO appears at a time of clinical need generated by: a) audiologists fitting the majority of custom corrective amplification in all contexts, b) audiologists fitting those hearing aids deeper within the EAC, c) cerumen management emerging within the scope of audiological practice and , perhaps most significantly, d) a growing recognition of audiology as a cost-effective resource for direct referral of patients with suspected hearing loss by primary care physicians, the "gatekeepers" of health care. [8,15,16,17,18,19]

Basic categories of VO applications for audiological practice are shown in Table 1. These categories may be appraised relative to their direct or indirect value for the patient, the Primary Care and ENT physician and the audiologist. For example, VO benefits the audiologist by verifying acoustic and physical access to the EAC and TM for both hearing evaluation and hearing aid fitting. It can also be used in direct and referred cerumen management. For example, with referred patients, the physician benefits from the high quality of clinical documentation provided by the audiologist. VO provides detailed clinical information correlating pathology and conditions observable in the EAC and at the TM with audiological findings and the outcome of medical treatment. The patient may benefit specifically from a better understanding of their ear, of any observable otic condition that may exist requiring treatment and in hearing aid fitting and orientation. The audiologist also benefits from an enhanced appreciation, by both physician and patient, of his or her technological skills demonstrated in the application of VO.

In early medical practice, ears were examined by direct observation [Fig. 01]. This provided a view of the pinna, concha and outer canal recesses limited by tortuosity of the meatus and available natural or flame-based light. Use of a speculum [Fig. 02] enlarged the meatal aperture and straightened the canal. The concave perforated head mirror [Fig. 03] allowed light from an external source to be reflected along a concentric viewing axis through hand-held speculum. [Fig. 04] This increased the viewing depth and allowed physical access for treatment within the canal. [Fig. 05].

At this point, otoscopy took two developmental pathways, one for visual examination with parallel treatment (operating otoscopy), the other for visual examination with serial treatment (diagnostic otoscopy). Figure 06 presents one of the first devices for concurrent illumination and diagnostic examination of the recesses of the human external auditory canal. Alternately attributed to Brunton (1861) and Clark (1857), this otoscope used a perforated angled mirror to reflect the light from a lamp flame into the ear canal. The canal and tympanic membrane were viewed through the mirror’s central perforation. An embellishment of the diagnostic otoscope, the Siegle examining otoscope [Fig. 07] required a collimated, reflected light source. With the addition of a rubber bulb for introducing positive or negative pressure into the sealed EAC, both intactness and mobility of the TM could be observed. Figure 08 shows one of the earliest self-powered otoscopes manufactured by Welch-Allyn in 1923, using two D-size cells.

The light source / head mirror / speculum combination evolved into the open head or operating otoscope, designed for monocular otoscopy with open access to introduce instruments into the ear canal for removal of cerumen and topical treatment. Figure 09 demonstrates contemporary versions of the (A) diagnostic otoscope, (B) Siegle otoscope (C) and operating otoscope. Operating otoscopy reached its present level of optical quality in the 1950s. Pioneered by Zeiss, the stereoscopic operating microscope had a collimated light source for magnified three dimensional examination with sterile field surgical exploration of the ear canal, tympanic membrane and middle ear spaces. [Fig. 10] The steroscopic operating microscope also features a takeoff tube for a second observer, 35mm or video camera.

Until the advent of the rigid rod otoscope by Hopkins in the 1960’s, a device resembling a truncated nasopharyngoscope [Fig. 11], otoscopic fields of view of the TM were limited by the diameter and insertion depth of the otic speculum, in turn limited by the diameter of the EAC. In flexible fiber optic endoscopy, as used in direct laryngoscopy, both source light and clinical image are carried by relatively long, separate bundles parallel fiber optical strands arranged concentrically. In contrast, the endoscopic rod otoscope uses solid glass rod lenses in a rigid, relatively short, narrow diameter [2-4 mm], tubular casing to transmit the image directly to the observation point. Field illumination for the rod otoscope is provided from a remote high intensity light source transmitted via a coaxially peripheral fiber optic bundle. The rod otoscope [Fig. 12] may be situated medially within millimeters of the TM. As only source light waves are passed through the fiber optic bundle, the result is a thermally cool field of illumination.

Introduced to the audiological market by Jedmed in 1983, the video otoscope presented an unprecedented opportunity for practitioners to examine a large video field monoscopic view of the external ear and tympanic membrane with a degree of definition heretofore not achievable with a hand-held otoscope. In video otoscopy, a miniature color video camera is substituted for the eye at the rod lens otoscope focal point. Consequently, enlarged, detailed, full color, monoscopic, as opposed to stereoscopic, images of the EAC and TM may be viewed on a television monitor. The size of the televised image is limited only by the size of the TV monitor. Color quality and resolution of the image are a qualitative function of the rod optical lenses, video format, camera and monitor capabilities. Figures 13 to 15a present clinical video otoscopy systems from U.S. auppliers: MedRx, Starkey, Welch-Allyn / GSI and IPC, respectively. Suitcase / portable VO [Fig. 16] systems are available as well.

A block diagram of contemporary video otoscopy system components is illustrated in Figure 17. The components of a video otoscope examination head are shown in Fig. 18. The endoscope can be easily detached and replaced with a macro lens. When used endoscopically, the term Video Oto-Endoscopy (VOE) is applicable, to be differentiated from Video Oto-Macroscopy (VOM) where a macro-lens presentation of the entire external ear is obtained with or without a hearing aid. A detailed discussion of video otoscopy instrumentation has been presented elsewhere by the author [16].

Video otoscopy facilitates identifying conditions of the pinna, concha, external auditory canal (EAC) and of the middle ear. These conditions, manifest at the tympanic membrane (TM) [Table 2], may influence physical and acoustic access for audiological diagnostic and hearing aid related procedures. Pinna and concha conditions include anomalies [Fig. 1_01, 1.02], dermatologic pathology [Fig 1.03] and neoplasms [Fig. 1_04]. Canal conditions can be categorized as: anomalies [Fig. 1_05], endogenous residue [Fig. 1_06], exogenous factors [Fig. 1_07], external otic pathology [Fig. 1_08], TM perforations [Fig. 1.09] and status post-middle ear surgery [Fig. 1.10].

In many instances, one is able to correlate observed VO findings at the TM with pure tone conductive overlays and tympanometric findings. Minute TM perforations can be visually differentiated from monomeric scars by integrating the Siegle maneuver into the VO examination. A large monomeric scar can often be associated with a tympanogram demonstrating a high static acoustic admittance. In the absence of effusion or inflammation, observed perforations may account for flat tympanograms and enlarged equivalent EAC volume measures. TM scarring, retraction and visible middle ear effusion levels can be associated with tympanometric and audiometric findings. In other cases, however, the relationship between VO and audiometric or tympanometric findings can be more complex [Fig. 1_11]. Figures 1_12 -14 illustrate the relationship between VO and audiological findings on a 52 year old adult male patient with Downs syndrome.

A major point of entry into the professional hearing health care system, the audiologist is uniquely situated to identify pathology requiring medical referral, evaluation and treatment. Video otoscopy is a tool for visual identification and documentation. VO serves as a motivational enhancement to the patient to seek the audiologically recommended medical consultation [Fig. 1_15; 1_16]. When forwarded to the ENT or primary care physician, the VO printout serves to delineate the specific area of concern. In potential hearing aid patients, the pinna and concha, as well as the EAC, should be VO -screened for dermatological abnormalities. The EAC and TM should be examined for conditions that not only influence the fitting of a hearing aid but which may require medical attention. Even Eustachian tube-related problems may be observed dynamically via VO. Fig. 1_16 demonstrates the consequences of a patulous Eustachian tube note on VO. The degree of TM displacement, in response to Valsalva, Toynbee and Politzer maneuvers can be observed.

Video otoscopy is an invaluable tool for communicating clinical information about the ear. However, rather than deluging the physician with gratuitous, undocumented videographs of the EAC and TM, the audiologist must identify and describe with accepted medical terminology, though not necessarily diagnosing, otic conditions noted in the video otoscopic examination.

VO is valuable for the audiologist in focusing the referred physician’s attention on a specific otic condition requiring medical diagnosis and treatment. [Fig. 2_01] In some cases, the need for referral may precede the actual audiological evaluation. For example, an EAC occlusion, dermatological condition or acute outer or middle ear pathology may require treatment with resolution prior to the evaluation of hearing, taking of an ear impression and fitting of a hearing aid. [Fig. 2_02]

In those cases where the patient is known to a physician, referring or otherwise, VO is helpful in establishing a high level of professional discourse concerning physical features of the patient’s ear(s). Known anatomical abnormalities and pathological conditions already under medical treatment may be documented for the PCP or ENT. [Fig. 2_03, 2_04, 2_05]

For those cases under ongoing medical care for specific otic pathology, the audiologist can take advantage of audiologically-related visits to document visible changes in the ear condition for his/her own records and those of the treating physician. Figure 2_06a-f illustrates the treatment time course in the left ear of a 77 year old male patient with chronic serous otitis media. The fluctuating conductive overlay on a moderate sensorineural loss necessitated frequent changes in the custom hearing aid fitting. In consultation with the ENT, a decision was made to stabilize hearing with a pneumatic equalization (PE) "T" tube. Over a five month period the tube was patent in situ (a), extruded (b-d), left a sizeable posterior inferior perforation (e) and spontaneously healed within three months leaving a monomeric scar (f). The "T"-tube is shown in figure 2_07.

Figures 2_08 presents the left ear of a 42 year old female patient who experienced a sharp unilateral otalgia associated with an airplane landing. The patient was seen one week after the precipitating incident. While no shift in the essentially sensorineural hearing thresholds or normal tympanogram was noted, an intralaminar hemorrhage was observed in the posterior inferior quadrant and the superior anterior annular area of the left TM. The patient was referred with VO documentation for ENT consultation. The VO images show the condition resolving spontaneously over three weeks. Figure 2_09 demonstrates the lateral migration of a left myringotomy scar over a seven week post-operative monitoring period . Figure 2.10 illustrates the left ear of a 57y M patient 20 years post-radical mastoidectomy, AS. A) Acute OE/ME infection treated with gentian violet. B) AS status post-treatment. Round window niche indicated by arrow.

As e-mail becomes accepted as a medium for clinical data exchange in routine audiological and medical practice, VO images can be transmitted as compressed (.jpg or .gif) attachments to e-mailed reports of audiological findings. The audiologist can transmit progress report VO images to the caretaking physician. Some medical institutions have established telemedicine programs for regions inaccessible to direct medical care. In those cases, via telephone-transmitted images, a hospital-based physician can provide diagnosis and a guidance for some direct treatment of otic pathology at a remote site. For example, such a program employing audiologists at remote sites in northern Maine is described on the Internet <http://www.ume.edu/~ittproj/abstears.htm> [13]

Hearing aid technology has advanced to such an extent that the dispensing audiologist is more likely to encounter morphologically based fitting problems than challenges of an electro-acoustical nature. Video oto-endoscopy (VOE) and video oto-macroscopy (VOM) are valuable techniques in this regard.

Various anatomical variations can prevail in the EAC which may rule out certain hearing aid morphologies for one or both ears. Natural variations of this nature include exostoses [Fig. 3_01], collapsed and tortuous canals, the latter often more zetoid than sigmoid, and stepped canals [Fig. 3_02] which demarcate sharply from an ample cartilaginous portion to an off-axis, narrowed bony segment. VO can be used to observe dynamically the impact of temporo-mandibular joint (TMJ) and facial muscle activity on the lateral EAC anterior-posterior (A-P) dimensions [Fig. 3_03]. Congenital deformities of the pinna, concha and canal can be visually explored for fitting potential. Pathological conditions to be considered include keratomas, other neoplasms {Fig. 3_04], chronic dermatitis and otitis externa. Surgical artifacts include canal plasty, otoplasty, radical and modified radical mastoidectomies, fenestrations and external otic resections secondary to excised malignancies in the periotic area [Fig. 3_05].

Figure 3_06 shows a cotton block placement sequence in an ear post-modified radical mastoidectomy. Figure 3_07 presents a VO monitoring sequence of a real ear measurement (REM) 1.1mm probe tube placement in close proximity to the TM to avoid standing waves within the aided frequency range.

Custom acoustic coupling morphology (shells and molds) can be improved if anatomical deviations are noted with the impression. For example, unless the presence of an impression void due to an exostosis or keratoma is noted, it is likely to be interpreted as a defect and filled in by the shell technician [Fig. 3_08]. Hard-copy VOM images of the hearing aid in situ can be mailed with impression to enhance the laboratory shell technician’s efforts. The VO probe can also be used to probe the amount of elasticity at various depths in the EAC. As indicated above, one can also appraise the impact of TMJ activity of the anterior-posterior dimensions of the lateral external canal..

The VO system can be used to an extra advantage as a costly but highly reinforcing mirror substitute. Techniques of hearing aid insertion [Fig. 3_09] and removal [Fig. 3_10] may be repeated using the macro-lens attachment. Volume control [Fig. 3_11] and T-switch operation [Fig. 3_12] can be demonstrated. Proper hearing aid hygiene can be shown, minimizing risks of user-induced mechanical damage to the transducers [Fig. 3_13]. Finally, with VOM, the cosmetic impact of a fitting can be easily evaluated by the patient from a number of viewing angles. [Fig. 3_14]

Custom completely-in-canal hearing aids encroach into the medial bony EAC and require more intimate epidermal contact in the lateral canal to minimize slit leak and CIC extrusion caused by TMJ and facial muscle movement. With VO one can observe the hearing aid contact-based sites of irritation on the EAC epidermal surfaces. The corresponding ipsilateral or, in some cases, ipsi- and contralateral points on the shell can be ground and recast, if necessary, to reduce or remove the offending points of contact [Fig. 3_15]. The most common points of custom hearing aid irritation are the anterior, medial bony canal junction for CIC aids; the posterior aperture (concha-meatal junction) for canal aids [Fig. 3_16] and the anterior crus helicis for full concha morphology [Fig. 3_17]. The conchal surface of the inferior antitragus is often a source of VO-identifiable abrasion with larger custom instruments [Fig. 3-18]. It is important to not only identify the site of contact-induced lesion, sharing this information concurrently with the patient, but also to use VO to verify its remediation [Fig. 3_19].

It is most reinforcing to demonstrate causality to patients seen for service visits with hearing aids rendered inoperative by excessive organic debris in either microphone or receiver orifice. A patient tirade on hearing aid quality shortcomings can be easily quelled with the proverbial "one [VO] picture...." [Fig 3_20]. Figure 3_21 shows how a video otoscope may be used as a microscope to examine diagnostically hearing aid receivers, microphones and inner connections [Fig. 3_22].

VO provides a tangible reinforcement for patients to follow the audiologist’s recommendation for a medical or hearing aid-related course of action. This is applicable whether the patient is being referred to a primary care physician or dermatologist for medical diagnosis and treatment of an epithelial lesion noted in the external ear or to an ENT physician for other otic pathology. Figure 4_01a illustrates a case of chondrodermatis nodularis helicis, a painful chronic nodular condition involving the pinna or concha. The patient stopped using her canal hearing aid and was reluctant to seek medical attention until she viewed the lesion with VO. Figure 4_01b shows the ear after surgical excision of the lesion with the ear in remission and the aid in situ.

Parents of pediatric patients are appreciative of viewing their child’s PE tubes in situ to see that a chronic or acute otitis media, previously viewed, is resolving with medical treatment. Figure 4_02 shows a time sequence of right TM views of a 4 year old male child with chronic serous otitis media. Parents were reluctant to follow ENT recommendation for PE tubes until they viewed their child’s ear in the acute retracted [Fig. 4_02a] and fluid phases with obvious air bubbles in the serous effusion [Fig. 4_02b]. The parents followed through on the physician-recommended surgery [Figure 4_02c] with satisfactory resolution of the condition. The applications of video otoscopy for counseling of hearing aid patients have been described in the previous section.

Video Otoscopy is clearly within the purview of the audiologist’s scope of practice. Effectively applied, VO reinforces the valid perception, by both patient and physician, of technological contemporaneity and clinical astuteness. Patients appreciate the audiologist using VO to provide them with better understanding of their ear and hearing condition. Pre- and post-treatment VO has a reinforcing effect with patients and parents of pediatric patients. They also value the use of VO as an adjunct to the hearing aid orientation process.

Upon introducing VO into his established private audiological practice, the author received unprecedented complimentary letters from Otolaryngology, Dermatology and Primary Care Medicine physicians. Informed use of VO in discourse with referring and non-referring primary care physicians enhances the potential for future clinical recommendations and referrals.

Once video otoscopy has been incorporated into a practice, audiologists are immediately challenged to learn more about the clinical images with which they are confronted on a daily basis. In order to optimize the potential of VO, the audiologist must become aware of the normal range of external otological differences as well as the categories of pathology requiring medical referral. In order to observe, identify, cross-reference and refer cases to medical resources with cogent clinical commentary, the audiologist must use accurate medical descriptors of visible otic symptomatology. This acquired knowledge of both otologic and dermatologic pathology appearance is essential for the patient’s well-being and for the audiologist’s clinical credibility with referring physicians, both PCP and ENT .

A number of contemporary references containing high resolution 35mm color photographs of external otic pathology are listed in the bibliography [4,5,6,7,12,20]. More detailed decriptions of external otic abnormalities can be found in dedicated ENT [10, 11,14] and audiology [2] texts. These references are invaluable in the process of learning to correlate images with specific conditions.

The author has also published on the Internet World Wide Web an on-line atlas containing hundreds of VO images classified under major headings of Pinna/Concha, EAC, TM and Middle Ear and Hearing Aid Applications with sub-headings within each category. Information and published article reprints are also available about contemporary VO instrumentation and its application in audiological practice. The Uniform Resource Locator (URL) for the Audiology Forum: Video Otoscopy website is:

The technical skills of VOE and VOM image observation, capture, storage and processing via computer are facilitated by training courses offered through instrumentation manufacturers and clinical training institutions. Use of VO as an adjunct to more effective fitting of hearing aids is also an acquired skill facilitated by continuing education programs. At its annual conventions, the American Academy of Audiology continues to offer instructional courses in video otoscopic applications.

With experience, for example, the audiologist learns to use VO-determined status of the EAC to identify and remediate contact sources of physical discomfort and irritation in custom hearing aid morphology. The epidermis of the EAC can be interpreted in essentially a similar manner to the way an oral surgeon uses articulating paper in optimizing the occlusion of a dental filling, cap or crown. Finally, as outlined below, VO can be an invaluable instrumental component of the audiologist’s cerumen management armamentarium.

Audiologists have integrated within their scope of practice the removal of cerumen, which facilitates the requirements of hearing testing and hearing aid fitting. Table 3, including Figures T3_a-d, introduces a 0 to + 3 VO scale for classification of cerumen accumulation based on audiological access requirements. The system facilitates VO documentation by the audiologist of the need for and the outcome of both referred and direct cerumen management. The scale may also be used to describe limitations in audiological access within the EAC from non-ceruminous etiologies; i.e. desquamation, effusion, medication residue and other otic obstructions. Sample report phrasing is shown in Table 4.

For various reasons from risk management considerations through personal preference, not all audiological practices provide direct cerumen management services. Video otoscopy can be used to facilitate both referred and direct audiological management of patient cerumen conditions.

The following steps describe the use of VO in referred cerumen management:

1. Use VO to diagnose the presence of significant cerumen accumulation.

2. VO-demonstrate to the patient the need for prophylaxis and physician referral.

3. Refer the patient to the ENT or PCP with hard copy VO computer image or Polaroid printout in hand. This helps alleviate the not uncommon physician rejoinder after referred cerumenectomy: "...there wasn’t much there!".

4. Use VO to verify post-cerumenectomy status with demonstration to the

patient. Figure 7_01 presents a left ear with a known fenestration cavity pre- and post-cerumenectomy by an ENT physician.

5. If appropriate, counsel the patient on cerumen self-management techniques. Use VO to reinforce effectiveness or lack thereof. Figure 7_02a shows residual, self-applied cerumenolytic foaming in the inferior EAC. Figure 7_02b demonstrates residual cotton fibers from self-treatment with a cotton swab.

6. Recheck for cerumen accumulation during hearing aid service visits and periodic follow-up evaluations.

1. Use VO to observe the degree and quality of ceruminous impaction.

2. VO-demonstrate to the patient the need for prophylaxis to be performed by the audiologist. [Fig. 7_03a-b]

3. Document with computer-stored or Polaroid image and secure patient approval for the procedure.

4. Based on VO observation, determine the most appropriate technique or combination of techniques for cerumen extraction including: curettage, lavage, suction, VO-curettage (Fig. 7_04a-b; 7_05a-d), presoftening with a wetting agent.

5. Verify effectiveness of extraction and document the outcome with VO, especially if there was pain or bleeding in the EAC. Figure 7_06a-b illustrate a sizeable AD subdermal hematoma 24 hours and one month after (referred) cerumen curettage. Figure 7_07 shows an AD post-cerumenectomy (referred) with a small hematoma and contusion with bleeding in an area with multiple exostoses.

6. Routinely monitor cerumen status during routine and follow-up office visits.

The use of Video Otoscopy in either referred or direct cerumen management enhances both the professional scope and quality of audiological practice.

1. Bacon, G., Manual of Otology, Lea Brothers, New York, 1906

2. Ballachanda, B. The Human Ear Canal, Singular Publishing group, San Diego, 1995

3. Bruhl, G. and Politzer, A. Atlas and Eptiome of Otology, W. B. Saunders Philadelphia, 1902

4. Hawke, M., Clinical Pocket Guide to Ear Disease, Lea and Febiger, Philadelphia, 1987 [out of print]

5. Hawke, M. Keene, M. and Alberti, P., Clinical Otoscopy: An Introduction To Ear Diseases,Churchill, Livingstone, Edinburgh, 1990

6. Hawke, M., Otitis Media: A Pocket Guide, Smith, Kline, Beecham; Decker Periodicals, Toronto, 1994

7. Hawke, M. and McCombe, A., Diseases of the Ear: A Pocket Atlas, Starkey Laboratories, Manticore Communications, 1995

8. Hawke, M. and Sullivan, R., "Video otoscopy", Invited seminars delivered at the annual AAA conventions, 1994, 1995. Co-sponsored by Starkey Laboratories

9. Laurens, G., Oto-Rhino-Laryngology for the Student and Practitoner,William Wood, New York, 1919

10. Lucente, DF., Lawson, W., Novick, N., The External Ear, W. B. Saunders,Philadelphia, 1995

11. Perry, E., The Human Ear Canal, C.C. Thomas, Springfield, 1957 [out of print]

12. Pulec, J. and DeGuine, C., "ENT Otoscopic Clinic"; in ENT-Ear, Nose andThroat Journal

14. Selesnick,S., Ed. Diseases of the External Auditory Canal, Otolaryngology Clinics, Volume 26, #5, W.B. Saunders, Philadelphia, 1996.

15. Sullivan, R., "How video otoscopy benefits hearing health care practice", Hearing Instruments, Volume 44, #4, 1993, pp 14-17 [archived at Internet reference: <http://www.li.net/~sullivan/ears.htm>]

17. Sullivan, R., "Video Otoscopy: Basic and advanced systems", Hearing Review, Volume 2, #10, 1995b, pp 12-16 [archived at Internet reference: <http://www.li.net/~sullivan/ears.htm>]

18. Sullivan, R. "Video otoscopy in hearing aid fitting", Hearing Journal, Volume 50, #7, 1997, p.40 [archived at Internet reference: <http://www.li.net/~sullivan/ears.htm.]

19. Sullivan, R., Audiology Forum: Video Otoscopy, Internet site at: <http://www.li.net/~sullivan/ears.htm>

20. Wormald, P., Browning, G., Otoscopy: A Structured Approach, Singular Publishing Group, Inc., San Diego, 1996

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