Otoscopy Learning Module

Rudolf Riester GmbH

Last edited: Jan. 8, 2021

Basics of hearing


Due to the interrelated nature of the ear, nose and throat system, pain in the ear may not originate from the ear itself but may be related to adjacent structures such as the tonsils, the teeth or the temporomandibular joint (TMJ). The visualisation of the external auditory canal, the tympanic membrane and some aspects of the middle ear in a simple outpatient examination known as otoscopy helps diagnose the source of infection, disease or disorder within the ENT system. The otoscope is the instrument routinely used for this purpose both by primary care doctors and ENT specialists.

Importance of training

Several studies have found that otolaryngology training had a significant impact on the success rate of diagnosis when an otoscope was used by a non-specialist (Damery et al., 2018; Oyewumiet al., 2016). Studies on the use of video-otoscopy by untrained healthcare workers or by the general population yielded similar results (Shah et al., 2018, Demantet al., 2019). The importance of otolaryngology training should therefore be emphasized to the non-OTO-HNS clientele making use of an otoscope, whether it be handheld or fitted to a device. This is particularly true with the rapid advance of telemedicine.

Video- or remote otoscopy

Digital, portable and multifunctional medical camera system are available and offer the possibility of fitting an otoscope lens. Thanks to their ease of use and portability, an examiner in a remote location can capture images that will be sent to a physician for evaluation, or even be evaluated live via telemedicine, thereby making specialist healthcare more accessible. Several research studies have already been conducted and support the benefit of video-otoscopy, both in a synchronous and asynchronous manner. A study by Lundberg et al. (International Journal of Pediatric Otorhinolaryngology, 2017) which aimed to compare otoscopy performed by a general practitioner with video-otoscopy performed remotely and assessed asynchronously concluded the following:

“Video-otoscopy performed by a health care facilitator and assessed asynchronously by a general practitioner had similar or better accuracy compared to face-to-face otoscopy performed by a general practitioner.”

Left: Riester’s RCS-100 equipped with the otoscope lens and an image it captured of an eardrum. Riester’s RCS-100 allows for both imaging and videoing of the eardrum and is suitable for synchronous or asynchronous diagnosis.

When comparing ENT specialists and GPs in their usage of a conventional otoscope and video-otoscopy, video-otoscopy also showed great benefit over the conventional way. According to a study by Damery et al. (European Annals of Otorhinolaryngology, Head and Neck Diseases, 2019), diagnoses made by GPs on pathological eardrums were inadequate and significantly different from those of ENTs when using a conventional otoscope. However, the difference was no longer significant when GPs used video-otoscopy to make their diagnosis on pathological eardrums. Yancey et al. (International Journal of Pediatric Otorhinolaryngology, 2019) integrated video-otoscopy and an EMR to hearing screening in their study conducted in a rural area of Kenya. Community health workers with highly variable levels of medical experience were taught the use of automated audiometry, video-otoscopy and the use of an EMR mobile application by an otolaryngologist. The training lasted approximately 2 hours. They then proceeded with the screening of 155 children. The video-otoscopy that they performed combined with the asynchronous diagnosis made by an otolaryngologist lead to the identification of several pathologies: complete cerumen impaction, effusion, retraction, perforation, otitis media, CSOM and fungal otitis media. The authors believe that video-otoscopy is more practical than tympanometry in low- and medium-income countries as it can be performed with less equipment and expertise, in addition to facilitating remote diagnosis where in-person consultations are not possible. They concluded that video-otoscopy can “provide a much needed public health service”, even when performed by community health workers with little to no prior medical experience.

Key take-aways:

Riester's RCS-100 used in telemedicine.


An otoscope is an instrument that allows a user to look into the ear. The cylindrical handle contains the batteries and the head is comprised of two parts: a light source in a conical viewer at one end to insert into the ear and a low-power magnifying lens at the other end to enlarge the viewing area. Most otoscopes allow instrumentation either by making the lens removable or by using an open head system such as Riester’s operation lens. Riester’s operation lens is designed for the illumination and examination of the auditory canal and for insertion of external instruments into the auditory canal. Models that allow adjustable focusing are particularly useful for examiners who are long-sighted. Where increased magnification is necessary, a macro-otoscope can be used (e.g. Riester’s EliteVue fibre optic macro-otoscope). It is simply a variant on the standard otoscope which boosts the magnification to over 5x as opposed to the standard 3x.

Otoscope: handle and speculum

Pneumatic otoscope

An otoscope compatible with pneumatic otoscopy integrates a port to house an insufflation bulb that applies positive and negative air pressure to the eardrum. It is sometimes referred to as pneumatoscope when assembled. When a speculum is simultaneously attached to the head and fitted snugly into the patient’s ear canal, an air-tight chamber is generated. The behaviour and mobility of the tympanic membrane are observed through the lens as the bulb is being pressed. A healthy membrane moves in response to the pressure generated. Pneumatic otoscopy can help with the diagnosis of pathologic eardrums because a perforation, tympanosclerosis or the presence of fluid in the middle ear (key element of the diagnosis of otitis media with effusion) can render the tympanic membrane immobile.

Tip: Depending on the size of the ear canal, it may be difficult to create a seal using readily available specula. This difficulty can be alleviated by using a piece of medical adhesive tape (1/2 inch wide, length approx. 4 inch but may be shorter or longer depending on thickness needed to create seal), placed about 1/4 inch proximal to the tip of the speculum and wrapped around it to create a thick and soft bevel.

What to choose?

Light transmission

Fibre optic filaments are now commonly used in otoscopes. When using a direct light source, the light bulb sits inside the speculum so that its light can be directed into the ear canal. This can obstruct vision through the lens. When fibre optic filaments are used, the light comes from a ring around the speculum, ensuring that the vision is not obstructed. Fibre optic filaments can be used with filament bulbs or LED bulbs alike.

Two ratings are typically used when describing a light source: the colour-rendering index and the Kelvin colour temperature scale.
In short, the higher the Kelvin rating, the whiter the light and the closer to 100 the CRI rating, the higher the quality of its colour compared to the light spectrum we can see thanks to the sun (natural daylight).

Light source

Otoscopes come with either a filament bulb (halogen, xenon) or a LED bulb.

Damery, E. Lescanne, K. Reffet, C. Aussedat, D. Bakhos, Interest of video-otoscopy for the general practitioner, European Annals of Otorhinolaryngology, Head and Neck Diseases, Volume 136, Issue 1, 2019, Pages 13-17, ISSN 1879-7296, https://doi.org/10.1016/j.anorl.2018.10.016.

How Do We Hear? | NIDCD (nih.gov)

Kristen L. Yancey, Loyce J. Cheromei, Jackie Muhando, Jim Reppart, James L. Netterville, Asitha D.L. Jayawardena, Pediatric hearing screening in low-resource settings: Incorporation of video-otoscopy and an electronic medical record, International Journal of Pediatric Otorhinolaryngology, Volume 126,2019, 109633, ISSN 0165-5876, https://doi.org/10.1016/j.ijporl.2019.109633.

Malene Nøhr Demant, Ramon Gordon Jensen, Mahmood F. Bhutta, Gunnar Hellmund Laier, Jørgen Lous, Preben Homøe, Smartphone otoscopy by non-specialist health workers in rural Greenland: A cross-sectional study, International Journal of Pediatric Otorhinolaryngology, Volume 126, 2019, 109628, ISSN 0165-5876, https://doi.org/10.1016/j.ijporl.2019.109628.

Manan Udayan Shah, Maheep Sohal, Tulio A. Valdez, Christopher R. Grindle, iPhone otoscopes: Currently available, but reliable for tele-otoscopy in the hands of parents?, International Journal of Pediatric Otorhinolaryngology, Volume 106, 2018,Pages 59-63, ISSN 0165-5876, https://doi.org/10.1016/j.ijporl.2018.01.003.

Modupe Oyewumi, Michael G. Brandt, Brian Carrillo, Adelle Atkinson, Karl Iglar, Vito Forte, Paolo Campisi, Objective Evaluation of Otoscopy Skills Among Family and Community Medicine, Pediatric, and Otolaryngology Residents, Journal of Surgical Education, Volume 73, Issue 1,2016, Pages 129-135, ISSN 1931-7204, https://doi.org/10.1016/j.jsurg.2015.07.011.

Pneumatic Otoscope Examination: Overview, Indications, Contraindications (medscape.com)

Thorbjörn Lundberg, Leigh Biagio de Jager, De Wet Swanepoel, Claude Laurent, Diagnostic accuracy of a general practitioner with video-otoscopy collected by a health care facilitator compared to traditional otoscopy, International Journal of Pediatric Otorhinolaryngology, Volume 99,2017, Pages 49-53, ISSN 0165-5876, https://doi.org/10.1016/j.ijporl.2017.04.045.

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