OBJECTIVE: The COVID-19 pandemic has spurred a growing demand for telemedicine. Artificial intelligence and image processing systems with wireless transmission functionalities can facilitate remote care for otitis media (OM). Accordingly, this study developed and validated an algorithm-driven tele-otoscope system equipped with Wi-Fi transmission and a cloud-based automatic OM diagnostic algorithm.
METHODS: Prospective, cross-sectional, diagnostic study.
METHODS: Tertiary Academic Medical Center.
METHODS: We designed a tele-otoscope (Otiscan, SyncVision Technology Corp) equipped with digital imaging and processing modules, Wi-Fi transmission capabilities, and an automatic OM diagnostic algorithm. A total of 1137 otoscopic images, comprising 987 images of normal cases and 150 images of cases of acute OM and OM with effusion, were used as the dataset for image classification. Two convolutional neural network models, trained using our dataset, were used for raw image segmentation and OM classification.
RESULTS: The tele-otoscope delivered images with a resolution of 1280 × 720 pixels. Our tele-otoscope effectively differentiated OM from normal images, achieving a classification accuracy rate of up to 94% (sensitivity, 80%; specificity, 96%).
CONCLUSIONS: Our study demonstrated that the developed tele-otoscope has acceptable accuracy in diagnosing OM. This system can assist health care professionals in early detection and continuous remote monitoring, thus mitigating the consequences of OM.

To systematically evaluate the development of Machine Learning (ML) models and compare their diagnostic accuracy for the classification of Middle Ear Disorders (MED) using Tympanic Membrane (TM) images.
PubMed, EMBASE, CINAHL, and CENTRAL were searched up until November 30, 2021. Studies on the development of ML approaches for diagnosing MED using TM images were selected according to the inclusion criteria. PRISMA guidelines were followed with study design, analysis method, and outcomes extracted. Sensitivity, specificity, and area under the curve (AUC) were used to summarize the performance metrics of the meta-analysis. Risk of Bias was assessed using the Quality Assessment of Diagnostic Accuracy Studies-2 tool in combination with the Prediction Model Risk of Bias Assessment Tool.
Sixteen studies were included, encompassing 20254 TM images (7025 normal TM and 13229 MED). The sample size ranged from 45 to 6066 per study. The accuracy of the 25 included ML approaches ranged from 76.00% to 98.26%. Eleven studies (68.8%) were rated as having a low risk of bias, with the reference standard as the major domain of high risk of bias (37.5%). Sensitivity and specificity were 93% (95% CI, 90%-95%) and 85% (95% CI, 82%-88%), respectively. The AUC of total TM images was 94% (95% CI, 91%-96%). The greater AUC was found using otoendoscopic images than otoscopic images.
ML approaches perform robustly in distinguishing between normal ears and MED, however, it is proposed that a standardized TM image acquisition and annotation protocol should be developed.
NA Laryngoscope, 133:732-741, 2023.

To create a new strategy for monitoring pediatric otitis media (OM), we developed a brief, reliable, and objective method for automated classification using convolutional neural networks (CNNs) with images from otoscope.
Prospective study.
An otoscopic image classifier for pediatric OM was built upon the idea of deep learning and transfer learning using the two most widely used CNN architectures named Xception and MobileNet-V2. Otoscopic images, including acute otitis media (AOM), otitis media with effusion (OME), and normal ears were obtained from our institution. Among qualified otoendoscopic images, 10,703 images were used for training, and 1,500 images were used for testing. In addition, 102 images captured by smartphone with WI-FI connected otoscope were used as a prospective test set to evaluate the model for home screening and monitoring.
For all diagnoses combined in the test set, the Xception model and the MobileNet-V2 model had similar overall accuracies of 97.45% (95% CI 96.81%-97.94%) and 95.72% (95% CI 95.12%-96.16%). The overall accuracies of two models with smartphone images were 90.66% (95% CI 90.21%-90.98%) and 88.56% (95% CI 87.86%-90.05%). The class activation map results showed that the extracted features of smartphone images were the same as those of otoendoscopic images.
We have developed deep learning algorithms for the successfully automated classification of pediatric AOM and OME with otoscopic images. With a smartphone-enabled wireless otoscope, artificial intelligence may assist parents in early detection and continuous monitoring at home to decrease the visit frequencies.
NA Laryngoscope, 131:E2344-E2351, 2021.

Otitis media (OM) or middle ear infection is one of the most common diseases in young children around the world. The diagnosis of OM is currently performed using an otoscope to detect middle ear fluid and inflammatory changes manifested in the tympanic membrane. However, conventional otoscopy cannot visualize across the tympanic membrane or sample middle ear fluid. This can lead to low diagnostic certainty and overdiagnoses of OM. To improve the diagnosis of OM, we have developed a short-wave infrared (SWIR) otoscope in combination with a protease-cleavable biosensor, 6QC-ICG, which can facilitate the detection of inflammatory proteases in the middle ear with an increase in contrast. 6QC-ICG is a fluorescently quenched probe, which is activated in the presence of cysteine cathepsin proteases that are up-regulated in inflammatory immune cells. Using a preclinical model and custom-built SWIR otomicroscope in this proof-of-concept study, we successfully demonstrated the feasibility of robustly distinguishing inflamed ears from controls (p = 0.0006). The inflamed ears showed an overall signal-to-background ratio of 2.0 with a mean fluorescence of 81 ± 17 AU, while the control ear exhibited a mean fluorescence of 41 ± 11 AU. We envision that these fluorescently quenched probes in conjunction with SWIR imaging tools have the potential to be used as an alternate/adjunct tool for objective diagnosis of OM.

BACKGROUND: Microscopic type-1 tympanoplasty (T1T) is a classical method for the treatment of chronic otitis media. However, it has its limitations. The development of otoendoscopy provided a new method for T1T.
OBJECTIVE: To investigate the difference between endoscopic T1T and microscopic T1T.
METHODS: Seventy-four patients who underwent T1T were evaluated retrospectively. About 52 cases underwent endoscopic T1T, and 22 cases accepted microscopic T1T. Parameters including operative duration, incision size, graft site, duration of postoperative hospitalization, visual analog scale (VAS) score, complications, hearing improvement, and expenses were compared.
RESULTS: Operative duration of endoscopic T1T (47.0 ± 8.2 min) was shorter than microscopic T1T (58.0 ± 9.3 min) (p < .05). The VAS score under endoscopic T1T (1.5 ± 0.2) was lower than microscopic T1T (5.6 ± 0.4) (p < .05). There was no complication during endoscopic T1T, but damage to the chorda tympani nerve (one case) was noted for microscopic T1T. There was no difference in hearing improvement between endoscopic (15.0 ± 1.5 dB) and microscopic T1T (16.0 ± 1.1 dB). Duration of postoperative hospitalization and expenses were lower for endoscopic T1T.
CONCLUSIONS: Endoscopic T1T is a minimally invasive surgery with similar graft success rate, comparable hearing improvement, fast recovery, low cost, and high patient satisfaction compared to microscopic T1T.

OBJECTIVE: To evaluate the feasibility of a two-stage screening strategy for otitis media with effusion (OME) in pre-school and school children. The risk factors of OME were also studied.
METHODS: One hundred and eighty-nine children aged 4-8 years were recruited. The two-stage screening consisted of an on-site screening with a portable otoscopy along with a questionnaire to both diagnose children with OME and identify children at risk, and a standard screening performed at a regional hospital for final diagnosis. The prevalence detected from the two-stage screening approach was compared to the actual prevalence.
RESULTS: The detection rate of OME through the two-stage screening approach was not significantly different from the actual prevalence rate (12.7% vs. 13.4%, P = 0.847). Children from the urban area had a lower risk for OME than that from the rural area (P = 0.007, odds ratio (OR) = 0.28, 95% confidence interval (CI): 0.11-0.74). Compared to childcare dining, family dining helped to reduce the chance of OME (P < 0.001, OR = 0.15, 95% CI: 0.06-0.38).
CONCLUSIONS: The two-stage screening strategy was effective for screening for OME among pre-school and school children. It can be used in rural areas that have a high prevalence of OME and limited medical resources.

To evaluate the efficacy of acellular collagen scaffold (ACS) in combination with basic fibroblast growth factor (bFGF) for the repair of traumatic tympanic membrane (TM) perforation in a rat model.
A prospective controlled animal study in a rat model of traumatic TM perforation.
Tertiary medical center.
Sprague-Dawley rats (N = 84) with unilateral traumatic perforation of the right TMs were randomized to receive ACS, bFGF, ACS in combination with bFGF (ACS/bFGF), or nothing (spontaneous healing without any interventions as a control group). The healing outcomes were evaluated by otoscopy, optical coherence tomography, histology, and transmission electron microscopy at 1, 2, and 4 weeks postoperatively. The hearing outcomes were assessed with auditory brainstem response testing.
ACS/bFGF resulted in higher perforation closure rates at an earlier stage than spontaneous healing, ACS, and bFGF. Based on histology, optical coherence tomography, and transmission electron microscopy, a trilaminar structure and uniform thickness with mature, densely packed collagen fibers were seen in the ACS/bFGF group. Auditory brainstem response evaluation also showed that ACS/bFGF treatment promoted faster functional hearing recovery as compared with the control group.
ACS is an effective TM scaffold and a carrier for bFGF. ACS/bFGF improves the TM closure rate, results in better-reconstructed TMs, and improves hearing. ACS/bFGF serves as a potential substitute for TM perforations in clinical settings.

OBJECTIVE: To explore the rule of extended high-frequency (EHF) audiometry recovery in patients with acute otitis media.
METHODS: From January 2016 to July 2019, patients with acute otitis media in the outpatient department of otology were studied. The diagnosis was made according to the otoscopy and acoustic impedance tests, and antibiotics and other treatment programs were given. The patients were followed up to compare the effects of different recovery time on extended high-frequency audiometry in patients with acute otitis media.
RESULTS: 146 patients with acute otitis media (69 in the left ear and 77 in the right ear) were selected for observation and follow-up. The patients were divided into three groups according to the time from the onset to the disappearance of hyperacusis and earache symptoms: ≤ 5 days group (26 patients, 17.8%), 6-10 days group (74 patients, 50.7%), and > 10 days group (46 patients, 31.5%). The threshold of EHF in the study group was significantly higher than that in the control group in the early stage. According to the study design for follow-up, we found that with the prolongation of the duration of acute otitis media, the extended high frequency of different groups had different changes.
CONCLUSIONS: Our results show that the recovery time of EHF in patients with acute otitis media was later than that of the standard audiogram and was closely related to the course of the disease. This is of great significance for discovering the hidden hearing loss of the patients and taking the treatment plan as soon as possible.

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Objective: (1) To test the feasibility of the Rapid Assessment of Hearing Loss (RAHL) survey protocol in Malawi (Ntcheu); (2) To estimate the prevalence and probable causes of hearing loss (adults 50+).Design: Cross-sectional population-based survey.Study sample: Clusters (n = 38) were selected using probability-proportionate-to-size-sampling. Within each cluster, 30 people aged 50+ were selected using compact-segment-sampling. All participants completed smartphone-based audiometry (hearTest). Prevalence was estimated using WHO definitions (PTA of thresholds 0.5, 1, 2, 4 kHz in the better ear of >25 dB HL (any) and >40 dB HL (≥moderate)). Otoscopy and questionnaire were used to assess probable causes. Participants with hearing loss and/or ear disease were asked about care-seeking and barriers.Results: Four teams completed the survey in 24 days. 1080 of 1153 (93.7%) participants were examined. The median time to complete the protocol was 24 min/participant. Prevalence of hearing loss was 35.9% (95% CI = 31.6-40.2) (any level); and 10.0% (95% CI = 7.9-12.5) (≥moderate). The majority was classified as probable sensorineural. Nearly one third of people (30.9%) needed diagnostic audiology services and possible hearing aid fitting. Hearing aid coverage was <1%. Lack of perceived need was a key barrier.Conclusion: The RAHL is simple, fast and provides information about the magnitude and probable causes of hearing loss to plan services.