Pediatric tympanostomy tube assessment via deep learning.

PURPOSE: Tympanostomy tube (TT) placement is the most frequently performed ambulatory surgery in children under 15. After the procedure it is recommended that patients follow up regularly for "tube checks" until TT extrusion. Such visits incur direct and indirect costs to families in the form of days off from work, copays, and travel expenses. This pilot study aims to compare the efficacy of tympanic membrane (TM) evaluation by an artificial intelligence algorithm with that of clinical staff for determining presence or absence of a tympanostomy tube within the TM. METHODS: Using a digital otoscope, we performed a prospective study in children (ages 10 months-10 years) with a history of TTs who were being seen for follow up in a pediatric otolaryngology clinic. A smartphone otoscope was used by study personnel who were not physicians to take ear exam images, then through conventional otoscopic exam, ears were assessed by a clinician for tubes being in place or tubes having extruded from the TM. We trained and tested a deep learning (artificial intelligence) algorithm to assess the images and compared that with the clinician's assessment. RESULTS: A total of 123 images were obtained from 28 subjects. The algorithm classified images as TM with or without tube in place. Overall classification accuracy was 97.7 %. Recall and precision were 100 % and 96 %, respectively, for TM without a tube present, and 95 % and 100 %, respectively, for TM with a tube in place. DISCUSSION: This is a promising deep learning algorithm for classifying ear tube presence in the TM utilizing images obtained in awake children using an over-the-counter otoscope available to the lay population. We are continuing enrollment, with the goal of building an algorithm to assess tube patency and extrusion.

The Use of Hand-Held Digital Otoscope as a Basic Nasal Endoscopy Tool for Lacrimal Evaluation and Pedagogy Instrument.

PURPOSE: To investigate the utility of a hand-held digital otoscope for nasal endoscopy and as a pedagogy tool for residents and fellows in patients undergoing external dacryocystorhinostomy (DCR) surgery. METHODS: A digital otoscope (MS450-NTE, Teslong Inc., USA) comprising a digital screen device and a connectible camera probe was used for performing nasal endoscopy. Inspection of nasal cavities was performed pre-, intra-, and post-operatively in sequential patients with nasolacrimal duct obstruction, who underwent DCR or lacrimal probing. Images (1920 × 1080 pixels) and videos (1280 × 720 pixels) were captured. The device was also used for training residents and fellows in performing nasal endoscopy, and to teach basic concepts. RESULTS: The digital otoscope could be used for routine outpatient nasal examination and for performing minor procedures. 53.8% (n = 13) of ophthalmology trainees had never observed nasal endoscopy and 84.6% could not identify more than one major structure correctly prior to the current training. Post-training, all trainees could independently perform nasal endoscopy with the device and 76.9% identified all structures correctly. CONCLUSION: A digital otoscope with a camera probe is a handy tool for nasal endoscopy and pedagogy. Low-cost gadgets such as this device can effectively be used for performing outpatient nasal endoscopy when expensive endoscopes are unavailable and in peripheral healthcare centers.

Prevalence and clinical findings of feline otitis externa in Midwest Brazil.

This study was conducted to evaluate the prevalence of otitis externa (OE) in cats using cytology, direct otoscopic examination, and parasitological examination through swabs and curettage, and to compare the accuracy between collection methods for parasitological examination. Direct otoscopic evaluation of the external auditory canal (right and left), swabs for cytological examination of the external auditory canal, and collection of cerumen for parasitological examination through swabs and curettage of 137 cats from a veterinary hospital care were conducted between March 2021 and March 2022. The influences of age, sex, habitat, street access, and the presence of fleas on OE were evaluated. Cytological evidence of OE was observed in 25.5 % of cats and was statistically associated with flea and mite parasitism. Otodectes cynotis was found in 13.9 % of the cats. Cocci and Bacilli were the secondary factors in 34.3 % and 22.9 % of cats with OE, respectively. The Malassezia genus was a secundary factor in 57.1 % of the cats with OE. The frequency of OE was high in cats receiving hospital care. O. cynotis was a frequent primary cause of OE in cats. The curette sampling method is a great option for diagnosing O. cynotis infestation due to its ease of use.

"Seeing inside out": revealing the effectiveness of otoscopy training in virtual reality enhanced practical exams - a randomized controlled trial.

BACKGROUND: The study aimed to assess the impact of different training modalities on otoscopy performance during a practical exam using a high-fidelity simulator and to determine if objective evaluation of otoscopy is feasible using a simulator that records insertion depth and tympanic membrane coverage. METHODS: Participants were assigned to one of four groups: control and three intervention groups with varying training approaches. Participants received otoscopy training and then were assessed through a practical exam on a high-fidelity simulator that uses virtual reality to visualize the ear canal and middle ear. Performance was evaluated using a modified Objective Structured Assessment of Technical Skills checklist and Integrated Procedural Performance Instrument checklist. Insertion depth, tympanic membrane coverage, and correct diagnosis were recorded. Data were tested for normal distribution using the Shapiro-Wilk test. One-way ANOVA and, for non-normally distributed data, Kruskal-Wallis test combined with Dunn's test for multiple comparisons were used. Interrater reliability was assessed using Cohen's κ and Intraclass correlation coefficient. RESULTS: All groups rated their training sessions positively. Performance on the OSATS checklist was similar among groups. IPPI scores indicated comparable patient handling skills. The feedback group examined larger tympanic membrane areas and had higher rates of correct diagnosis. The correct insertion depth was rarely achieved by all participants. Interrater reliability for OSATS was strong. IPPI reliability showed good correlation. CONCLUSION: Regardless of training modality, participants perceived learning improvement and skill acquisition. Feedback improved examination performance, indicating simulator-guided training enhances skills. High-fidelity simulator usage in exams provides an objective assessment of performance.

When Can Children Perform Valsalva and Toynbee Maneuvers? An Exploratory Study.

OBJECTIVES: Barochallenge-induced Eustachian tube dysfunction (ETD) is difficult to diagnose because the examination is often normal during clinical assessment. In adults, functional tympanometry testing, performed by asking the patient to Valsalva and Toynbee while measuring the pressure shift, can aid in the diagnosis of ETD. However, standardized values do not exist in children. We aim to determine the age at which children can perform these maneuvers and the normative values in this population. METHODS: Patients with a normal basic ear examination 4 years and older, presenting to the pediatric Otolaryngology clinic, were recruited. Otoscopy, baseline tympanometry, followed by Valsalva and Toynbee maneuvers were performed. Because there are no pediatric norms, we hypothesized that children would achieve the same minimum normal pressure shift as cited in the adult literature (+20 daPa or higher for Valsalva and -20 daPa or lower for Toynbee). The data were analyzed using receiver operating characteristic curves and logistic regression. RESULTS: One hundred sixty-eight children (276 ears) were assessed. Participants as young as 4 years old were able to perform a Valsalva and Toynbee. Age cut-offs at which children achieved adult norms were 12.5 years ( p = 0.016) and 8.5 years ( p = 0.071) for Valsalva and Toynbee maneuvers, respectively. Mean pressure shift ranged from +29 to -36 daPa, and males were 2.5 times more likely to achieve Toynbee compared with females ( p = 0.006). CONCLUSIONS: Functional tympanometry testing may be used to help diagnose barochallenge-induced ETD in older children.

Otoscopy-assisted intranasal cyst marsupialization for congenital dacryocystocele.

We describe 3 infants with congenital dacryocystocele resistant to conservative treatment who were treated with a novel, simple intranasal cyst marsupialization (ICM) technique. Otoscopy-guided ICM was performed by an otolaryngologist in the manner of otoscopic myringotomy for cases with nasal cyst distension. All 3 infants were treated successfully by a single surgical procedure under topical anesthesia in an office setting.

Algorithm-Driven Tele-otoscope for Remote Care for Patients With Otitis Media.

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. STUDY DESIGN: Prospective, cross-sectional, diagnostic study. SETTING: 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%). CONCLUSION: 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.

Bone cement repair of malleus handle fractures: Intraoperative video and case report of two patients.

Isolated malleus fractures are a rare occurrence with few reported cases in the literature. Symptoms include sudden otalgia, hearing loss, tinnitus and aural fullness. Work-up and diagnosis are based on a combination of thorough anamnesis and careful otoscopic evaluation or high-resolution computer tomography. We present two cases of isolated malleus handle fractures who were diagnosed based on a combination of pneumatic otoscopy and tympanometry. Both fractures were surgically repaired using hydroxyapatite bone cement as showcased in the supplemental video material. Post-operative audiometry showed improvement in the pure-tone-average of both patients as well as normalisation of tympanometry. Isolated malleus fracture should be suspected in cases of sudden hearing loss and tinnitus following digital manipulation of the outer ear canal together with a conductive hearing loss with a mostly high-frequent air-bone-gap and hypercompliant tympanometry with hypermobility of the tympanic membrane on pneumatic insufflation. Surgical repair of the fracture using bone cement has good hearing outcomes and leads to improvement in auditory symptoms.

Development and Validation of an Automated Classifier to Diagnose Acute Otitis Media in Children.

Importance: Acute otitis media (AOM) is a frequently diagnosed illness in children, yet the accuracy of diagnosis has been consistently low. Multiple neural networks have been developed to recognize the presence of AOM with limited clinical application. Objective: To develop and internally validate an artificial intelligence decision-support tool to interpret videos of the tympanic membrane and enhance accuracy in the diagnosis of AOM. Design, Setting, and Participants: This diagnostic study analyzed otoscopic videos of the tympanic membrane captured using a smartphone during outpatient clinic visits at 2 sites in Pennsylvania between 2018 and 2023. Eligible participants included children who presented for sick visits or wellness visits. Exposure: Otoscopic examination. Main Outcomes and Measures: Using the otoscopic videos that were annotated by validated otoscopists, a deep residual-recurrent neural network was trained to predict both features of the tympanic membrane and the diagnosis of AOM vs no AOM. The accuracy of this network was compared with a second network trained using a decision tree approach. A noise quality filter was also trained to prompt users that the video segment acquired may not be adequate for diagnostic purposes. Results: Using 1151 videos from 635 children (majority younger than 3 years of age), the deep residual-recurrent neural network had almost identical diagnostic accuracy as the decision tree network. The finalized deep residual-recurrent neural network algorithm classified tympanic membrane videos into AOM vs no AOM categories with a sensitivity of 93.8% (95% CI, 92.6%-95.0%) and specificity of 93.5% (95% CI, 92.8%-94.3%) and the decision tree model had a sensitivity of 93.7% (95% CI, 92.4%-94.9%) and specificity of 93.3% (92.5%-94.1%). Of the tympanic membrane features outputted, bulging of the TM most closely aligned with the predicted diagnosis; bulging was present in 230 of 230 cases (100%) in which the diagnosis was predicted to be AOM in the test set. Conclusions and Relevance: These findings suggest that given its high accuracy, the algorithm and medical-grade application that facilitates image acquisition and quality filtering could reasonably be used in primary care or acute care settings to aid with automated diagnosis of AOM and decisions regarding treatment.

Tympanic membrane perforations cannot be reliably detected using computed tomography based on 15 cadaver dogs.

The integrity of the tympanic membrane is an important factor when deciding treatment and therapeutic recommendations for dogs with ear disease; however, otoscopic examination may be difficult to perform due to features of external ear canal disease or patient compliance. CT is useful for the evaluation of middle ear disease, including cases in which middle ear disease is detected incidentally. The tympanic membrane is detectable using CT, but anecdotally, apparent focal defects or discontinuities of the tympanic membrane are often seen in patients with and without ear disease. The purpose of this prospective, observer agreement study was to determine if perforations of the tympanic membrane are reliably detectable on CT. Fifteen cadaver dogs underwent CT and video otoscopy to verify the integrity of each tympanic membrane. Cadavers were randomly assigned to have the tympanic membranes left intact or to undergo a myringotomy on either the left, the right, or both sides. CT was performed immediately following the myringotomies. Four blinded evaluators evaluated the pre- and post-myringotomy scans for a total of 30 scans (60 tympanic membranes). Average accuracy was low (44%), and interobserver agreement for all four evaluators was fair. Although the tympanic membrane is visible on CT, perforations of the tympanic membrane are unlikely to be accurately detected or excluded. The appearance of an intact tympanic membrane or defect in the membrane on CT should not be used as criteria to guide clinical treatment recommendations based on this cadaver model.

Registration of preoperative temporal bone CT-scan to otoendoscopic video for augmented-reality based on convolutional neural networks.

PURPOSE: Patient-to-image registration is a preliminary step required in surgical navigation based on preoperative images. Human intervention and fiducial markers hamper this task as they are time-consuming and introduce potential errors. We aimed to develop a fully automatic 2D registration system for augmented reality in ear surgery. METHODS: CT-scans and corresponding oto-endoscopic videos were collected from 41 patients (58 ears) undergoing ear examination (vestibular schwannoma before surgery, profound hearing loss requiring cochlear implant, suspicion of perilymphatic fistula, contralateral ears in cases of unilateral chronic otitis media). Two to four images were selected from each case. For the training phase, data from patients (75% of the dataset) and 11 cadaveric specimens were used. Tympanic membranes and malleus handles were contoured on both video images and CT-scans by expert surgeons. The algorithm used a U-Net network for detecting the contours of the tympanic membrane and the malleus on both preoperative CT-scans and endoscopic video frames. Then, contours were processed and registered through an iterative closest point algorithm. Validation was performed on 4 cases and testing on 6 cases. Registration error was measured by overlaying both images and measuring the average and Hausdorff distances. RESULTS: The proposed registration method yielded a precision compatible with ear surgery with a 2D mean overlay error of 0.65 ± 0.60 mm for the incus and 0.48 ± 0.32 mm for the round window. The average Hausdorff distance for these 2 targets was 0.98 ± 0.60 mm and 0.78 ± 0.34 mm respectively. An outlier case with higher errors (2.3 mm and 1.5 mm average Hausdorff distance for incus and round window respectively) was observed in relation to a high discrepancy between the projection angle of the reconstructed CT-scan and the video image. The maximum duration for the overall process was 18 s. CONCLUSIONS: A fully automatic 2D registration method based on a convolutional neural network and applied to ear surgery was developed. The method did not rely on any external fiducial markers nor human intervention for landmark recognition. The method was fast and its precision was compatible with ear surgery.

Remote paediatric ear examination comparing video-otoscopy and still otoscopy clinician rated outcomes.

OBJECTIVE: Telemedicine, particularly real time video-otoscopy in rural and remote Australia holds great potential in assessing and managing otology conditions. There is good evidence of store and forward images for assessment, however limited evidence exists for the use of real-time video-otoscopy. The objective of this study was to assess the validity of using real time video-otoscopy, compared to standard store and forward still image otoscopy, in a paediatric population. METHOD: Fifty-two paediatric tympanic membranes in 27 patients were examined and photographed by a telehealth facilitator with prior otoscope training. This occurred at two rural Western Australian health centre sites. These images were stored and forwarded to a tertiary paediatric hospital for otolaryngology department assessment on the day of real-time video-otoscopy consultation. During this consultation the same twenty-seven patients underwent real-time video-otoscopy assessment, which was recorded. Across six domains including, image quality, focus, light, cerumen amount, field of view and tympanic membrane landmarks, real-time video-otoscopy was compared against still image capture. The recording of each real-time video-otoscopy and still image tympanic membrane was assessed by two otology specialists for the ability to diagnose each as either normal or abnormal. An inter-rater reliability agreement was then calculated. RESULTS: There was greater image adequacy across five of the six domains for real time video-otoscopy compared to standard store and forward otoscopy images. Substantial agreement in diagnosing each tympanic membrane as either normal or abnormal between each rater was evident. CONCLUSION: This study supports the use of real time video-otoscopy during telemedicine consultation. With greater image quality, focus, light, field of view and identification of tympanic membrane landmarks video-otoscopy compared to still images has broad clinical applications. This includes primary assessment of the tympanic membrane and post operative follow-up clinical settings. Video-otoscopy offers a promising new way to over-come barriers in delivering ear health care in rural populations.

Acute otitis media diagnosis in childhood: still a problem in 2023?

BACKGROUND: Diagnosis of acute otitis media (AOM) in children can be challenging, given that symptoms are often non-specific or absent, and that the direct observation of the tympanic membrane in its entirety through otoscopy can sometimes be difficult. The aim of this study is to assess the diagnostic concordance in detection of AOM episodes between primary care paediatricians and physicians especially trained in paediatric otoscopy, and to characterize the most misleading elements in diagnostic failure. METHODS: Consecutive clinical charts of children regularly followed for recurrent AOM (RAOM, i.e.: >3 episodes in 6 months or > 4 episodes in 1 year) at our Otitis Media paediatric outpatient clinic were retrospectively screened, in order to collect any diagnosis of AOM episode (and the related clinical findings/middle ear complaints) performed by primary care paediatricians/emergency room paediatricians. Diagnosis of AOM episode was validated by the same experienced physician (FF) in case of otoscopic relief of a bulging eardrum with at least one of the following: hyperaemia or yellow-like colour. The diagnostic concordance in detection of AOM episodes between primary care/emergency room paediatricians and our internal validator was expressed as the percentage of matching diagnosis. RESULTS: One hundred and thirty-four single AOM episodes occurring in 87 children (mean age: 26.9 +/- 18.9 months) were included in the analysis. Diagnostic concordance in detection of AOM episodes between primary care/emergency room paediatricians and our internal validator was reported in 72.4% of cases. The most common pitfall found in our study was the misleading diagnosis of AOM in case of hyperaemic tympanic membrane without bulging (32/37 out of non-validated diagnoses). CONCLUSIONS: AOM diagnosis still represents a relevant issue among paediatricians in our country, and the presence of tympanic membrane hyperaemia without concomitant bulging can be confusing.

Novel ENT live telehealth and live video-otoscopy clinics in remote Australia: outcomes and comparisons to traditional clinic models.

BACKGROUND: Coronavirus disease 2019 challenged the delivery of healthcare in Australia, disproportionately impacting vulnerable patients, including Aboriginal and/or Torres Strait Islander peoples and those living in remote regions. The otolaryngology service provided to remote Western Australia adapted to these barriers by altering clinical consultations to a digital model. METHODS: A review was undertaken of patients in regional Western Australia. Demographics and clinical outcomes from 20 live telehealth clinics were retrospectively reviewed and compared to 16 face-to-face clinics. RESULTS: The demographics of patients reviewed in both live telehealth and face-to-face clinics were similar, except for a larger proportion of Aboriginal and/or Torres Strait Islander patients utilising telehealth. The outcomes of patients reviewed through each model of care were comparable. Live video-otoscopy provided diagnostic quality images in 92 per cent of cases. CONCLUSION: The findings of our review suggest that, despite its limitations, a large proportion of ENT patients may be safely assessed through a live telehealth model.

Feasibility of a Video Otoscope for Diagnosis of Otologic Pathology in the Pediatric Emergency Department.

OBJECTIVES: Performing pediatric otoscopy can be difficult secondary to patient compliance, which potentiates misdiagnosis and inaccurate treatment of acute otitis media. This study used a convenience sample to assess the feasibility of using a video otoscope for the examination of tympanic membranes in children presenting to a pediatric emergency department. METHODS: We obtained otoscopic videos using the JEDMED Horus + HD Video Otoscope. Participants were randomized to video or standard otoscopy, and a physician completed their bilateral ear examinations. In the video group, physicians reviewed otoscope videos with the patient's caregiver. The caregiver and physician completed separate surveys using a 5-point Likert Scale regarding perceptions of the otoscopic examination. A second physician reviewed each otoscopic video. RESULTS: We enrolled 213 participants in 2 groups (standard otoscopy, n = 94; video otoscopy, n = 119). We used Wilcoxon rank sum, Fisher exact test, and descriptive statistics to compare results across groups. For physicians, there were no statistically significant differences between groups with ease of device use, quality of otoscopic view, or diagnosis. There was moderate agreement between physician video otoscopic view satisfaction and slight agreement between physician video otologic diagnosis. Estimates of length of time to complete the ear examinations were longer more often for the video otoscope compared with standard for both caregivers (OR, 2.00; 95% confidence interval, 1.10-3.70; P = 0.02) and physicians (OR, 3.08; 95% confidence interval, 1.67-5.78; P < 0.01). There were no statistically significant differences between video and standard otoscopy with regard to caregiver perception of comfort, cooperation, satisfaction, or diagnosis understanding. CONCLUSIONS: Caregivers perceive that video otoscopy and standard otoscopy are comparable in comfort, cooperation, examination satisfaction, and diagnosis understanding. Physicians made a wider range of more subtle diagnoses with the video otoscope. However, examination length of time may limit the JEDMED Horus + HD Video Otoscope's feasibility in a busy pediatric emergency department.

Diagnostic accuracy of the video otoscope in tympanic membrane perforation.

OBJECTIVE: The video otoscope has already proven to be useful for the diagnosis of several pathologies, so the objective of this study was to evaluate the diagnostic accuracy of the video otoscope in cases of tympanic membrane perforation. METHODS: This is a diagnostic accuracy study performed at the hearing health division of a tertiary-level referral hospital. Patients older than 8 years of age who had any symptom that could be related to perforation (otalgia, otorrhea, tinnitus, and/or hypoacusis) were invited to participate in the study. Participants were evaluated by three different diagnostic methods (otomicroscope, conventional otoscope, and video otoscope) performed by three different evaluators in a blind fashion. The microscope was considered the reference standard. RESULTS: 176 patients were evaluated, totaling 352 tympanic membranes. Twenty-seven tympanic membrane perforations were diagnosed by the microscope, a prevalence of 7.7%. The video otoscope showed a sensitivity of 85.2% (95% CI 81.5%‒88.9%), specificity of 98.1% (95% CI 96.7%‒99.5%) and accuracy of 97.1% (95% CI 95.4 %-98.8 %). The conventional otoscope showed a sensitivity of 96.3% (95% CI 94.3-98.3), specificity of 98.8% (95% CI 97.7-99.9) and accuracy of 98.6% (95% CI 97.4-99.8). The Kappa value between the microscope and the video otoscope was 0.8 and between the microscope and the conventional otoscope was 0.9. Regarding the participants' perception, 53.4% (p< 0.001) considered the video otoscope as the best method for understanding the tympanic membrane condition presented by them. CONCLUSIONS: The video otoscope showed relevant sensitivity and specificity for clinical practice in the diagnosis of tympanic membrane perforation. Moreover, this is an equipment that can facilitate the patient's understanding of the otologic pathology presented by him/her. In this regard, this method may be important for better patient compliance, requiring further studies to evaluate this hypothesis. LEVEL OF EVIDENCE: Is this diagnostic or monitoring test accurate? (Diagnosis)-Level 2 (Individual cross-sectional studies with consistently applied reference standard and blinding).

Rigid normograde rhinoscopy-assisted traction-avulsion removal of small middle ear polyps from the auditory tube in five cats.

CASE SERIES SUMMARY: This study aims to describe a novel minimally invasive technique for the removal of small middle ear polyps from the auditory tube openings in cats. Five cats with clinical signs of otitis externa and/or otitis media, and/or upper respiratory tract inflammation were included. All cats underwent pharyngolaryngoscopy under anaesthesia, CT scan of the head, neck and thoracic cavity, video-otoscopic examination, retrograde nasopharyngoscopy and normograde rhinoscopy. The five cats described in this study were all found to have significant respiratory tract inflammation (rhinitis, sinusitis, nasopharyngitis, otitis media) with small polypous protrusions from the auditory tube openings. A normograde rhinoscopy-assisted traction-avulsion (RATA) removal of these small polyps was performed in all cases without complications. The rostral nasopharynx was visualised by a unilaterally normograde advanced rigid endoscope passing the choana, and polyps were removed using a grasping forceps introduced in the contralateral nostril. Telephone follow-up revealed clear improvement in all cases. One of the cases was re-evaluated with a CT scan and endoscopy 4 weeks after treatment. The CT scan showed a significant improvement with no abnormalities in both external ear canals and air opacity in both tympanic bullae. Video-endoscopic examination revealed intact tympanic membranes with mild chronic abnormalities and patent auditory tube openings upon normograde rhinoscopy. RELEVANCE AND NOVEL INFORMATION: Rigid normograde RATA is a novel, minimally invasive and effective technique for the removal of small middle ear polyps from auditory tube openings in cats with otitis media.

Evaluating the generalizability of deep learning image classification algorithms to detect middle ear disease using otoscopy.

To evaluate the generalizability of artificial intelligence (AI) algorithms that use deep learning methods to identify middle ear disease from otoscopic images, between internal to external performance. 1842 otoscopic images were collected from three independent sources: (a) Van, Turkey, (b) Santiago, Chile, and (c) Ohio, USA. Diagnostic categories consisted of (i) normal or (ii) abnormal. Deep learning methods were used to develop models to evaluate internal and external performance, using area under the curve (AUC) estimates. A pooled assessment was performed by combining all cohorts together with fivefold cross validation. AI-otoscopy algorithms achieved high internal performance (mean AUC: 0.95, 95%CI: 0.80-1.00). However, performance was reduced when tested on external otoscopic images not used for training (mean AUC: 0.76, 95%CI: 0.61-0.91). Overall, external performance was significantly lower than internal performance (mean difference in AUC: -0.19, p ≤ 0.04). Combining cohorts achieved a substantial pooled performance (AUC: 0.96, standard error: 0.01). Internally applied algorithms for otoscopy performed well to identify middle ear disease from otoscopy images. However, external performance was reduced when applied to new test cohorts. Further efforts are required to explore data augmentation and pre-processing techniques that might improve external performance and develop a robust, generalizable algorithm for real-world clinical applications.