ObjectivesThis study investigated the usefulness and performance of a two-stage attention-aware convolutional neural network (CNN) for the automated diagnosis of otitis media from tympanic membrane (TM) images.DesignA classification model development and validation study in ears with otitis media based on otoscopic TM images. Two commonly used CNNs were trained and evaluated on the dataset. On the basis of a Class Activation Map (CAM), a two-stage classification pipeline was developed to

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... accuracy and reliability, and simulate an expert reading the TM images.Setting and participantsThis is a retrospective study using otoendoscopic images obtained from the Department of Otorhinolaryngology in China. A dataset was generated with 6066 otoscopic images from 2022 participants comprising four kinds of TM images, that is, normal eardrum, otitis media with effusion (OME) and two stages of chronic suppurative otitis media (CSOM).ResultsThe proposed method achieved an overall accuracy of 93.4% using ResNet50 as the backbone network in a threefold cross-validation. The F1 Score of classification for normal images was 94.3%, and 96.8% for OME. There was a small difference between the active and inactive status of CSOM, achieving 91.7% and 82.4% F1 scores, respectively. The results demonstrate a classification performance equivalent to the diagnosis level of an associate professor in otolaryngology.ConclusionsCNNs provide a useful and effective tool for the automated classification of TM images. In addition, having a weakly supervised method such as CAM can help the network focus on discriminative parts of the image and improve performance with a relatively small database. This two-stage method is beneficial to improve the accuracy of diagnosis of otitis media for junior otolaryngologists and physicians in other disciplines.