Patient Use of Digital Videoscopes and Smartphones for Remote Ear and Oropharyngeal Examinations (2024)

Key Points

Question Are patient-acquired images using low-cost digital videoscopes and smartphones for remote ear and oropharyngeal examinations feasible and usable?

Findings In this quality improvement study, 23 participants self-captured smartphone videos of the oropharynx, which yielded a higher percentage of acceptable examination images (63%) compared with digital endoscope images (40%). For ear examinations with a digital otoscope, 95% of the images obtained were acceptable, and 90% of the patients rated it as easy to use; furthermore, 70% of the participants were willing to purchase a digital videoscope for $35.

Meaning Results of this study suggest that digital otoscopes and smartphones may facilitate remote examinations of the ear and oropharynx.

Importance During the novel coronavirus disease 2019 pandemic, telehealth has become a vital component of health care delivery. For otolaryngology evaluations, examination of the ear and oropharynx is important but difficult to achieve remotely.

Objective To assess the feasibility of patient use of low-cost digital videoscopes and smartphones for examination of the ear and oropharynx.

Design, Setting, and Participants A prospective quality improvement study was conducted in an academic adult otolaryngology clinic including 23 patients who presented for an in-person appointment and owned a smartphone device. The study was conducted from July 1 to 15, 2020.

Interventions Participants were asked to capture pictures and videos of their ear canals and oropharynx with digital videoscopes and their smartphones under real-time guidance over a telehealth platform. They were then surveyed about their experience.

Main Outcomes and Measures The primary outcomes were ratings by health care clinicians and a blinded otolaryngologist reviewer of image acceptability. Secondary outcomes included participant time to image acquisition and willingness to purchase digital videoscopes for telehealth use.

Results Of the 23 participants included, 14 were women (61%); mean age was 50 years (range, 21 to 80 years). Of the images obtained using the digital otoscope ear examination, 95% were considered acceptable by the health care clinicians and 91% were considered acceptable by the blinded reviewer; 16 participants (70%) reported that the otoscope was easy to use. The mean time to acquire images for both ears was 114 seconds (95% CI, 84-145 seconds). Twenty-one participants (91%) were willing to pay for a digital otoscope for telehealth use. For the oropharyngeal examination, a greater proportion of smartphone video examinations were considered acceptable by clinicians (63% acceptability) and the blinded reviewer (55%) compared with the digital endoscope (clinicians, 40%; blinded reviewer, 14%). The mean time required for the oropharyngeal examination smartphone video capture was shorter at 35 seconds compared with both the digital endoscope (difference, −27 seconds; 95% CI, −7 to −47 seconds) and smartphone photo capture (difference, −53 seconds; 95% CI, −20 to −87 seconds).

Conclusions and Relevance Digital otoscopes and smartphones apparently can facilitate remote head and neck physical examination in telehealth. Digital otoscopes were useful for ear examinations, and smartphone videos appeared to be the most useful for oropharyngeal examinations. Further studies are required to determine specific diagnostic capabilities in various telehealth practice settings.

Although telehealth has been historically underused due to technological barriers, high implementation costs, and limited clinician reimbursem*nt,^1,2 it has become commonplace during the novel coronavirus disease 2019 (COVID-19) pandemic as a way of reducing viral spread while delivering clinical care. New federal legislation has accelerated telehealth adoption with improved reimbursem*nt of telemedicine visits and temporary changes to videoconferencing regulations.^3,4 Given the rate of health system investment in telemedicine infrastructure during the COVID-19 pandemic, continued growth and widespread adoption are expected.

One challenge of telehealth encounters lies in the physical examination. Before the pandemic, telehealth was typically performed in satellite facilities with technicians obtaining key examination components or reserved for encounters that did not require a physical examination. Now, many telehealth visits are being conducted entirely from home for patients and even clinicians. Although many aspects of the basic physical examination may be elicited remotely at home,^5,6 the otolaryngologic examination is among the most challenging owing to obstacles in visualizing anatomic spaces, such as the oropharynx or the external auditory canal (EAC) that are small, poorly lit, or otherwise inaccessible without specialized equipment.^7,8 This difficulty with the examination is a concern for otolaryngology patients, with 70% of 525 outpatients in a recent study declining a telehealth visit during the pandemic owing to lack of a physical examination.⁹

Suggested practices for optimizing the remote oropharynx examination include patient use of a light source to illuminate the oropharynx and household items to serve as tongue depressors.^10,11 In addition, smartphone cameras allow patients to capture photos of their oropharynx for examination purposes.¹² In these cases, patient submission of self-acquired photos through the electronic medical record or messaging with health care professionals is 1 form of useful remote examination. Despite these strategies, remote oropharyngeal visualization continues to have limitations.^7,10

Remote visualization of the EAC and tympanic membrane (TM) are even more challenging given that examination requires an otoscope. Digital video otoscopes allow users to capture and share digital videos of the EAC and TM with health care practitioners for remote diagnosis. Earlier studies of pediatric ear examinations using such digital otoscopes have shown higher parental satisfaction and improved patient-centered care compared with traditional otoscopes, and these devices ranged in price from hundreds to thousands of dollars.^13,14 Since then, lower-cost digital endoscopes have been developed that are priced less than $50 and display real-time images on computers or mobile phones. These lower-cost otoscopes are marketed directly to consumers and are available for purchase online, but patient interest and ability to use these devices remain to be evaluated.

While smartphones and digital otoscopes have the potential to facilitate acquisition of remote oropharynx and ear examination images, lack of patient training in physical examination provides a barrier to successful use. A previous study comparing images taken from a smartphone otoscope attachment by health care practitioners with images taken by pediatric patients’ parents with no real-time instruction found that parent-captured images were unreliable but health care practitioner–captured images were suitable for diagnosis.¹⁵ Therefore, there is a need to evaluate the potential utility of low-cost tools with real-time guidance for home telehealth visits. Herein, we present what we believe to be the first study examining patient experiences with low-cost digital videoscopes, including a digital otoscope and endoscope, and smartphone images in simulated telehealth encounters.

This pilot quality improvement study was approved by the institutional review board at the University of California, San Francisco and conducted at an academic outpatient otolaryngology clinic from July 1 to 15, 2020. The study workflow is shown in the eFigure in the Supplement. All English-speaking outpatients who owned a smartphone device were eligible to participate. All patients provided informed consent electronically for participation, access to relevant medical records, recording of digital videos and images, and publication of nonidentifiable photos for research purposes. Participants were informed about the study and provided informed consent after their clinic visits; no financial compensation was provided. Demographic information, including age and gender identity, were obtained from the electronic health record. This study adhered to the Declaration of Helsinki standards¹⁶ and followed the Standards for Quality Improvement Reporting Excellence (SQUIRE) reporting guideline for quality improvement studies.

Health Insurance Portability and Accountability Act–compliant video conferencing software (Zoom Video Communications Inc) was used to obtain electronic consent, guide participants in acquiring self-examination images, and survey the participants regarding their experiences. Research staff were in a room separate from the participants to simulate a remote encounter with a video-based physical examination. Video recordings of the EAC and TM examinations were obtained using a digital otoscope (Shenzhen Anykit Technology Co Ltd), and recordings of the oropharyngeal examinations were obtained using a digital endoscope (Shenzhen Huishixin Technology Co Ltd). These digital camera devices were connected to the computer in the participants’ room via USB ports (Figure 1). No software installation was necessary to render these devices useful. Both devices were disinfected before use by a new participant using disposable, germicidal wipes (PDI Healthcare), and new disposable otoscope tips were provided for each participant. These cameras, which are commercially available online and not sold as medical diagnostic equipment, were chosen owing to their accessibility and low price, with both the otoscope and endoscope priced less than $35 at the time of purchase. The digital endoscope was used for oropharynx examination owing to a longer focal length (3-10 cm) compared with the digital otoscope focal length (2.5 cm). None of the authors have any financial ties to the above companies or had any experience with these devices prior to the study.

First, participants were asked to use the digital endoscope to examine their oropharynx. Next, they used the digital otoscope to examine both ears. Cerumen was left in place and not removed during study participation. A high-definition (1280 × 720 pixels) video of the examinations was recorded over Zoom at a fixed frame rate of 30 frames/s using a 600-megabits-per-second internet connection and uploaded to an encrypted online platform (Box Inc) for future, asynchronous analysis. Following the videoscope portion of the remote examinations, participants were asked to take both a photo and a video of their oropharynx using the rear-facing camera of their smartphone with the flash feature. Smartphone photo capture was followed by smartphone video capture in all encounters. Participants were provided a tabletop mirror as well as an instruction sheet (Figure 1) with an example of the desired images to facilitate the self-examination. The instruction sheet also provided information on how to switch video input sources between the digital endoscope and otoscope for the Zoom encounter. Participants were allowed to retake any blurry or unfocused images and videos twice. Images were reviewed by researchers (Y.C., Y.J.Z., and A.G.) before upload to ensure no identifying features were included. Participants were then given access to a unique link to upload images and videos directly from their personal smartphone using Research Electronic Data Capture (REDCap), a secure electronic data capture tool.

As the final step, participants completed a nonvalidated questionnaire consisting of a Likert scale, multiple choice options, and open-ended questions regarding their experience in using their smartphone and the digital cameras. Participants rated ease of use (very difficult, difficult, neutral, easy, and very easy) and satisfaction (not at all satisfied, somewhat dissatisfied, neutral, somewhat satisfied, and completely satisfied) on 5-point Likert scales. Survey responses were also stored using REDCap. The times required for image acquisition of the anatomic structures for each camera source were also recorded. For each anatomic structure and image capture method, participants were timed from the end of the research staff’s delivery of instructions for image capture to the point at which they were told to stop by the research staff when an adequate image was obtained.

After participants completed the study, their clinician and a blinded otolaryngologist reviewer (A.B.) were given online access to stored-and-forwarded full-resolution videos and images taken with the digital endoscopes and participants’ smartphones. Clinicians and the blinded reviewer assessed the acquired images in terms of acceptability for use in clinical examination using 4-point Likert scales (very unacceptable, unacceptable, acceptable, and very acceptable). Right and left ear images were examined as a set for each participant. For scenarios in which image acceptability differed between a participant's right and left ear, clinicians were advised to provide a rating based on the less acceptable image. In addition, the clinicians assessed the images for comparability with impressions from their in-person examination findings. To allow comparison with the in-person examination, clinicians were not blinded to the participants’ identities and assessed the acquired images shortly after the in-person visit. However, the additional otolaryngologist reviewed image acceptability on a blinded basis.

Participant and physician survey responses were aggregated using Microsoft Excel 2016 (Microsoft Corp) and analyzed using Stata, version 13 (StataCorp LLC). The timing for different examination components and 95% CIs are reported. Findings were considered significant at α = .05.

Twenty-three participants from 7 clinicians participated in the study, including 8 new patients (35%) and 15 follow-up patients (65%). Mean age was 50 years (range, 21-80 years), with 7 participants (30%) between 18 and 39 years, 10 (43%) between 40 and 64 years, and 6 (26%) aged 65 years or older. Nine (39%) participants were men and 14 (61%) were women. Common reasons for the visit included postoperative follow-up (n = 8), ear drainage or pain (n = 6), and cerumen impaction (n = 3). Seventeen participants (74%) reported having a prior telehealth appointment in the past year, and 17 individuals (74%) had never used smartphone images for physical examination purposes before. One-way travel time to their appointment was less than 30 minutes for 9 participants (39%), 30 to 60 minutes for 6 (26%), and more than 60 minutes for 8 (35%). Sixty-five percent of the patients reported a less than $25 cost to attend their appointment, and 13% reported a cost greater than $35 when asked to consider parking, gasoline, time off work, and childcare costs as applicable. Three individuals (13%) were unable to obtain select images during the study, with 1 participant unable to acquire any type of videoscope image and 2 unable to acquire adequate smartphone images.

The digital otoscope was reported as easy or very easy to use by 16 participants (70%). Seven participants (30%) had initial difficulties orienting and angling the scope in a manner that matched the trajectory of the EAC and showed an unobstructed view of the TM, but only 1 individual (4%) was unable to complete the examination and obtain an adequate view of their TM. All participants completed the study safely with no TM perforations, EAC injuries, or reported pain.

The amount of time that participants took to acquire images for both ears was 114 seconds (95% CI, 84-145 seconds). The average time required for participants to obtain an acceptable view of the first ear (73 seconds) was longer than that of the second ear (44 seconds), for a difference of 29 seconds (95% CI, −1 to 59 seconds) (Figure 2).

Clinicians rated 21 of the 22 obtained sets of ear images taken with the digital otoscope as acceptable or very acceptable for use in the clinical examination and the 22 sets of images (86%) as moderately or significantly representative of their in-person physical examination. Similarly, the blinded reviewer rated 20 of these images (91%) as acceptable or very acceptable. Images from participants whose clinic visit included capture of the ear examination using rigid or flexible endoscopy are shown for comparison in Figure 3.

Twenty-one participants (91%) rated oropharyngeal image capture as easy or very easy with the digital endoscope compared with 15 participants (65%) when using their smartphones. Difficulties that participants faced during oropharyngeal examination with the digital endoscope included proper endoscope orientation (5 [22%]) and turning on illumination (5 [22%]). Meanwhile, when using smartphones, patients had difficulties activating the flash feature for illumination (4 [17%]).

The average amount of time that participants took to acquire images for the oropharyngeal examination was less than 90 seconds for all 3 methods of image acquisition (Figure 2). The average time required for video capture using the smartphone was shorter at 35 seconds compared with both the digital endoscope (difference, −27 seconds; 95% CI, −7 to −47 seconds) and smartphone photo capture (difference, −53 seconds; 95% CI, −20 to −87 seconds).

The proportions of clinicians who rated oropharyngeal examination images as moderately or significantly representative of their physical examination findings were similar at 58% for the digital endoscope, 63% for the smartphone photo, and 56% for the smartphone video. However, a higher proportion of clinicians rated oropharyngeal images obtained with the smartphone as acceptable or very acceptable for clinical examination (63% of videos and 56% of photos) compared with digital endoscope images (40% of images). The blinded reviewer rated 55% of smartphone video and 50% of smartphone photo images of the oropharynx as acceptable or very acceptable for diagnosis compared with 14% for digital endoscope images. Furthermore, a higher percentage of clinicians rated smartphone oropharyngeal videos as very acceptable for examination purposes (32%) compared with smartphone photos (6%). Similarly, the blinded reviewer rated 32% of smartphone videos as very acceptable compared with 10% for smartphone photo images of the oropharynx. Example images from the digital endoscope, smartphone photo, and smartphone video oropharyngeal examinations along with the blinded reviewer ratings are shown in Figure 4.

Twenty participants (87%) indicated they were satisfied with their experience using the digital otoscope. Fifteen participants (65%) indicated a preference for telehealth visits over in-person visits if the same visit goals could be accomplished over telehealth. Twenty-one participants (91%) indicated that they would be willing to pay for a similar digital otoscope for telehealth visits, and 16 (70%) were willing to purchase one for personal use. In addition, 16 participants (70%) indicated they would pay more than $35 (Figure 5).

The shift of telehealth toward at-home encounters has created a need to understand the capabilities of resources that facilitate remote evaluation and patient self-examination. Herein, we present a study assessing the use of smartphones and digital endoscopes or otoscopes in simulated telehealth self-examinations of the oropharynx, EAC, and TM. In our pilot group of participants, most were receptive to the use of both digital videoscopes and smartphones for telehealth encounters and were open to purchasing digital videoscopes for telehealth use.

Our clinician and blinded reviewer ratings suggest that use of digital otoscopes is promising for remote examination of the EAC and TM, with digital otoscope examination images correlating well with in-person physical examinations of the ears. Smartphones were more reliable than digital endoscopes in facilitating acceptable images of the oropharynx. The suitability of the digital otoscope and smartphone for various parts of the head and neck examination illustrates their strengths and limitations for remote examinations.

Strengths of the digital otoscope included patient ease of use and willingness to purchase along with high clinician ratings for image quality of the ear examination. There was a significant decrease in the average amount of time needed for image capture between the first and second ear, which suggests a learning curve to digital videoscope use. Furthermore, although the image quality for the oropharyngeal examination was poorer with the digital endoscope than with the smartphone, participants reported greater ease of use with the digital endoscope, which may be due to the ability to see the digital endoscope images on the computer screen instead of using a mirror while adjusting the angle of a smartphone camera for optimal illumination. Meanwhile, the camera focal length needed to achieve an optimal image (2.5 cm) may have necessitated placement of the endoscope further into the oropharynx than was comfortable for the participants.

Strengths of the smartphone use were in oropharynx image capture. Unlike the digital endoscope, the smartphone camera was less susceptible to breath condensation and subsequent blurring of oropharynx images. Orientation of oropharyngeal examination images was also more intuitive with the smartphone than with the videoscope. Furthermore, patients were asked to rate ease of use for the smartphone without differentiating between their experience with smartphone photo vs video. Given that the time to image capture with the smartphone video was shorter, it is possible that the patient ease of use ratings specific to this method would have been higher. In addition, patients may be able to enlist help from others in taking photos at home for transmission to their health care clinicians, which would potentially make photo capture and illuminating the appropriate anatomic structures easier than with patient self-capture.

By assessing multiple aspects of digital otoscope use and willingness to pay for these devices, our study adds to literature reporting on the utility of digital otoscopes in remote physical examination of the ear.^13,17-19 Most previous studies have found video otoscopy to be reliable for the assessment and diagnosis of a variety of ear abnormalities using higher-cost digital otoscopes,^17,18,20 but a study of the CellScope digital otoscope (CellScope Inc) for pediatric patients found that parents had difficulty with adequately visualizing TMs.¹⁵ However, parents were not given any instructions or demonstrations on how to use the device other than the training video included in the CellScope application. In contrast, our study allowed for real-time guidance for participants while they obtained images, which may have optimized the capture of adequate images.

Furthermore, our study used a more affordable digital otoscope compared with the digital otoscopes used in most studies that ranged in cost from hundreds to thousands of US dollars.^{13-15,17,18,21} Further studies will be required to understand whether these lower-cost otoscopes are reliable for diagnosis of ear abnormalities.

In addition, smartphone video capture of the oropharynx may be a valuable adjunct to remote clinical encounters or even in-person clinical visits. Given the ubiquity of smartphones,²² use of the smartphone would be an accessible method for self-examination image capture for many patients. In our study, participants uploaded and transmitted images and videos through a secure, electronic data capture system for review. However, for in-person visits, patients could also capture these videos before their visits and show them to their clinicians. If the examination captured was adequate and obviated the need for the clinician to conduct an in-person oropharyngeal examination, this process could also potentially reduce COVID-19 transmission risks.

The COVID-19 pandemic has provided impetus to establish robust alternatives to in-person clinic appointments and physical examination. Reducing contact between patients, clinicians, and clinic staff when possible may reduce the risk of transmission in health care facilities. Taken together, our results suggest that patient self-acquisition of useful images of the ear using digital otoscopes and of the oropharynx using smartphones is feasible and achievable. These approaches are applicable in a broad range of practices and may possibly expand the utility of telehealth visits. Additional benefits for patients include eliminating travel time or costs, time taken off from work, and other potential direct and indirect costs. Future studies should also investigate the applicability of these strategies during in-hospital consultations and postoperative care.

This study has limitations. The study focused on the feasibility of digital otoscopes and smartphones for visualization of the EAC and oropharynx rather than diagnosis of specific conditions. Other limitations include the potential for selection bias and the nonrandomized order of the tools used to examine the oropharynx, which may affect the time to image acquisition. Our study population was also limited to patients who spoke English, so these findings may not apply to encounters in different languages where an interpreter may be required. Similarly, smartphone ownership was part of the inclusion criteria and may increase the willingness to purchase a device or the likelihood of having the expendable income to do so, thus limiting the generalizability of the findings. In addition, our study results do not reflect scenarios in which internet bandwidth or speed may limit the quality or real-time transmission of images. We also recognize that there are irreplaceable aspects of the in-person examination, such as 3-dimensional assessment and palpation.

The results of this study suggest that patients, with instruction and guidance, are able to use digital videoscopes and smartphones to produce images useful to their clinicians. Digital otoscopes appear to be useful for remote EAC and TM examinations, and smartphone video capture may be useful for remote oropharyngeal examinations. Remote use of these tools suggests potential routes for more effective telehealth appointments or for circ*mstances that previously would have necessitated an in-person visit. In the era of the COVID-19 pandemic, such tools can enable otolaryngologists and general practitioners to enhance use of telehealth while reducing risks for virus transmission and maintaining patient satisfaction.

Accepted for Publication: November 16, 2020.

Published Online: January 21, 2021. doi:10.1001/jamaoto.2020.5223

Corresponding Author: Yi Cai, MD, Department of Otolaryngology–Head and Neck Surgery, University of California, San Francisco, 2380 Sutter St, 2nd Floor, San Francisco, CA 94115 (yi.cai@ucsf.edu).

Author Contributions: Drs Cai and Chang had full access to all of the data in the study and take responsibility for the integrity of the data and the accuracy of the data analysis.

Concept and design: Cai, Krauter, Goldberg, Chang.

Acquisition, analysis, or interpretation of data: All authors.

Drafting of the manuscript: Cai, Zheng, Gulati, Chang.

Critical revision of the manuscript for important intellectual content: All authors.

Statistical analysis: Cai, Zheng, Gulati, Sharon, Chang.

Obtained funding: Chang.

Administrative, technical, or material support: Cai, Gulati, Butrymowicz, Chang.

Supervision: Cai, Pletcher, Sharon, Goldberg, Chang.

Conflict of Interest Disclosures: Dr Goldberg is a paid consultant and minor stockholder in Keyssa Inc and a minor stockholder in Siesta Medical as well as an inventor on a pending sinus diagnostics and therapeutics patent. The terms of this arrangement have been reviewed and approved by the University of California, San Francisco in accordance with its policy on objectivity in research. No other disclosures were reported.