Approximately 8.7 million children were diagnosed with acute otitis media (AOM) in 2009, adding an average of 2 physician visits and 1.6 prescriptions per case of AOM at a direct cost of $314 per case. Although the number of visits for AOM has decreased over the past decade, it remains the number one reason for antibiotic prescribing for children under six. And adding to the costs of AOM are missed work and school days for physician visits and the stress of uncertain diagnosis when parents do not have easy access to medical evaluation.

The Oto CLINIC by CellScope, an iPhone otoscope, is designed to help fill this gap by turning one’s iPhone 5, 5S, or 6 into a mobile otoscope. CellScope is marketing its otoscope both to parents (as the Oto HOME) and clinicians, but this review will focus on its use in a clinical setting.

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The Oto CLINIC comes with either a full case for the iPhone 5/5S or an adapter for the iPhone 6. The Oto clicks into the case or adapter over the iPhone’s rear camera and is compatible with standard Welch-Allyn specula (two adult and two child specula come in a nifty carrying case). There is also an adapter for a standard insufflator bulb (not included).

69565-2. oto, outside  69565-2. Oto, Top

The CellScope app integrates nicely with the Oto CLINIC attachment. Users create an account with CellScope and can then log in with their password or with TouchID fingerprint (on the iPhone 5S or 6). The home page enables two click access to the Otoscope function. Users can take a video (for novices, there are helpful arrows pointing the way to the tympanic membrane when the “ear drum finder” setting is enabled) or still shots. The images can be saved and uploaded to CellScope’s HIPAA compliant server. Data can be added under the “diagnosis,” “symptom” and “treatment” tabs on the bottom of the screen, along with notes on the visit.

69565-3. Home screen  69565-4. Patient view
Prior images are sorted by date and by patient. Adding patient identifiers (name, date of birth, and MRN) permits users to compare the patient’s images over time. Users can also compare images between patients, which is useful for teaching purposes — both for trainees and for parents. Images can be saved without identifiers if you’re planning on using it for that.

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CellScope’s “Genius” service promises the ability to unlock their ear image library and access diagnostic assistance tools but that functionality is “coming soon.” The app also permits some customization, such as turning on the “eardrum finder” which will be helpful to trainees, and the ability to tap to record which makes one handed use easier.

Using the Oto CLINIC in clinic, I was struck by how well designed it is.  Aesthetically, it looks great and the hardware is well integrated with the software. The image quality was generally very good on my iPhone 6 although it was blurry on my iPhone 5. And there was a definitive “wow” factor among other clinicians and staff. Parents and children loved the ability to see the ear exam, which previously had been completely opaque — I even had a child barter TV time with his sibling to see the patient’s TM on my iPhone, which had certainly never happened with a traditional otoscope.

And the potential functionalities for the Oto CLINIC are exciting – for example the ability to share images with otorhinolaryngologists for consultation or track evolving exams over time. CellScope also offers an “Expert” service free for one year which offers the ability to store images on their HIPAA compliant server and export the exams (as a PDF) for scanning into EMRs. Currently, CellScope does not integrate with EMRs, although their website states that they are “working on seamless integrations for remote care.”

There were a couple of drawbacks to using the Oto CLINIC in clinic. Users trained with traditional otoscopes will face a learning curve for using the Oto CLINIC — it took a few tries before I was comfortable with using it. At first, I used both the traditional otoscope and Oto CLINIC to ensure my view of the TM. This is especially true for younger kids — it is harder to get a good seal with the CellScope on squirming toddlers than it is with traditional otoscopes.

There was also the minor hassle of taking my iPhone 6 out of its case to attach the adapter. While the full case for the iPhone 5/5S helps with that, it is not a particularly aesthetically pleasing case and may not be what providers want to use outside of clinic.

And then there is the device’s $299 price tag; which while not much more expensive than a portable otoscope, it may make it unaffordable to some providers.  While a traditional otoscope can last several years, with changing iPhone sizes and phones often being upgraded or changed yearly, a $299 investment for just one or two years would be hard to justify.  Lastly, we did note that some of the treatment recommendations (such as azithromycin) are no longer recommended for use due to S. pneumoniae resistance. We asked Cellscope about that and they indicated they would update treatment recommendations.

Comment on Oto Home

CellScope also offers the Oto HOME otoscope for parents. The Oto HOME is more affordable at $79; that includes one free consultation with subsequent consultations costing $49 via their Oto CONNECT service. This service, currently only available in California due to licensing strictures and limited reimbursement rules for telehealth services, enables parents to take a video or still shot of the TM and send it securely to a physician for recommendations within 2 hours. We recently discussed this service, the opportunities it presents, the limitations, and frankly the concerns.

Oto HOME could be a great option for kids with frequent ear infections or even to remotely follow up kids in whom a watchful waiting strategy is being pursued. The Oto CONNECT service may be more lucrative, and disruptive, long-term for CellScope but does risk balkanizing patient care and possibly increasing inappropriate antibiotic use if their consultants are less willing to discuss “watchful waiting” strategies as recommended by the AAP. There is also the concern of a missed or delayed alternative diagnoses if the ear exam is negative. We hope that as this service expands, Cellscope commits to rigorous quality control, particularly when third-party clinicians are performing the evaluation.

Ed. Note: Cellscope provided a demo device for the purposes of review.

  • Price
    • $299 for the device and Cellscope account; app itself is free (but not useful without the device).
    • easy to use interface
    • ability to store and compare images for teaching and longitudinal patient care
    • ability to share images
    • “wow” factor
  • Dislikes
    • hassle of taking iPhone out of its case and putting on the CellScope adapter
    • lack of integration with EHR
  • Overall

    Overall, the CellScope is a joy to use — it is a product so well designed, even Jony Ive (Apple’s lead product designer) would likely endorse its use. While its full potential to decrease visits may take a few years to be realized, it points to the potential for smartphones to revolutionize medicine.

  • Overall Score
  • User Interface

    Extremely easy to use, well-designed interface.

  • Multimedia Usage

    From the ability to compare images to use of video, the CellScope makes great use of the iOS format.

  • Price

    $299 is a steep price, even compared to portable otoscopes, but there is a lot of functionality for that price. It is unclear what the pricing scheme will be for the “genius” service.

  • Real World Applicability

    Works very well for older children and adolescents, a bit trickier to use with toddlers. Does take some getting used to.

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