Across the included studies, asynchronous store-and-forward approach was the most commonly used approach, accounting for 35 studies (67.3%; Table 2).

In this approach, images or videos were captured by nonphysicians or caregivers and interpreted remotely by otolaryngologists. This includes laptop-tethered video-otoscopy in primary care [29], smartphone otoscopy with consultant review in rural clinics [36], parent-submitted videos in specialty care [39], nurse or technician capture with specialist interpretation in community programs [61], and a multidisciplinary pathway using scheduled remote reviews [14].

Synchronous models accounted for 11 of 52 studies (21.2%) and included real-time postoperative reviews and acute assessments [32,37,52,53,58], whereas blended stored media with live guidance or interconsultation accounted for 6 of 52 studies (11.5%) [13,22,35,49,64,68]. Telemedicine-supported otologic care was implemented across a variety of settings, including primary care clinics, emergency departments, specialty outpatient services, schools, community screening programs, and home environments.

A diverse range of hardware and software solutions were reported across the included studies (Table 3).

The most frequently used solution was smartphone-connected digital otoscopes and otoendoscopes, such as CellScope Oto, Cupris TYM, TYMPA system (TympaHealth), and endoscope-i, which were applied in emergency, outpatient, school, and home settings [11,36,37,41,44,49-51,53,54,71]. Earlier clinical evaluation of smartphone-enabled otoscopy for OM diagnosis and management were reported, supporting feasibility in routine care [66]. USB video-otoscopes, including the Dino-Lite Pro Earscope, were used to support store-and-forward apps in clinics [29,34]. Non-smartphone digital otoscopes, such as Welch Allyn Digital MacroView Otoscope, TeleHealth Flexican Otoscope, and Welch Allyn USB Otoscope, were used for real-time follow-up and teleconsultations [22,32].

Apart from imaging, several digital tools were used. A smartphone-only acoustic system, using a paper funnel and the phone’s microphone, enabled the detection of middle ear effusion (MEE) [42]. Mobile health (mHealth) apps facilitated diary-based episode detection and home management [33,45]. By contrast, although acceptability was high, a culturally tailored multimedia or text messaging intervention for Aboriginal children with tympanic membrane perforation did not improve clinic attendance or short-term ear health outcomes [70]. A low-cost, open-source smartphone tympanometer was evaluated against the GSI TympStar systems (Grason-Stadler) [60]. Decision support innovations included the Karl Storz Smart Scope with the i-Nside app (Inception-v2) and an inexpensive (~US $10) USB endoscope integrated with a Dense Convolutional Network (DenseNet) classifier for self-examination [15,16]. A consumer Android-tethered otoendoscope, coupled with a rule-based model, demonstrated performance comparable to that of clinicians in diverse otology settings [47]. Community programs frequently used Medtronic’s ENTraview integrated with ClickMedix, and 1 program used the Mebird T5 SO (Black Bee Intelligent Manufacturing [Shenzhen] Technology Co., Ltd.) for asynchronous case discussion [35,46,56,57]. A multisensor kit (TytoPro) enabled remote pediatric interconsultation [13]. The school-based hybrid audiology program integrated Madsen A450 audiometry (Otometrics Natus Medical), Natus Aurical Otocam 300 video-otoscopy, and Interacoustics MT10 tympanometry with videoconferencing [64]. For training, Otosim2 (OtoSim Inc.) via AudioProConnect and a low-cost KZYEE USB otoscope improved teaching and landmark recognition [38,44]. Teslong pen endoscopes and the Mimi Hearing Test app (Mimi Hearing Technologies) were piloted for supervised home capture and hearing checks [49,63]. A structured “Ear Portal” pathway combined hearX HearScope video-otoscopy, HearScreen audiometry, Interacoustics Titan wideband tympanometry, and distortion product otoacoustic emissions into a scheduled multidisciplinary review [14,65].

Figure 2 maps technology categories against care models. Most studies used asynchronous store-and-forward workflows, primarily tele-otoscopy imaging alone or tele-otoscopy combined with adjunct testing (Figure 2). Hybrid models were less common and tended to involve multisensor kits or tele-otoscopy plus adjunct testing. Notable gaps included limited evidence for integrated pathway models beyond a small number of programs and sparse evaluation of outcomes beyond diagnostic performance, including long-term child outcomes and cost-effectiveness.

Figure 3 summarizes who captured otoscopic media (clinicians, nurses/community facilitators, caregivers/parents) and who interpreted it. Studies consistently indicated that diagnostic yield depended strongly on operator training and workflow support, which includes checklists, feedback loops, and cerumen management. Evidence gaps included limited direct comparisons of training intensity and limited reporting of minimum image quality thresholds.

When images were captured by trained operators and interpreted by experienced clinicians, store-and-forward tele-otoscopy showed substantial agreement with in-person otomicroscopy. In a primary care cohort, asynchronous video-otoscopy yielded Cohen κ values of 0.68‐0.75 across raters and 2 review sessions, 72.4%‐79.3% and specificities of 93.2%‐98% [29]. In another clinic, repeated readings improved weighted κ from 0.69 to 0.82, with specificity up to 0.98 [34]. Smartphone otoscopy used by trainees, with remote consultant review, achieved 95% ear-level concordance with on-site specialist otoscopy (κ=0.89; sensitivity 0.94; specificity 0.96) and 100% concordance with referral decisions [36]. For training, pediatric emergency department residents demonstrated similar diagnostic accuracy when using a smartphone device compared with a traditional otoscope (0.74 vs 0.69; nonsignificant). However, novice users tended to favor the conventional tools, as they felt confident with them [37]. A separate academic comparison showed that digital otoscopy improved trainee accuracy by 11.2%, increased interrater agreement (from Fleiss κof 0.40 to 0.69), and reduced repeat confirmatory examinations from 97.9% to 27.2% [53].

Parent and nonspecialist performance was highly dependent on training and cooperation. After structured teaching, parents produced videos of sufficient quality in 62%‐64% of submissions during the intervention periods, and the evaluators showed substantial agreement for detecting or excluding AOM (κ=0.69) [12]. In contrast, a brief tutorial yielded lower agreement with pneumatic otoscopy (parent κ=0.42 vs physician κ=0.74), while automated cerumen alerts showed negligible agreement (κ=0.01), highlighting the advantage of structured teaching [39]. Without hands-on training, local health care workers produced diagnostically useful videos in only 18% of cases, with insertion errors and cerumen as major barriers; usefulness increased proportionally with child age [43]. Educational approaches also included a smartphone-adaptable video-otoscopy quiz developed to support otoscopic image interpretation skills, reflecting ongoing efforts to standardize competency development for tele-otoscopy workflows [67].

Beyond optical otoscopy workflows, a smartphone-based acoustic method to detect MEE achieved an area under the receiver operating characteristic curve (AUC) of 0.898, with approximately 85% sensitivity and 82% specificity under surgical and/or specialist reference standards, and caregiver performance approximated clinician performance in a subset [42]. A smartphone tympanometer also demonstrated approximately 86% classification agreement with commercial devices, with only minor bias in peak admittance and pressure, supporting the feasibility of adjunct middle ear assessments beyond optical imaging [60]. In contrast, a pediatric hearing test app demonstrated very poor agreement with booth audiometry (κ≈0.06) [48,55]. These findings underscore that performance estimates are not directly comparable across studies when index test modality, outcome definition, and reference standards differ. Artificial intelligence–supported classifiers have shown high performance on curated datasets but lower sensitivity for OM and limited external validation across devices and sites [15,16,47].

Tele-enabled programs have broadened access and accelerated clinical decision-making. A school or community program completed 2111 assessments in 1053 children, demonstrating 85% coverage. In another evaluation, it reduced waiting times and tertiary referrals as the program expanded [28,31]. A general practitioner-to-ear, nose, and throat (ENT) specialist smartphone endoscopy pathway was able to manage 83% of the 53 referrals remotely, with a median specialist response time of 48 (IQR 22-148) minutes [50]. In a pediatric emergency department, a smartphone otoscope showed substantial within-physician agreement versus a traditional otoscope and changed the reported tympanic membrane view in 12%‐16% of examinations, including clinically relevant diagnostic changes to or from AOM in 6%‐7% of examinations [71]. Community screening of 3000 individuals generated 54% of referrals, but only 13% were ultimately presented for hospital evaluation; nearly half of those evaluated required surgery, underscoring the barriers of pathway follow-through [46]. A telehealth-supported surgical model achieved 80% clinical resolution, 88% hearing improvement, and reduced travel costs for postoperative review [32]. Home tympanostomy tube surveillance demonstrated high interrater and intrarater agreement, rapid clinician review (1‐3 min), and high family satisfaction with reported time and cost savings [54]. The Ear Portal pathway substantially shortened time to diagnosis and care plan (median 28 [IQR 19.8] days), and an economic analysis showed that it lowered per-visit costs, reached a break-even point after ~223 appointments, and increased specialist throughput [14,65]. A community service integrating smartphone otoscopy with tablet audiometry discharged most patients at their first visit at a lower cost than other services using conventional methods, with specialist review rarely leading to changed decisions [62]. However, televisits, which were performed predominantly without ear imaging, produced similar rates of tube recommendations but substantially lower documentation of effusion at surgery compared with encounters that incorporated ear imaging, indicating a potential risk of suboptimal decision-making when otoscopy is omitted [52]. During the COVID-19 pandemic, telehealth encounters were overall less likely to end with tube recommendations, underscoring the limitations imposed by restricted physical examination [58]. A multisensor interconsultation device demonstrated high agreement for several systems but lower sensitivity for ear canal and tympanic membrane findings than conventional methods, reinforcing the necessity of dedicated otoscopy using generalist kits [13]. In pediatric telehealth, live video-otoscopy provided superior image quality and landmark visualization compared to still images, supporting synchronous visualization when feasible [22]. A school-entry hybrid model demonstrated close agreement with face-to-face audiometry and tympanometry, with acceptable agreement for otoscopy [64].

Table 5 summarizes the distribution of outcome domains reported across included studies (N=52). Diagnostic performance was the most frequently reported domain (38/52, 73.1%), followed by implementation and usability outcomes (29/52, 55.8%). Clinical and management impact (22/52, 42.3%) and audiology and tympanometry outcomes (19/52, 36.5%) were reported less often, while image or capture quality was reported in 15 of 52 studies (28.8%). Training and education and economic outcomes were each reported in 8 of 52 studies (15.4%), and artificial intelligence or automation was reported in 4 studies (7.7%; Table 5). Reports of longer-term patient outcomes and adverse events were uncommon, indicating priorities for future research.

Tele-enabled tools were applied in 4 management scenarios for pediatric ear diseases. For AOM diagnosis, asynchronous video-otoscopy demonstrated substantial agreement with otomicroscopy when images were captured by trained operators, as reported in South Africa using a laptop-tethered Dino-Lite Pro Earscope and specialist review [29] and in a primary care study in which repeated readings of stored video sequences closely tracked the microscopic reference [34]. At the bedside, smartphone-based digital otoscopy (CellScope Oto) demonstrated accuracy comparable to, or modestly better than, that of trainees using a conventional otoscope in a pediatric ED [37]. With structured instructions, parents successfully captured diagnostically useful otoscopy videos at home, supporting remote triage for suspected AOM [12]. For posttympanostomy tube surveillance and postoperative follow-up, home digital otoscopy with CellScope Oto enabled asynchronous specialist review and was rated highly acceptable by families. In remote Australian communities, a telehealth-supported surgical pathway cut travel and costs for postoperative care [32,54]. For screening and triage in underserved settings, school- and community-based programs—ranging from mobile ear-screening services in Queensland to large-scale campaigns using the ENTraview smartphone otoscope integrated with the ClickMedix platform—efficiently detected pathology, shortened time to specialist input, and improved surgical case prioritization, although barriers such as transport and out-of-pocket costs limited follow-through [28,46]. Additionally, a recent parent-led home ear health check pilot targeting children with complex needs highlighted feasibility and potential access benefits for populations facing barriers to clinic-based otoscopy [68].

Although feasibility was consistently high across settings and devices, the diagnostic yield depended on operator training, child cooperation, and cerumen management. Parents performed better after structured teaching, but accuracy declined with only brief instructions or when wax removal was not addressed [39]. Hands-on practice with a live tele-otoscopy simulation using Otosim2 with the AudioProConnect platform preserved accuracy and shortened task time, whereas written-only instructions under field conditions produced a low proportion of diagnostically useful videos [43]. Clinicians generally rated smartphone otoscopy imagery as adequate and highlighted supervisory advantages of shared visualization, including fewer repeat confirmatory examinations during training encounters [41,53]. Conversely, environmental noise and calibration issues materially influenced app-based hearing tools, which demonstrated poor agreement with booth-based audiometry in children with OME, and a smartphone screening app demonstrated high sensitivity but low specificity when ambient noise was not well controlled [48,55].

Limitations include small, single-site samples; convenience sampling; mixed adult and pediatric cohorts in some studies; lack of blinded reference standards; heterogeneous operator training; device or discontinuation issues; and industrial involvement in some implementations. Parent and nonspecialist performance was sensitive to training and cerumen management, while omitting otoscopy in televisits risked misclassification of MEE [52].

Across the included studies, the following points were notably identified as key practical takeaways:

1. Diagnostic performance depended strongly on who captured the otoscopic media and on the training and quality protocol rather than on the device alone.

2. Predefined image quality thresholds, multiview capture, and repeat capture when needed materially affected interpretability and downstream clinical decisions.

3. Telehealth encounters conducted without otoscopic imaging risk underdetecting middle ear pathology, including effusion, and may therefore alter management decisions when objective findings are required.

4. Hub-based or hybrid workflows—such as facilitated capture with remote review—appear to support access and feasibility while maintaining diagnostic reliability in many settings.

5. Evidence remains limited regarding scale-up outcomes (including sustainability/maintenance), formal economic evaluations (particularly in lower-middle-income countries), and external validation of artificial intelligence–enabled tools across devices and sites.

When image acquisition was standardized and performed by trained facilitators, remote specialists and generalists demonstrated diagnostic agreement with in-person reference standards that are clinically feasible for triage and management in many settings [29,34,36,50]. Programs embedding store-and-forward video-otoscopy, tympanometry, and audiometry in school- and community-based screening have demonstrated high coverage, efficient specialist sorting, reduced wait times, and identified surgical candidates [28,31,64]. In primary care, asynchronous tele-referral pathways allowed most cases to be managed without face-to-face review while offering timely specialist input and educational feedback to referrers [50].

Simultaneously, telehealth visits performed without otoscopic visualization carry a risk of misclassification. In a pandemic-era cohort, children evaluated for RAOM via video-only visits were less likely to have effusion confirmed at the time of tympanostomy tube placement than office-based comparators (39% vs 79%), highlighting that history alone is insufficient for surgical decision-making [52]. These findings support hybrid models—telehistory plus rapid access to digital otoscopy (clinic kiosk, drive-through nurse station, and community facilitators) or validated home solutions—especially when management depends on objective middle ear findings [52,54,68].

Evidence has consistently demonstrated that the person capturing the image is as critical as the device used. Across included studies, capture quality and diagnostic yield varied substantially by operator type, training intensity, child cooperation, and cerumen burden [12,39,43]. Hands-on coaching and structured capture approaches were associated with higher proportions of interpretable recordings in parents and nonspecialists, whereas written-only or brief instruction yielded lower rates of diagnostically useful media in field settings [12,39,43]. In simulation settings, trained facilitators using Otosim2 with the AudioProConnect platform maintained expert accuracy without time penalties [38]. In clinical supervision settings, digital otoscopy improved trainee accuracy by approximately 11 percentage points and increased trainee-supervisor agreement from kappa 0.40 to 0.69, while reducing confirmatory reexaminations from ~98% to ~27% [53]. A randomized comparison in pediatric emergency department demonstrated similar accuracy for smartphones versus conventional otoscopy (0.74 vs 0.69) but revealed lower confidence among inexperienced users, emphasizing the value of familiarization [37]. Smartphone otoscopy may meaningfully affect clinical impressions. In a pediatric emergency department study, CellScope Oto altered the reported view in 12% to 16% of exams, with clinically relevant diagnostic changes in approximately 6%; notably, it was rated by clinicians as easy to use and valuable for teaching [71].

Given the established effectiveness of video-otoscopy, careful consideration of the methods and timing of use may enable promising integration [72]. Standardized training packages and minimum quality thresholds should be considered prerequisites for scaling, particularly for parents, community health workers, and very young children, in whom cooperation and ear canal size may complicate capture [12,39,43].

Smartphone-only acoustic reflectometry with embedded machine learning demonstrated high accuracy for effusion detection and performed comparably across platforms and even in parents’ hands [42]. This suggests a low-barrier screening pathway that does not depend on optical access, which is particularly valuable in toddlers with narrow ear canals or when video quality is suboptimal [42,43]. Early studies of automated image classification demonstrated throughput advantages, but clinical readiness remains limited due to scarce external validation across devices, sites, and pediatric populations and incomplete reporting of training datasets and labeling methods, which constrains generalizability and risk-of-bias assessment [15,16,47]. Although numerous models were developed using artificial intelligence to classify middle ear diseases on the basis of tympanic membrane findings or short-wave infrared imaging, there were few studies addressing its actual clinical implementation [15,16,73-76]. It is therefore necessary to consider not only the accuracy of these models but also the optimal point and method of integration within the clinical workflow [15,47]. Most studies also provide limited information on deployment pathways, including regulatory considerations, governance for performance monitoring, and safeguards when image quality is insufficient, and direct comparisons with human experts under identical capture conditions remain uncommon [15,47]. Accordingly, priority next steps include multisite, device-agnostic external validation using real-world pediatric data and prospective evaluations of workflow-level impact and safety rather than reliance on curated test-set metrics alone. In parallel, self-management apps for OME demonstrated high acceptability and reasonable correlation with clinic audiometry, supporting family engagement and between-visit monitoring rather than diagnosis [45].

Across randomized and comparative studies, smartphone otoscopy did not increase AOM diagnosis or antibiotic prescription in emergency settings compared to conventional otoscopy, and in some trainee contexts, it was associated with fewer prescriptions, likely due to better shared visualization and supervision [41,53]. Programs that integrate remote reviews into perioperative pathways have demonstrated high postoperative success rates and measurable cost savings for families in remote regions [32,54]. Collectively, these findings support protocolized tele-otoscopy within antibiotic stewardship approaches and access pathways that do not rely exclusively on family-owned smartphones, such as facilitated capture in schools, community programs, and clinics [28,29,34,61,64]. Additionally, remote hearing screening initiatives, when paired with follow-up during rehabilitation, may integrate synergistically with OM care, ultimately contributing to comprehensive pediatric ear health services [64,77-79]. In this review, reporting on governance and medicolegal arrangements was uncommon, representing a gap in implementation evidence. Implementation should include explicit consent, minimum image quality thresholds with default to in-person examination when unmet, and red-flag escalation [52,58,72]. Future studies should report on adverse events and medicolegal frameworks.

Tele-otoscopy is particularly valuable in indigenous and rural settings with few specialists, where school-based or outreach models led by local health workers can achieve over 80% screening coverage and facilitate timely surgical intervention [28]. Jacups et al [80] reported that the telehealth model was the most cost-effective method for providing ENT surgery to children living in remote regions, primarily by reducing patient travel. However, equity implications depend strongly on implementation design, including whether capture is facilitated and whether connectivity and device requirements are minimized [28,43,50]. Not all low-burden mHealth interventions translate into short-term clinical improvements; for example, multimedia or text messaging alone did not increase clinic attendance or improve ear outcomes over 6 weeks in a high-risk remote population, despite good acceptability [70]. Digital divide factors—device availability, connectivity and bandwidth requirements, caregiver digital and health literacy, and accessibility beyond geography (including language support and cultural adaptation)—were infrequently reported or measured systematically across included studies [43,50]. Age-related constraints are also salient in pediatrics, with lower capture quality reported in children under 24 months, which can shift burden onto caregivers when programs rely primarily on home capture [43]. Care model choice has direct equity consequences. In lower-middle-income countries, implementation models pairing screening with video-otoscopy and electronic medical record capture can broaden the scope beyond hearing thresholds alone by identifying otologic pathology, even among children with normal hearing, while enabling structured follow-up workflows [69]. Hub-based or facilitated capture workflows (community-hosted capture hubs or school programs) can reduce reliance on family-owned devices and high-bandwidth connections while enabling standardized training and explicit image quality thresholds [28,29,34]. In contrast, home-based models can improve convenience but may disproportionately disadvantage families facing barriers in time, literacy, language, connectivity, or device access unless hardware and support are provisioned [43,68].

Therefore, equity-focused deployment should prioritize community-hosted capture hubs, offline-capable apps, and hardware provision [28,43,50]. In pediatrics, careful consideration of caregivers’ role is essential, as their involvement can influence capture quality and follow-through [12,65]. Importantly, few included studies conducted formal health equity analyses or reported outcomes stratified by socioeconomic status, geography, or ethnicity, limiting conclusions on differential benefits across populations and underscoring the need for equity endpoints and subgroup reporting in future evaluations [43,50].