Patent Publication Number: US-2022218187-A1

Title: Surgical visualization and treatment system

Description:
BACKGROUND 
     Middle ear surgery is performed on patients for a number of different reasons, most commonly for chronic recurring ear infections. When performing middle ear surgery, the ear, nose and throat (ENT) surgeon (or “otolaryngologist”) typically visualizes the middle ear and the surgical procedure in one of two ways. In some cases, the surgeon uses a microscope, positioned in front of the surgeon&#39;s eyes, and she typically uses her non-dominant hand to hold a suction device and her dominant hand to hold a surgical tool. In other cases, the surgeon uses a handheld endoscope to visualize the middle ear. The use of a handheld endoscope is problematic in several different ways. 
     First, standard endoscopes have long shafts and are not made for use in the ear. When the ENT surgeon uses an endoscope in the ear, he has to hold the handle of the scope up in the air, over the patient&#39;s head, with the surgeon&#39;s hand suspended in the air, unsupported. This factor alone is problematic, because if the surgeon accidentally moves his unsupported hand during surgery, he could very easily move the distal end of the endoscope in a way that could damage the tympanic membrane or one or more of the delicate structures of the middle ear. 
     Second, compounding on the first issue, endoscopes are generally much heavier than the small, thin surgical tools used in middle ear procedures. The surgeon thus has an ergonomic imbalance between a relatively heavy endoscope in her non-dominant hand and a relatively light surgical device in her dominant hand. This imbalance adds to the difficulty in stabilizing the endoscope. Additionally, holding a heavy endoscope suspended over the patient&#39;s head during a surgical procedure may quickly lead to arm and hand fatigue for the surgeon. 
     Third, since the surgeon is holding the endoscope in one hand, that hand is no longer free to hold a suction device or a surgical tool. Thus, when an endoscope is used for visualization, the surgeon cannot use a suction device and visualize the inside of the ear at the same time. 
     Fourth, standard endoscopes have straight shafts, so the surgeon must hold the endoscope in a direct line straight back from the patient&#39;s ear. This straight-line position makes it impossible, or at least incredibly challenging, to use an endoscope and a microscope in the same surgical procedure, since the position of the endoscope is directly in the path of vision of the microscope. This is a drawback, because in some procedures an ENT surgeon would like to be able to switch back and forth quickly and easily between viewing with a microscope and viewing with an endoscope. It is also challenging for a surgeon to manipulate multiple tools with straight shafts held in two hands during an ear surgery procedure, because the hands must be held very close together (due to the small diameter of the ear canal), and the tools tend to bump into one another as the surgeon manipulates them to perform the procedure. 
     For at least these reasons, it would be advantageous to have an improved system and method for ear visualization. Ideally such a system and method would be easy to use, allow for good visualization of the ear, and be compatible with use of other ear surgery devices. At least some of these objectives will be addressed in this disclosure. 
     BRIEF SUMMARY 
     This disclosure describes various embodiments of an ear endoscope device, system and method for visualizing an ear surgery procedure. In some embodiments, the ear endoscope device includes a handle, a main visualization shaft that holds a visualization component (e.g., a camera), and a tool attachment mechanism for coupling a surgical tool with the ear endoscope. Some embodiments also include the surgical tool itself. Specifically, several embodiments include a visualization component and a suction component, which work together as one device. The suction component (or other tool in alternative embodiments) may be coupled with the visualization component in a number of different ways, such as by a sheath, via one or more tubes or lumens, through the main visualization shaft, etc. 
     The device is configured to be held in, and operated with, one hand, and it is short enough and thin enough to be advanced easily into the ear canal and to allow the surgeon to rest her hand on the patient&#39;s head during the ear procedure while holding the device, which surgeons often do with their tool-holding hand in ear surgery procedures for stability. In various embodiments, the camera may be free to roll (or “spin”) about its own axis within a sheath, the camera may be free to rotate around the longitudinal axis of the suction device within the sheath, and/or the attached suction device or other surgical tool may be free to spin around the camera and/or around its own axis. 
     In one aspect of the disclosure, a device for visualizing and providing suction for a surgical procedure in an ear may include a handle, a main shaft extending from the handle and defining a longitudinal axis, an imaging sensor at a distal end of the main shaft, a light source at the distal end of the main shaft, a suction shaft extending from the handle parallel to the longitudinal axis of the main shaft, and a spring coupled with the suction shaft and/or the handle, such that when the suction shaft is advanced in a distal direction and then released, the suction shaft retracts automatically. Some embodiments may further include a thumb depress member coupled with a proximal end of the suction shaft, where the spring is disposed over a proximal portion of the suction shaft, between a top of the handle and a bottom of the thumb depress member. 
     In some embodiments, the suction shaft includes a straight proximal portion that extends parallel to the longitudinal axis of the main shaft and a distal curved portion, where the suction shaft is coupled with the handle such that it can spin and thus cause the distal curved portion to point in different directions. Such an embodiment may further include a thumb depress member coupled with a proximal end of the suction shaft. Optionally, a surface feature may be included on a top surface of the thumb depress member for facilitating a user spinning the thumb depress member to spin the suction shaft. In some embodiments, the device may also include a handle suction port on the handle, a free spin suction member disposed over a proximal portion of the suction shaft such that the free spin suction member does not spin when the suction shaft spins, a suction shaft suction port on the free spin suction member, and a suction tube connecting the handle suction port with the suction shaft suction port. In some embodiments, the free spin suction member houses two O-rings positioned above and below a hole in the suction shaft that communicates with the suction shaft suction port on the free spin suction member, and the O-rings and the free spin suction member form a seal with the suction shaft over the hole. 
     In various embodiments, the suction shaft has an outer diameter of no more than 1.1 millimeter. Some embodiments further include a suction shaft guide positioned on one side of the main shaft, where the suction shaft extends through the suction shaft guide. In some embodiments, the device includes a first suction shaft guide positioned on a first side of the main shaft, and a second suction shaft guide positioned on a second side of the main shaft, where the suction shaft may be passed through either the first suction shaft guide or the second suction shaft guide to provide suction on either side of the main shaft. 
     In some embodiments, the suction shaft includes a sharp distal tip for piercing a tympanic membrane, and the device further comprises a stop member on the suction shaft for preventing an ear tube positioned on the suction shaft from sliding proximally past the stop member along the suction shaft. In some embodiments, the handle is adjustable from a straight configuration to an angled configuration. Other embodiments may include a handle angle adjustment member removably attachable to the handle to adjust an angle by which the handle is held by a user. 
     In some embodiments, the suction shaft extends alongside the main shaft. Alternatively, the suction shaft may extend through the main shaft. The handle may include at least one suction tube port for attaching a suction tube between the handle and the suction shaft. The handle may also include at least one suction finger control port, configured to allow a user to control application of suction by placing a finger over the finger control port and releasing the finger from the finger control port. Additionally, the handle may include a finger loop configured to allow the device to be held by a single finger of the user. In one embodiment, the finger loop is configured to extend around a middle finger of one hand of the user, the device further includes a thumb depress member to be manipulated by the thumb of the same hand, and the handle further includes a suction control port configured to be covered by the index finger of the same hand. 
     In another aspect of the disclosure, a device for visualizing a surgical procedure on an ear may include a suction tube, a camera coupled with the suction tube in a side-by-side arrangement, and a sheath disposed around an outside of the suction tube and an outside of the camera to couple the suction tube and the camera together. In some embodiments, the sheath holds the camera and the suction tube in such a way that the camera is free to roll or spin about its own axis within the sheath, and the camera is also free to rotate about a longitudinal axis of the suction tube within the sheath. In some embodiments, the suction tube may have an outer diameter of no more than about 1.1 millimeters, and the camera may have an outer diameter of no more than about 2.5 millimeters. In some embodiments, for example, the sheath is disposed around the camera and the suction tube but is not fixedly attached to either one, so they are free to roll and rotate within the sheath. For example, the surgeon may want to roll the camera for image orientation and/or may want to rotate the camera around the suction tube for ergonomic reasons, such when moving the device from one hand to the other. 
     In some embodiments, the suction tube is rigid and includes a tubular portion with a distal suction end, a suction device attachment end opposite the distal suction end, and a bend in the tubular portion. In some embodiments, for example, the tubular portion is located about 40-100 millimeters from the distal suction end. In one embodiment, the bend in the tubular portion forms an angle of about 45 degrees, although other angles are possible in alternative embodiments. In some embodiments, the sheath is shorter than a distance from the distal suction end to the bend in the tubular portion, and the camera and the sheath are configured to slide along the tubular portion of the suction tube from a first position, in which a distal end of the camera is adjacent to the distal suction end of the tubular portion, and a second position, in which the distal end of the camera is proximal to the distal suction end. In some embodiments the suction tube is made of metal. In some embodiments, at least a portion of the camera may be flexible. In some embodiments, the sheath is made of a heat-shrink polymer. 
     In another aspect of the disclosure, a method for performing a surgical procedure on an ear of a patient involves holding a combined visualization and suction device in one hand and advancing a distal end of the combined visualization and suction device into the ear. The combined visualization and suction device may be the same as or similar to the one described immediately above, and it may have any or all of the features described above. The method also involves viewing using the camera to view inside of the ear, activating the suction tube inside of the ear, and performing the surgical procedure on the ear, using a surgical tool held in the hand that is not holding the combined visualization and suction device. The method may also involve using the activated suction tube of the device to hold and move one or more structures within the ear. The activated suction tube may alternatively or additionally be used to suction fluid from the ear. 
     In some embodiments, the method may further involve rolling the camera about its own longitudinal axis within the sheath. The method may also involve rotating the camera around a longitudinal axis of the suction tube within the sheath. In some embodiments, the method may involve additionally viewing the ear using a microscope. Optionally, the suction tube may include a bend, and the method may further involve holding the combined visualization and suction device outside of a direct line of sight between a surgeon&#39;s eyes and the ear. The method may also involve supporting the hand that is holding the combined visualization and suction device on the patient&#39;s head during the surgical procedure. Optionally, the method may involve supporting the hand that is holding the surgical tool on the patient&#39;s head during the surgical procedure. 
     In another aspect of the present disclosure, a device for visualizing a surgical procedure in an ear may include an ear endoscope and a coupler. The ear endoscope includes a handle, a shaft extending from the handle and having a bend with an angle of 90-155 degrees, an outer diameter of no more than 2.5 millimeters, and a length of 30-80 millimeters, an imaging sensor at a distal end of the shaft, and a light source. The coupler is attached to a side of the ear endoscope shaft for attaching a tool to the endoscope. In various embodiments, the surgical tool and the overall device may include any of the features described above. The surgical tool may be a suction device, as previously described, or alternatively it may be any other suitable tool, such as but not limited to a cutting device, a piercing device, an ear tube placement device, a seeker, tweezers or forceps. 
     In another aspect of the disclosure, a method for performing a surgical procedure in an ear of a patient may first involve attaching a tool to an ear endoscope in a side-by-side arrangement, using a coupler, where the ear endoscope includes a shaft with a bend and an outer diameter of no more than 2.5 millimeters. The method may further involve holding a handle of the ear endoscope in one hand, advancing a distal end of the ear endoscope into the ear with the tool attached, viewing an inside of the ear, using the ear endoscope, and using the tool attached to the ear endoscope to facilitate or perform at least part of the surgical procedure. The combined visualization and surgical tool device may be the same as, or similar to, the embodiment described above, and it may include any of the features described above. 
     In another aspect of the present disclosure, an ear endoscope device for use in a surgical procedure in an ear may include a handle, a visualization shaft extending from the handle, a tool guide extending from the handle parallel to the visualization shaft and configured to guide a tool into the ear with the visualization shaft, an imaging sensor at a distal end of the visualization shaft, and a light source. In one embodiment, the ear endoscope device may include at least one tool coupler on a side of the shaft, at least one suction shaft insertion port at or near a distal end of the handle, two side suction tube connection ports at or near the distal end of the handle, a rear suction tube connection port at or near a proximal end of the handle, and a suction lumen connecting the rear suction tube connection port to the two side suction tube connection ports. In various embodiments, the shaft and the handle may form an angle of between about 90 degrees and about 155 degrees. In some embodiments, the shaft may have an outer diameter of no more than about 2.5 millimeters and a length of between about 30 millimeters and about 80 millimeters. 
     In some embodiments, the ear endoscope further includes a suction device. The suction device may include a suction shaft for passing through the at least one suction shaft insertion port and the at least one tool coupler, a thumb depress member coupled with the suction shaft for allowing a user to advance the suction shaft, a side suction tube for attaching the suction shaft, via the thumb depress portion, to one of the two side suction tube connection ports, and a rear suction tube for connecting the rear suction tube connection port to a suction source. The suction device may further include a spring disposed over a proximal portion of the suction shaft, between the thumb depress member and the handle of the ear endoscope. The spring may be configured to automatically retract the suction shaft relative to the shaft when the thumb depress portion is released. In some embodiments, an open one of the two side suction tube connection ports that is not attached to the side suction tube is configured to act as a finger operated suction control for controlling the application of suction force with a user&#39;s finger. 
     In some embodiments, the handle includes two suction shaft insertion ports and two tool couplers disposed on opposite sides of the shaft, where each of the two suction shaft insertion ports feeds into a corresponding one of the two tool couplers. In some embodiments, the handle includes a finger loop for facilitating holding the device with a user&#39;s finger under the handle. Alternatively, the handle may include any other finger hold shape or other ergonomic shape to facilitate gripping the device with one hand. 
     In another aspect of the present disclosure, a method for performing a surgical procedure in an ear canal of a patient may involve holding in one hand an ear endoscope with an attached suction device, advancing a distal end of the ear endoscope with the attached suction device into the patient&#39;s ear canal, depressing a thumb depress member of the suction device with a thumb of the hand, to advance a suction shaft of the suction device relative to a visualization shaft of the ear endoscope, applying suction in the ear canal with the suction device, and viewing an inside of the ear canal, using the ear endoscope. In one embodiment, applying suction in the ear canal involves applying a finger of the hand to an open suction control opening on the handle. 
     In some embodiments, the method also involves releasing the thumb depress portion to allow a spring on the suction shaft to expand to cause the suction shaft to retract relative to the shaft of the ear endoscope. In some embodiments, depressing the thumb depress member causes the suction shaft to advance through a suction shaft insertion port on a handle of the ear endoscope and through a tool coupler attached to the shaft of the ear endoscope. The spring may be disposed over the suction shaft, between the thumb depress member and the handle. The method may optionally also involve supporting the hand that is holding the ear endoscope on the patient&#39;s head during the surgical procedure. 
     These and other aspects and embodiments are described in further detail below, in relation to the attached drawing figures. 
    
    
     
       BRIEF DESCRIPTION OF THE DRAWINGS 
         FIG. 1  is a perspective view of a surgeon&#39;s hands and a surgical field, including a patient&#39;s ear, illustrating how a prior art endoscope and surgical tool are typically held; 
         FIG. 2  is a side view of an ear visualization system, shown with a suction device, according to one embodiment; 
         FIG. 3  is a close-up illustration of a distal portion of the ear endoscope shown in  FIG. 2 ; 
         FIG. 4  is a perspective view of coupler for use with an ear visualization system, according to one embodiment; 
         FIG. 5A  is a side view of a combined visualization and suction device for use in ear surgery procedures, according to one embodiment; 
         FIG. 5B  is a side view of the visualization/suction device of  FIG. 5A , with the suction component advanced distally, relative to the visualization component; 
         FIG. 5C  is a side, exploded view of the visualization/suction device of  FIGS. 5A and 5B ; 
         FIG. 5D  is a front, end-on view of the shafts of the combined visualization and suction device of  FIGS. 5A-5C ; 
         FIG. 6  is a perspective view of a surgeon&#39;s hands and a surgical field, including a patient&#39;s ear, illustrating how a combined visualization and suction device, according to one embodiment, may be held and used during an ear surgery procedure; and 
         FIG. 7  is a side view of a combined visualization and suction device for use in ear surgery procedures, where the camera has a bend near its distal end, according to one embodiment; 
         FIG. 8  is a side view of a combined visualization and suction device for use in ear surgery procedures, where the sheath couples the camera and suction tube together at an angle relative to one another, according to another embodiment; 
         FIGS. 9A-9C  are side, front and exploded views, respectively, of a combination visualization and suction device, according to an alternative embodiment; 
         FIGS. 10A and 10B  are side views of a portion of the combination device of  FIGS. 9A-9C , illustrating a method for advancing and retracting a suction shaft relative to a visualization shaft, according to one embodiment; 
         FIG. 11  is a perspective view of portion of a patient&#39;s head, including the ear, and a physician&#39;s hand holding the combination device of  FIGS. 9A-10B ; 
         FIG. 12  is a perspective view of a visualization component of the combination device of  FIGS. 9A-11 , along with a viewing system, according to one embodiment; 
         FIGS. 13A-13C  are right/rear perspective, left/rear perspective and left side views, respectively, of an ear endoscope device, according to one embodiment; 
         FIG. 14A  is a side view of the ear endoscope device of  FIGS. 13A-13C , with a detached optional suction device for the ear endoscope, according to one embodiment; 
         FIG. 14B  is a side view of the ear endoscope and suction device of  FIG. 14A , with the suction device attached to the ear endoscope; 
         FIG. 14C  is a perspective view of the ear endoscope with suction device of  FIGS. 14A and 14B , shown in the left hand of a physician user; 
         FIG. 15  is a distal-end view of a shaft of an ear endoscope, according to an alternative embodiment; 
         FIGS. 16A and 16B  are side views of an ear endoscope with a curved tip suction shaft, showing the suction shaft advanced distally ( FIG. 16A ) and retracted proximally ( FIG. 16B ), according to one embodiment; 
         FIG. 17  is a side view of an ear endoscope with a curved tip suction shaft and a handle with a finger loop, according to an alternative embodiment; 
         FIGS. 18A-18D  are perspective views of four different embodiments of a thumb depress member of an ear endoscope with a curved tip suction shaft; 
         FIG. 19  is a side view of an ear endoscope device with an adjustable-angle handle, according to one embodiment; 
         FIG. 20  is a side view of an ear endoscope device with a malleable handle, according to one embodiment; 
         FIG. 21A  is a side view of an ear tube placement, visualization and suction device, advanced partway into an ear canal, according to one embodiment; 
         FIG. 21B  is a side view of the device of  FIG. 21A , showing placement of an ear tube across the tympanic membrane, according to one embodiment; 
         FIG. 22  is a side view of a curved distal end of an ear tube placement, visualization and suction device, according to one embodiment; and 
         FIGS. 23 and 24  are side views of a portion of an ear visualization/suction device, illustrating a removable handle adjustment feature ( FIG. 24 ); 
         FIGS. 25 and 26  show the portion of the device from  FIGS. 23 and 24  without ( FIG. 25 ) and with ( FIG. 26 ) an optional handle adjustment feature; 
         FIGS. 27A and 27B  are diagrammatic illustrations of an ear visualization/suction device of the present application, shown in an orientation as if the device were being held in a left hand while inserted into a right ear ( FIG. 27A ) and a left ear ( FIG. 27B ), according to one embodiment; 
         FIGS. 28A and 28B  are diagrammatic illustrations of an ear visualization/suction device of the present application, shown in an orientation as if the device were being held in a left hand while inserted into a right ear ( FIG. 28A ) and a left ear ( FIG. 28B ), according to an alternative embodiment; 
         FIGS. 29A and 29B  are front perspective and side perspective views, respectively, of an ear visualization and suction device, according to an alternative embodiment; 
         FIG. 29C  is a side view of a suction shaft portion of the device of  FIGS. 29A and 29B ; 
         FIG. 30  is a side view of two different suction shaft portions of the device of  FIGS. 29A and 29B ; 
         FIG. 31A  is a rear perspective view of the device of  FIGS. 29A and 29B , with an alternative suction shaft portion attached and with part of the handle removed; 
         FIGS. 31B and 31C  are top views of a portion of the configuration of the device of  FIG. 31A ; 
         FIG. 32A  is a side view of an ear visualization and suction device with optional irrigation, according to one embodiment; 
         FIG. 32B  is a side view of the device of  FIG. 32A , with the suction component not shown and the irrigation portion removed from the handle; 
         FIG. 32C  is a side view of the device of  FIGS. 32A and 32B , with the suction component not shown and the irrigation portion inserted into the handle; and 
         FIG. 32D  is a top view of the device of  FIGS. 32A-32C , in the configuration of  FIG. 32C . 
     
    
    
     DETAILED DESCRIPTION 
     In general, the embodiments described herein are directed to a device, system and method for visualizing an ear surgery procedure. The ear visualization device generally includes an ear endoscope (or “camera”), with an attachment mechanism for attaching an additional tool to the endoscope. Oftentimes, the additional tool is a suction device, so the device provides for visualization and suction with one device, held in one hand. In alternative embodiments, however, any of a number of different tools may be attached to the endoscope, in addition to or instead of a suction device. In some embodiments, the attachment mechanism for attaching the additional tool is built into the endoscope. Alternatively, the attachment mechanism may be a separate coupler or sheath, which attaches to the shaft of the ear endoscope and allows any of a number of different types of surgical tools to be attached to the endoscope in a side-by-side arrangement. In yet other embodiments, visualization and suction may be integrated into the device. The ear visualization system may include the ear endoscope along with a separate attachment mechanism, a light source for the endoscope, a video monitor for displaying images captured by the endoscope and/or any other suitable components. In some embodiments, the system may also include a suction device or other surgical tool. In other embodiments, the ear endoscope device or system may be provided by itself, and may be used with one or more optional, stand-alone tools. 
     As mentioned immediately above, in some embodiments, the attachment mechanism is a separate piece, which may be removed from the endoscope shaft. In such embodiments, the endoscope and the coupler may be referred to as a “system,” due to the combination of two different devices. In alternative embodiments, the coupler may be integral with, or permanently attached to, the endoscope shaft, in which case the endoscope with coupler may be referred to as a “device.” In any case, use of the terms “system” and “device” herein should not be interpreted as limiting the scope of the invention. 
     In some embodiments, the device may include an endoscope and a suction tube that also operates as an ear tube placement device. The distal tip of the suction/ear tube placement component may have a sharp distal tip to pierce the tympanic membrane, and the device may also include a stop for preventing the ear tube from sliding proximally up the suction/ear tube placement component. This device embodiment is described in further detail below. 
     The shaft of the ear endoscope and whatever surgical tool it is used with may have very small diameters, so the distal end of the combined device fits easily into an ear canal, for helping visualize and perform an ear surgery procedure. In some embodiments, the coupler surrounds part of the endoscope shaft and part of the surgical tool in such a way that the shaft can rotate about a longitudinal axis of the tool and can also roll (or “spin”) about its own longitudinal axis. 
     In one embodiment, described in detail below, the surgical tool is a suction tube device. In alternative embodiments, however, the tool may be any suitable, small-diameter tool, such as but not limited to a cutting device, a piercing device, an ear tube placement device, a seeker, tweezers, forceps, a speculum, a grasper, or a curette. In the description below of the suction embodiment, the fact that any other suitably sized surgical tool may be substituted for the suction device will not be repeated with the description of every embodiment. Similarly, the devices and methods described below for use in an ear surgery procedure may be used or adapted for use in any other suitable surgical procedure. This, too, will not be repeated with the description of every embodiment. 
     Although the following description is focused on use of the devices, systems and methods for visualizing and facilitating ear surgery procedures, the same embodiments may be used, or adapted for use, in any other suitable procedures and parts of a human or animal body. Therefore, the invention is not limited to use in the ear. 
     Referring now to  FIG. 1 , a prior art method for performing an ear surgery using a standard endoscope  10  is illustrated. The figure shows a surgical field, with the patient&#39;s ear E exposed for the procedure. The surgeon is holding the endoscope  10  in his left hand L and a surgical tool  12  in his right hand. Due to the length of the endoscope  10 , the surgeon has to hold his left hand L up in the air, suspended over the patient, in order to hold the handle of the endoscope  10 . As mentioned previously, this can be very awkward and potentially dangerous to the tympanic membrane and/or structures of the middle ear, especially in longer procedures where the surgeon&#39;s left arm and left hand L get fatigued. Additionally, the surgeon does not have a free hand to hold a suction device or other surgical tool, since both of the surgeon&#39;s hands are occupied. To have suction in this scenario, a nurse or other assistant would have to hold the suction device in the patient&#39;s ear. 
     Referring to  FIG. 2 , an ear surgery visualization system  100 , according to one embodiment, may include an ear endoscope  102  and a coupler  112 . Also pictured in  FIG. 2  is a suction device  128 , which is not necessarily part of the system  100 , but which is shown in the figure for illustrative purposes. In alternative embodiments, the suction device  128  may be replaced by any other suitable surgical tool, such as the ones listed previously. 
     The ear endoscope  102  includes a handle  104 , a shaft  106  and a processor  122 , which may also act as a light source. The shaft  106  includes a proximal portion  107 , a bend  108  and a distal portion  110 , ending in a distal tip  111 . The endoscope  102  also includes a light source  120  in the handle  104 , and light fibers  118  that carry the light from the light source  120 , through the shaft  106 , to the distal tip  111 . A camera on a chip (described more fully below) may be positioned at the distal tip  111 , to acquire images of the ear. The system  100  may also include a video monitor  126 , although optionally the video monitor  126  may be a separate component that is not part of the system  100 . In another embodiment, the processor  122  and video monitor  126  may be combined in one unit. 
     The shaft  106  of the endoscope  102  may have a total length of about 30 millimeters to about 80 millimeters and an outer diameter of less than about 2.5 millimeters. In some embodiments, the outer diameter of the shaft  106  may be continuous along its length. Alternatively, the outer diameter of the distal portion  110  may be smaller than the outer diameter of the proximal portion  107 . The bend  108  may form an angle between the proximal portion  107  and the distal portion  110  of between about 90 degrees and about 155 degrees. The handle  104  may be very small and lightweight, compared to typical endoscope handles. In fact, the handle  104  may be shaped to have a comfortable pencil grip, so the surgeon may hold and manipulate the ear endoscope  102  like a pencil. Ear endoscope  102  may also include a cable  124 , attaching the handle  104  to the processor  122 . 
     The coupler  112  includes an endoscope attachment portion  114  and a tool attachment portion  116 . In some embodiments, each of the two portions  114 ,  116  is shaped as a tube or a semicircular tube. In some embodiments, the endoscope attachment portion  114  and the tool attachment portion  116  may have the same diameter. Alternatively, they may have different diameters. For example, in some embodiments the endoscope attachment portion  114  has a larger diameter than that of the tool attachment portion  116 . The coupler  112  may be permanently attached to the shaft  106 , or it may be removable, according to different alternative embodiments. The coupler  112  may be attached to the distal portion  110  of the shaft  106 , as shown. Alternatively, the coupler  112  may be attached to the proximal portion  107 , for example if the shaft  106  is straight, or of the coupler  112  follows the bend  108  in the shaft  106 . 
     The weight, size and feel of the ear endoscope  102  may be similar to that of other ear surgery tools. This makes it more comfortable for the surgeon to hold and prevents an imbalance between the ear endoscope  102  and other tools. The surgeon may hold the handle  104  with a pencil grip and may rest her hand and/or the handle  104  on the patient&#39;s head during the procedure. In order to achieve this desired weight, size and feel, any suitable materials may be used for the various parts of the ear visualization system  100 . For example, in one embodiment, the handle  104  may be made of any suitable lightweight plastic, and the shaft  106  may be made of any suitable metal, such as stainless steel. Alternatively, the handle  104  may be made of a lightweight metal. The coupler  112  may be made of plastic or metal, for example. Any suitable, medically safe materials may be used. 
     As mentioned above, a suction device  128  is illustrated in  FIG. 2 , attached to the shaft  106  of the endoscope  102  via the coupler  112 , in a side-by-side arrangement. Any other tool may be substituted for the suction device  128 , in alternative embodiments. The suction device  128  is also shown with a source of suction  130 , which may be a separate component, wall suction, or any suitable suction source. The suction tube portion of the suction device  128  is flexible, at least along part of its length, and has a distal portion with an outer diameter that fits within the tool attachment portion  116  of the coupler. Various embodiments and features of a suction device  128  are described in further detail below. 
     Referring now to  FIG. 3 , the distal portion  110  of the endoscope shaft  106  is illustrated in greater detail. At the distal end  111  of the shaft  106  are positioned an imaging sensor  140  and two light sources  142 . The imaging sensor  140  may be any type of suitable sensor, such as a complementary metal-oxide semiconductor (CMOS) camera or any other “camera on a chip” type of device. The two light sources  142  (or alternatively any other number of light sources) may be light emitting diode (LED) lights, for example. These may be in addition to, or as an alternative to, the light source  120  shown in the handle  104  in  FIG. 2 . In other words, according to various embodiments, one or more light sources for the endoscope device  102  may be located in the handle  104 , at the distal end  111  of the shaft  106 , or both. 
       FIG. 4  is a magnified view of an alternative embodiment of a coupler  212  for use with the ear endoscope  102 . The coupler  212  includes an endoscope attachment portion  214 , a tool attachment portion  216 , a longitudinal top opening  250  in the tool attachment portion  216 , and a longitudinal middle opening  252  between the endoscope attachment portion  214  and the tool attachment portion  216 . In this embodiment the endoscope attachment portion  214  has a larger diameter than that of the tool attachment portion  216 . The tool (not shown) may be inserted into the tool attachment portion  216  by pushing it down through the top opening  250  or by sliding it into the proximal end of the tool attachment portion  216  and advancing it distally. In the case where the tool is pushed through the top opening  250 , the coupler  212  may flex outward slightly, by expanding at the two openings  250 ,  252 , to accommodate the tool. In alternative embodiments, the endoscope attachment portion  214  and/or the tool attachment portion  216  may be formed as complete tubes, with circular cross-sections rather than semi-circular cross-sections. As mentioned above, the coupler may be made of any suitable material. 
     Referring to  FIGS. 5A-5D , one embodiment of an ear surgery visualization device  20  is illustrated. In this embodiment, the visualization device  20 , which may also be called “a combined visualization and suction device,” includes a suction tube  22 , a camera  30  and a coupler  38  (or “sheath”) disposed around the suction tube  22  and the camera  30 . The suction tube  22  has a distal end  24 , a proximal end  26  for connecting with suction tubing connected to a suction source, and a bend  28  along its length. The camera  30  includes a distal portion  32 , a proximal portion  36  and a distal end  34 . 
     The suction tube  22  may be any standard or customized suction tube device. In various embodiments, the suction tube  22  may be rigid and may be made out of any suitable material, such as stainless steel or other biocompatible metal or plastic. The suction tube  22  will have an overall diameter and length to allow it to be advanced easily into the ear and to allow a surgeon to hold the visualization device  20  with one hand, resting on the patient&#39;s head, during the procedure. In some embodiments, for example, the suction tube  22  has an outer diameter, at least along the portion between the bend  28  and the distal end  24 , of about 0.6 millimeter to about 1.1 millimeters. The bend  28  in the suction tube  22  is optional, and alternative embodiments may be straight. The bend  28  may be advantageous, however, because it allows the visualization device  20  to be held at an angle from the ear, so the hand holding the device  20  is not in the direct line of sight of the surgeon. This is especially advantageous in cases where the surgeon wants to use a microscope and the visualization device  20  in the same procedure, but it is also advantageous in keeping the suction tube  22  and the camera  30  out of the way of any surgical tools held in the surgeon&#39;s other hand. In various embodiments, for example, the bend  28  may be located about 40 millimeters to about 100 millimeters from the distal end  24  of the suction tube  22 . In one embodiment, the bend may be about 60 millimeters from the distal end  24 . In alternative embodiments of the device  20 , where the camera  30  is combined with a different type of surgical tool rather than the suction tube  22 , that surgical tool may also include the same or a similar bend. 
     The camera  30  may be any suitable, small-diameter camera for viewing an ear during an ear surgery procedure. In some embodiments, for example, the camera  30  may be a fiber optic camera or a complementary metal-oxide-semiconductor (CMOS) camera. As small-diameter cameras are well known, they will not be described in detail here. In some embodiments, at least the distal portion  32  of the camera  30  may be relatively rigid, so that the surgeon can easily roll it about its longitudinal axis and/or rotate it relative to the suction tube  22 . In some embodiments, the camera  30  may include a bend, which may coincide with the bend  28  in the suction tube. The camera  30  may include CMOS sensors with a lens array. The sensors may be arrayed in a cube of between 0.6 mm by 0.6 mm and 1.0 mm by 1.0 mm, with overall length of up to 3 mm, in some examples. Alternative embodiments may include a fiber optic bundle for image capture, rather than CMOS. The light source for illumination may be LED at the distal tip  34  or fiber infused with light from a remote LED. 
     The cross-sectional shape of the camera  30  may vary in different embodiments (round, oval, square, rectangular, etc.), but in the embodiment shown the camera  30  has a round cross-sectional shape. This is advantageous for rolling and rotating the camera  30  within the coupler  38  and relative to the suction tube  22 . The body of the camera  30  is made from a relatively rigid or at least semi-rigid material, such as stainless steel or plastic (e.g., thermoplastic). The length of the distal portion  32  may be, for example, about 5 mm to about 100 mm. In some embodiments, the distal portion  32  may be as long as the length of the suction tube  22  from its distal end  24  to the bend  28 , which in one embodiment is about 60 mm. In various embodiments, the camera  30  and a light source may be integrated into a metal tube, over-molded with plastic, encapsulated in a polymer, or the like. 
     The coupler  38  may be any suitable material and have any suitable length, thickness and size, according to various embodiments. In one embodiment, the coupler  38  is formed as a tube of heat-shrink polymer wrap that surrounds distal portions of the suction tube  22  and the camera  30 . The heat-shrink polymer may be polyethylene terephthalate (PET) in some embodiments, or may alternatively be any other suitable polymer, such as but not limited to a polyolefin, a polyimide or nylon. As illustrated in  FIGS. 5A and 5B , in one embodiment, the coupler  38  is disposed about the suction tube and the camera  30  such that the suction tube  22  can advance ( FIG. 5B ) and retract ( FIG. 5A ), relative to the coupler  38  and the camera  30 . For example, in some embodiments, the suction tube  22  can advance from a position where its distal end  24  is at or near the distal end  34  of the camera  30  ( FIG. 5A ) to a position where its distal end  24  is ahead of that of the camera  30  ( FIG. 5B ). In this embodiment, the camera  30  may also be able to slide forward and backward. In alternative embodiments, camera  30 , suction tube  22  or both may be fixed to the inner surface of the coupler  38 , such as by adhesive, thus reducing the amount of mobility of one or both components relative to the coupler  38 . 
       FIG. 5C  is an exploded view of the ear surgery visualization device  20 , showing the suction tube  22 , the camera  30  and the coupler  38  separate from one another. For assembly, the coupler  38  may be wrapped or slid over the suction tube  22  and the camera  30  in some embodiments. 
       FIG. 5D  illustrates possible directions of movement of the camera  30 , the suction tube  22  and the coupler  38 , relative to one another. In some embodiments, the coupler  38  may be positioned around but not fixedly attached to the camera  30  and the suction tube  22 , as described above. In addition to allowing the suction tube  22  and/or the camera  30  to advance longitudinally through the coupler  38 , this configuration also allows the suction tube  22  and the camera  30  to roll about their own axes within the coupler  38  (two small hollow arrows around perimeter of coupler  38 ). Additionally, the camera  30  may be rotated around a longitudinal axis of the suction tube  22  (larger hollow arrow). The suction tube  22  may also be rotated around a longitudinal axis of the camera  30 . This freedom of movement—rotation and rolling—allow the surgeon to adjust the orientation of the camera  30  and/or the suction tube  22  easily and quickly, without necessarily changing the orientation of both components. Again, however, in alternative embodiments the coupler  38  may be adhered or otherwise fixedly attached to either or both of the camera  30  and the suction tube  22 . 
       FIG. 6  shows a surgical field, including a patient&#39;s ear E, and the left hand L and the right hand R of a surgeon, performing a procedure on the ear E. The surgeon&#39;s left hand L is holding the ear surgery visualization device  20 , as described above, which includes the suction tube  22  and the camera  30 . The suction tube  22  is attached proximally to a suction hose  40 , which in turn is attached to a source of suction (not shown). The surgeon&#39;s right hand R holds a surgical tool  12 . As indicated by the large arrows on the figure, the surgeon&#39;s hands are approaching the ear E from two different angles, leaving a line of direct vision open from the surgeon&#39;s eyes to the patient&#39;s ear E (depicted by the middle/upper-right hollow arrow). This arrangement will allow a surgeon to visualize the surgical field using both a microscope and the camera  30 , if desired. As also illustrated in  FIG. 6 , the ear visualization device  20  is sized and shaped such that the surgeon can rest her hand on the patient&#39;s head during the procedure. In performing the procedure, the surgeon may advance the device  20  into the ear E, suction out the ear E using the suction tube  22 , visualize the ear E using the camera  30 , and perform the procedure. Alternatively or additionally, the suction tube  22  may be used to hold onto and move one or more small anatomical structures of the ear, such as but not limited to the bones of the middle ear. Suction may also be used to hold different devices, such as an ear tube or ossicular prostheses. The device  20  is generally small enough that the camera  30  can be used to visualize the middle ear through a natural hole or incision in the tympanic membrane. These actions may be performed in any sequence and in any combination. In some embodiments, it may be possible for the surgeon to separate the camera  30  from the suction tube  22  during the ear surgery procedure, so they can be used separately. 
     In some embodiments, the ear surgery visualization device  20  may be used with another, different ear surgery visualization device (not shown). For example, the combined camera/suction tube device  20  may be held in the surgeon&#39;s non-dominant hand, and a combined camera/surgical tool device may be held in the surgeon&#39;s dominant hand. These two devices  20  may be used at the same time, thus acquiring two images of the ear. The views from the two cameras may be displayed on a single, split video screen, for example, with the right half marked ‘R’ and the left half marked ‘L’. In all embodiments, the video screen may be separate and located above the patient&#39;s head and within the field of view of a microscope, so that the surgeon can view the surgical field through the microscope and look at the endoscopic view through the microscope as well, or simply switch from looking through the microscope to looking at the video screen. In another embodiment, it may be possible to digitally feed the endoscopic image into the microscope, so that the surgeon can view both of them through the microscope, or toggle between them by pressing a button, for example. 
     Referring now to  FIG. 7 , an alternative embodiment of an ear surgery visualization/suction device  50  is illustrated. As mentioned above, in some embodiments, the suction tube  22  may be advanced, relative to the camera  30 , as shown in  FIG. 5B , such that the distal end  24  of the suction tube  22  is ahead of the distal end  34  of the camera  30 . In embodiments where the distal portions of the suction tube  22  and the camera  30  are both straight and are connected in parallel with one another, the suction tube  22  may interfere with the field of view of the camera  30  in this configuration. The embodiment of the device  50  shown in  FIG. 7  is configured to address that issue. In this embodiment, the distal portion  32  of the camera  30  includes a bend  52 . This bend  52  orients the field of view  54  of the camera  30  at an angle, relative to the longitudinal axes of the suction tube  22  and the camera  30 , so the suction tube  22  does not interfere with or limit the field of view  54 . In various embodiments, the bend  52  may be located anywhere along the length of the camera  30 , although in many embodiments it will be located near the distal end  34 , so that it is distal to the distal end of the coupler  38 . 
     Referring now to  FIG. 8 , another alternative embodiment of an ear surgery visualization/suction device  60  is illustrated. This embodiment is alternative way of addressing the issue of the suction tube  22  cutting off part of the field of view  54  of the camera. In this embodiment, the sheath  68  has a wider distal end  64  and a narrower proximal end  66 . Thus, the sheath  68  couples the camera  30  and the suction tube  22  together such that they are oriented at an angle relative to one another. In other words, they are not parallel with one another. As with the previous embodiment, this helps prevent the field of view  54  of the camera  30  from being limited by the suction tube  22 . 
     Referring now to  FIGS. 9A-9C , one embodiment of an ear visualization system  300  is illustrated. The ear visualization system  300  includes an ear endoscope  302  and an optional suction device  310 . The ear endoscope  302  includes a handle  304 , a shaft  306  extending from one end of the handle  304 , two tool couplers  307   a ,  307   b  (see  FIG. 9B ) on either side of the shaft  306 , and a cable  308  extending from the opposite end of the handle  304 . Imaging components pass through the handle  304 , the shaft  306  and the cable  308 , which components may be any of those described above and which are not shown in these figures. The handle  304  includes two suction shaft apertures  305   a ,  305   b  (not visible in these drawings, because they are on the top surface of the handle  304 ), through which the shaft  316  of the suction component  310  is advanced. The shaft  316  of the suction component  310  advances through one of the two tool couplers  307   a ,  307   b , after exiting the distal end of the corresponding aperture  305   a ,  305   b . The handle  304  may have any of a number of suitable sizes, shapes and weights, but in this embodiment it is configured to be held easily in a pencil grip by the physician. The handle  304  may be made of lightweight plastic, in some embodiments. 
     The suction component  310  includes a suction tube  312 , a thumb depress portion  314 , a suction control aperture  320 , a suction shaft  316  with a distal end  317 , and a spring  318  disposed over the suction shaft  316 , between the thumb depress portion  314  and the handle  304 . The suction shaft  316  extends through the suction shaft aperture  305   a  in the handle  304 , through the tool coupler  307   a , and alongside the visualization component shaft  306 . As will be described further below, the user physician may depress the thumb depress portion  314  to advance the distal end  317  of the suction shaft  316  out of the distal end of the visualization shaft  306  and thus farther into the ear. When the user releases the thumb depress portion  314 , the spring  318  automatically retracts the suction shaft  316  back along the visualization shaft  306 , through the tool coupler  307   a  and the aperture  305   a . The physician may use an index finger (or other finger) to cover the suction control aperture  320  to apply suction, and she may remove the finger from the hole to remove or reduce suction at the distal end  317  of the suction shaft  316 . 
       FIG. 9B  is a front view of the ear visualization system  300 , which illustrates that this embodiment includes two suction tool couplers  307   a ,  307   b , one on either side of the visualization component shaft  306 . This embodiment thus also includes two suction shaft apertures  305   a ,  305   b , each feeding into one of the two suction tool couplers  307   a ,  307   b . The two tool couplers  307   a ,  307   b  facilitate holding and manipulation of the device  300  by either a right hand or a left hand, and placement of the suction tube/other tool either below or above the camera sensor. The visualization component shaft  306 , the tool couplers  307   a ,  307   b  and the suction shaft  316 , in some embodiments, may be made of metal, such as stainless steel or other biocompatible metal. In some embodiments, the visualization component shaft  306  has an outer diameter of about 2.5 millimeters or less. Similarly, each of the tool couplers  307   a ,  307   b  may have an outer diameter of about 2.5 millimeters or less. The suction shaft  316  has an outer diameter sized to fit through the inner diameter of the tool couplers  307   a ,  307   b . In some embodiments, the suction shaft  316  may have an outer diameter of about 1.1 millimeters or less. 
       FIG. 9C  is a side view of the ear visualization system  300 , with ear endoscope  302  separated from the suction device  310 . In this embodiment, the ergonomic design of the handle  304  may be important for facilitating handling of the system  300  by the physician. For example, the handle  304  includes a finger grip feature  322 , which may allow for easy gripping of the handle  304  with a middle finger (or other finger). The user&#39;s index finger may be used to control the suction control aperture  320 , and the user&#39;s thumb may be used to control the thumb depress portion  314  of the suction component  310 . In other embodiments, one of which is described below, the finger grip feature  322  may include a loop, an elastic ring or any other suitable shape. 
     In various alternative embodiments, one or more variations may be made to the ear endoscope device  300 . For example, in some embodiments, the couplers  307   a ,  307   b  may extend the entire length (or along a longer portion but not the entire length) of the endoscope main shaft  306 . In some embodiments, there may be only one coupler and one aperture, rather than two couplers  307   a ,  307   b  and two apertures  305   a ,  305   b.    
     Referring to  FIG. 15 , in yet another alternative embodiment, an ear endoscope shaft  500  may include an outer shaft body  502 , a tool guide  504  forming a tool lumen  506 , two light sources  508   a ,  508   b  and an imaging sensor. The tool guide  504  and tool lumen  506 , in this embodiment, are located inside the outer shaft body  502 , unlike the previously described embodiments that place the suction tube through a coupler on the outside of the main endoscope shaft. In some embodiments, the tool guide  504  may be used for applying suction or advancing a suction device through the shaft  500 . Alternatively, the tool guide  504  may be used for advancing any other suitable tool through the ear endoscope shaft  500 , such as any tool listed in this application. This embodiment of  FIG. 15  may be applied to any of endoscope embodiments described above or below to generate alternative embodiments. 
       FIGS. 10A and 10B  illustrate a method for advancing and retracting the suction shaft  316  in the ear visualization system  300 , according to one embodiment. In  FIG. 10A , the physician is depressing the thumb depress portion  314  of the suction component  310  with her thumb T. This advances the suction shaft  316  through the handle  304  and the tool coupler  307   a , thus advancing the suction shaft  316  along the side of the visualization shaft  306 . Thus, the distal end  317  of the suction shaft  316  would be advanced farther down into the patient&#39;s ear. In this configuration, the spring  318  is compressed. In  FIG. 10B , the physician has released her thumb T from the thumb depress portion  314 , allowing the spring  318  to expand and causing the suction shaft  316  to retract proximally through the tool coupler  307   a  and the handle  304 . Thus, the physician can easily adjust the position of the distal end  317  of the suction shaft  316  relative to the visualization shaft  306 . 
     In various embodiments, the distal end  317  of the suction shaft  316  may be positioned in a number of different locations relative to the distal end of the visualization shaft  306 . When the suction shaft  316  is fully advanced, its distal end  317  may be located at, proximal to or distal to the distal end of the visualization shaft  306 . Similarly, when the suction shaft  316  is fully retracted, its distal end  317  may be located at, proximal to or distal to the distal end of the visualization shaft  306 . For example, in one embodiment, the distal end  317  of the suction shaft  316  may be disposed even with the distal end of the visualization shaft  306  in the fully retracted position and then may be advanced to a position distally beyond the distal end of the visualization shaft  306 . In another embodiment, the distal end  317  of the suction shaft  316  may be disposed more proximally than the distal end of the visualization shaft  306  in the fully retracted position and then may be advanced to a position even with the distal end of the visualization shaft  306 . Any combination of locations is possible, according to various alternative embodiments. 
     Referring to  FIG. 11 , a physician&#39;s hand H is shown holding the combination device  300  over an anatomical model. As shown, the handle  304  fits comfortably in the hand H, with the middle finger on the bottom and the index finger on the top. The thumb is positioned on the thumb depress portion  314 , and the visualization component shaft  306  and the suction shaft  316  are extended into the model. During an ear procedure, the physician might rest his or her hand on the patient&#39;s head, for support and stability and to prevent arm fatigue. The very light weight of the handle  304  and the device  300  in general make it easy to manipulate and hold. 
     Referring now to  FIG. 12 , in some embodiments, the ear visualization system  300  may include the ear endoscope  302  and a viewing system  330 . The viewing system may include a video monitor  336 , a console  332  and a cable  334  connecting the two. The console  332  may include a connector  338 , into which a connector  337  on the visualization component  302  inserts. The various parts of the viewing system  330  may be any suitable off-the-shelf or custom components, according to various embodiments. In an alternative embodiment, the console  332  may include a built-in screen, rather than having a separate video monitor  336 , and the endoscope  300  would connect to the console  332 . In various embodiments, the ear endoscope  302  may be provided with the viewing system  330 , with the suction device  310  or as a stand-alone device. 
     Referring now to  FIGS. 13A-13C , another embodiment of an ear endoscope  400  is illustrated. In this embodiment the ear endoscope  400  includes a handle  402  with a finger loop  404 , a shaft  406 , two tool coupling shafts  408   a ,  408   b , two side suction tube connection ports  410   a ,  410   b , two suction tube insertion ports  412   a ,  412   b , a rear suction tube connection port  414  and a sensor interface cable  416 . In this embodiment, the ear endoscope  400  may be provided as a separate unit and may be used with an add-on suction device, or it may be provided with the suction device. In either case, a suction supply may be connected to the rear suction tube connection port  414 , which is in fluid communication with a suction lumen running through the handle  402  and exiting at the two side suction tube connection ports  410   a ,  410   b . One of the two side suction tube connection ports  410   a ,  410   b  may in turn be connected to a short suction tube, which is connected to a suction shaft that passes through one of the suction tube insertion ports  412   a ,  412   b  and one of the tool coupling shafts  408   a ,  408   b , as will be described further below. Whichever of the two suction tube connection ports  410   a ,  410   b  is left open may be used by the physician as a suction control, by placing a finger over the open port  410   a  or  410   b  to apply suction or releasing the finger from the open port  410   a  or  410   b  to turn off suction. 
     The finger loop  404  on the handle  402  may be flexible in some embodiments and rigid in others. In alternative embodiments, the finger loop  404  may have any other suitable shape or size for facilitating gripping the endoscope  400 . The finger loop  404  allows the physician user to hold and operate the ear endoscope  400  with one hand. In fact, the finger loop  404  may allow the physician to hold the handle  402  with one finger (middle finger, for example) and operate other functions of the device  400  with other fingers. For example, the user may pass a middle finger through the finger loop  404 , use the thumb of the same hand to advance the suction tube, and use the index finger of the same hand to control suction by covering and uncovering the open port  410   a  or  410   b . Alternatively, the fingers may be placed and used in a different configuration on the handle  402 . As is evident from  FIGS. 13A-13C , the shaft  406  is straight in this embodiment, but it is angled relative to the handle  402 , so that the overall endoscope device  400  is angled, to allow the physician to place the shaft  406  in the ear canal without obstructing a direct viewing path into the ear canal. 
     Referring now to  FIGS. 14A-14C , the ear endoscope  400  of  FIGS. 13A-13C  is now shown with an optional suction device  420 .  FIG. 14A  shows the suction device  420  detached from the ear endoscope  400 . The suction device  420  includes a suction shaft  422 , connected to a thumb depress member  424 , which is connected to a side suction tube  426 . A spring is disposed over a proximal portion of the suction shaft  422 , to provide for automatic retraction of the suction shaft  422  relative to the main shaft  406  of the ear endoscope  400 , when the user releases pressure off of the thumb depress member  424 . The suction device  420  may also include a rear suction tube  428 . The suction shaft  422  is passed through either of the two suction tube insertion ports  412   a ,  412   b  and thus through the corresponding tool coupling shaft  408   a ,  408   b . Side suction tube  426  may be connected to either of the two side suction tube connection ports  410   a ,  410   b , leaving the opposite side port  410   a ,  410   b  open for finger control of suction. Additionally, the rear suction tube  428  is attached to the rear suction tube connection port  414 , to supply suction force from a suction supply (such as wall suction, canister suction, etc.—not shown in  FIG. 14A ) to the suction device  420 . As explained above, a suction lumen in the handle  402  of the endoscope  400  (not visible in the figures) connects the rear suction tube connection port  414  with the two side suction tube connection ports  410   a ,  410   b.    
       FIG. 14B  shows all the components of the suction device  420  attached to the ear endoscope. As shown in this figure, the spring  418  resides over the suction shaft  422  and between a bottom surface of the thumb depress member  424  and a top surface of the handle  402 . When the user presses down on the thumb depress member  424 , the suction shaft  422  advances distally along the main shaft  406 , and the spring  418  compresses. When the user then releases pressure off of the thumb depress member  424 , the suction shaft  422  automatically retracts proximally, relative to the handle  402  and the main shaft  406 . 
       FIG. 14C  shows a physician&#39;s left hand H holding the combined ear endoscope  400  and suction device. As illustrated here, the physician&#39;s thumb is positioned on the thumb depress member  424  and is used to advance the suction shaft  422 . The physician&#39;s middle or ring finger may be placed through the finger loop  404  of the handle  402 , and the physician&#39;s index finger may be placed over or removed from the open side suction tube connection port  410   b , to control the application of suction through the suction shaft  422 . If the physician prefers to hold the ear endoscope  400  in his right hand, the side suction tube  426  and suction shaft  422  may simply be shifted to the opposite side of the ear endoscope  400 . 
       FIG. 15  is a cross-sectional view of a distal/shaft portion of an ear visualization device  500 , according to one embodiment. The portion of the device  500  illustrated in  FIG. 15  may be used with any of the embodiments described above or below. The illustrated portion of the device  500  includes an outer shaft  502 , inside of which there is a suction shaft  504  forming a suction lumen  506 . Also located inside the outer shaft  502  are a camera  510  and two sets of light fibers  508   a ,  508   b , which are illustrated as rectangular but may be bundled in circular, ovoid or any other suitable shapes. In some embodiments, the inside of the outer shaft  502  may be solid or filled with a material, and the camera  510  and light fibers  508   a ,  508   b  may reside in lumens formed within the material in the outer shaft  502 . The camera  510  may be located at or near the distal end of the outer shaft  502  and may be any kind of suitable camera, such as but not limited to a complementary metal-oxide-semiconductor (CMOS) or charge-coupled device (CCD) camera. The light source may be any type of suitable light source, as well, including but not limited to light fibers  508   a ,  508   b , one or more light emitting diodes (LEDs), etc. Again, this is only one exemplary embodiment of the shaft portion of a device  500 . 
       FIGS. 16A and 16B  illustrate another embodiment of an ear visualization/suction device  600 . As with previous embodiments, device  600  includes a handle  602 , a main shaft  606  (or “endoscope shaft,” which includes a camera at its distal end), a suction guide shaft  607  on the side of the main shaft  606 , a thumb depress portion  624  attached to a suction shaft  622  and a suction tube  626 , and a spring  618  disposed over a portion of the suction shaft  622  to automatically retract the suction shaft  622  when the user releases her thumb from the thumb depress portion  624  (as in  FIG. 16B ). In this embodiment, the suction shaft  622  of the ear visualization/suction device  600  further includes a curved distal tip  623 , and the thumb depress portion  624  includes a surface feature  628 . The physician user may apply pressure to the thumb depress portion  624  (as in  FIG. 16A ) and use the surface feature  628  (a bump in the present embodiment) to spin the thumb depress portion  624  and thus the suction shaft  622  and the curved distal end  623 . In this way, the suction distal end  623  may be directed in multiple different directions to suction different areas within the ear. The curved distal tip  623  may have different shapes and angles and the surface feature  628  may also have many different shapes and configurations, some of which are described in further detail below. For example, in one alternative embodiment, the extreme end of the curved distal end  623  may be slanted, rather than the blunt/flat end illustrated in  FIGS. 16A and 16B , which may help facilitated suctioning over surfaces as the distal end  623  is spun around. 
       FIG. 17  illustrates another embodiment of an ear visualization/suction device  700 . This embodiment also includes a handle  702 , which in this case is attached at its proximal end to an endoscope cable  730  and a suction tube  732 , both of which pass through the body of the handle  702  to the front/distal end of the handle  702 . Suction tube  732  passes through the body of the handle  702  and terminates at two suction ports  708  (only the left port is visible in  FIG. 17 ), one on each side of the handle  702 . One suction port  708  is attached to a short suction tube  712 , which in turn attaches to a suction port  710  on a free spin suction member  715  that is disposed over, and spins freely around, the suction shaft  722 . The suction port  710  on the free spin suction member  715  is in fluid communication with the lumen of the suction shaft  722 , so that suction force passes through the port  710  and into the lumen of the shaft  722 . In use, suction travels from the suction tube  732 , through the handle  702 , through the suction port  708 , through the short suction tube  712 , through the suction port  710 , and down the suction shaft  722  to the distal end of the suction shaft  722 . The physician user will cover an opposite-side, open suction port (corresponding to  708 , but on the side of the handle  702  that is not visible in  FIG. 17 ) with his finger to apply suction to the suction shaft  722  and will release his finger from the open suction port to allow suction to flow out of the open port and thus stop the flow of suction through the suction shaft  722 . 
     As with the previously described embodiment, the ear visualization/suction device  700  includes a main shaft  706 , which includes a camera at its distal end for visualizing the ear. It also includes a suction guide shaft  707 , and a suction shaft  722  with a curved distal tip  723 . The device  700  may also include a spring  718  disposed over the proximal portion of the suction shaft  722 , between the top of the handle  702  and the bottom of the free spin suction member  715 . The free spin suction member  715  is disposed over the proximal end portion of the suction shaft  722 , just below the thumb depress member  724 , which again includes a surface feature  728 . The free spin suction member  715  houses two O-rings  714 , one of which is positioned above the hole in the suction tube  722  into which the port  710  leads, and one of which is below the hole. The free spin suction member  715  and O-rings  714  form a liquid sealed chamber that will pass suction from the short suction tube  712 , through the suction port  710  on the free spin suction member  715  and finally into the suction shaft  722 . At the same time, the suction shaft  722  can be rotated, while the free spin suction member  715  stays in one place (does not rotate), thus preventing the short suction tube  712  from twisting around the suction shaft  722 . Again, in this embodiment, when the user spins the thumb depress member  724 , using the surface feature  728 , the free spin suction member  715  does not rotate with the thumb depress member  724  or the suction shaft  722 , but instead remains in the same place, by rotating freely over the suction shaft  722  as the shaft spins. In this way, the suction port  710  does not spin together with the suction shaft  722  but stays in one place. This is important, because if the free spin suction member  715 , along with the suction port  710 , were to spin around with the thumb depress member  724  and the suction shaft  722 , the short suction tube  712  would twist around the suction shaft  722  and make it difficult for the user to spin the suction shaft  722 . It would also prevent free, continuous, 360-degree rotation of the suction shaft  722  and could potentially also result in pulling off of one of the suction ports  708 ,  710 , spinning the suction shaft  722  back to its original orientation, or even hampering advancement of the suction shaft  722  in and out of the ear. Advantageously, the free spin suction member  715  allows the user to spin the thumb depress member  724  and the suction shaft  722  continuously, 360 degrees or more, as much as desired, without twisting the short suction tube  712 . 
     One additional feature of this embodiment of the ear visualization/suction device  700  is an adjustable finger loop  704  on the handle  702 . In this embodiment, the user may place her finger (for example her middle or index finger) through the looped portion of the finger loop  704  and pull the free end of the finger loop  704  to tighten the looped portion. The looped portion may also be pulled, to make it larger. This is but one example of a finger hold member that may be included on the handle  702  to facilitate holding of the handle  702  using one finger. In one embodiment, the user may hold the device  700  with her middle finger, via the finger loop  704 , and operate the device  700  with other fingers of the same hand (index finger and thumb, for example). 
       FIGS. 18A-18D  are perspective views of a portion of an ear visualization/suction device, according to four different embodiments, where each embodiment includes a differently configured thumb depress member for rotating a suction shaft with a curved distal tip. Referring to  FIG. 18A , one embodiment of an ear visualization/suction device  800  includes a generally circular thumb depress member  802  with an elliptical, off-center, raised surface feature  804 . The thumb depress member  802  also includes a slightly concave upper surface for receiving the thumb. Having an off-center surface feature  804  allows the user to rest a finger (typically the thumb) against the surface feature  804  and ergonomically easy spinning of the suction shaft. Also pictured in this and the following embodiments are a handle  801 , a handle suction port  808 , a suction shaft  810 , and a suction shaft suction port  806 . 
     In the embodiment of  FIG. 18B , the ear visualization/suction device  810  includes a similarly circular, slightly concave thumb depress member  812 , with a more round shaped (or oval) surface feature  814 . In the embodiment of  FIG. 18C , the ear visualization/suction device  820  includes an asymmetrical, bean-shaped thumb depress member  822  with a round-shaped (or oval) raised surface feature  824  on a lateral portion of the thumb depress member  822 . In the embodiment of  FIG. 18D , the ear visualization/suction device  830  includes another asymmetrical thumb depress member  832  with a raised, upwardly curving edge at one side. As  FIGS. 18A-18D  illustrate, in any given embodiment, the thumb depress member and the surface feature may have any suitable shape, size and configuration. 
     Referring now to  FIG. 19 , another embodiment of an ear visualization/suction device  900  is illustrated. This embodiment includes many of the features of previous embodiments, which will not be explained again here. In addition, this embodiment of the device  900  includes an adjustable handle  902 , which may make holding the handle  902  more comfortable for a given user. The handle  902  has a distal portion  904 , a proximal portion  906 , and an adjustment member  908  between the two. The adjustment member  908  acts as an axis, to allow the proximal portion  906  to rotate down (and back up as desired), so that the proximal portion  906  can be angled, relative to the distal portion  904 . Thus, the user can direct the tip of device  900  in the direction of the ear canal (typically superiorly-posteriorly), regardless of whether the device  900  is being used in a left ear or a right ear, without changing the orientation of the user&#39;s entire hand. In various embodiments, the adjustment member  908  may have specific adjustment angles that the proximal portion  906  clicks into and/or may have a locking feature to allow the user to lock the proximal portion  906  in a desired angle. In alternative embodiments, the adjustment member  908  may be positioned farther distally or farther proximally along the body of the handle. 
     Referring now to  FIG. 20 , in another embodiment, an ear visualization/suction device  1000  may include a handle  1002  that is malleable or includes a malleable section  1004 . As with the similar embodiment, the malleable section  1004  allows the user to create an angle in the handle  1002 , which may enhance ergonomics and comfort. 
     Referring now to  FIGS. 21A and 21B , one embodiment of an ear tube placement device  1100  is illustrated. In this embodiment, the ear tube placement device  1100  also functions as an ear visualization/suction device. Ear tubes are often placed in tympanic membranes TM (or “ear drums”) that lie between the outer ear (or “ear canal,” labeled in the figures as EC) and the middle ear, primarily in children but also adults with frequent ear infections or other problems involving the middle ear. Although one handle/suction tube configuration is illustrated in  FIGS. 21A and 21B , alternative embodiments may include any of the handle/suction configurations described in this disclosure. As with previously described embodiments, the device  1100  includes a handle  1102 , a thumb depress portion  1104 , a suction tube  1106 , a main shaft  1114 , a suction guide tube  1112 , a suction shaft  1110 , and a spring  1108  positioned over a proximal portion of the suction shaft  1110 . This embodiment further includes a stop member  1120  located near the distal end of the suction shaft  1110  and a sharp distal tip  1116  on the suction shaft  1110 . An ear tube  1118  may be part of the device  1100  or, more likely, the ear tube  1118  may be any currently available or to-be-developed ear tube, which is placed over the distal end  1116  of the suction shaft. 
       FIG. 21A  illustrates the ear tube placement device  1100  in a pre-deployment position, with the ear tube  1118  mounted on the suction shaft  1110  and the distal end of the device  1100  being advanced into the ear canal EC. The thumb depress member  1104  is not yet depressed.  FIG. 21B  shows the device  1100  in position to deploy the ear tube  1118  in the tympanic membrane TM. In use, the suction shaft  1110  will typically be advanced toward the TM, until the sharp distal tip  1116  of the suction shaft  1110  pushes against the tympanic membrane TM to pierce the membrane. Next, the suction shaft  1110  will be further advanced, to push the ear tube  1118  through the new hole in the tympanic membrane TM, as illustrated in  FIG. 21B . While  1118  is pushed through the hole, the stop member  1120  prevents  1118  from being pushed back by the TM and sliding back over suction shaft  1110 , as the suction shaft  1110  advances through the TM. The stop member  1120  may be any suitable piece or surface feature on (or of) the suction shaft  1110 , such as but not limited to a washer-like member, a raised ring on the suction shaft  1110 , another tube disposed over the suction shaft  1110  or the like. In general, any piece or feature that will prevent the ear tube  1118  from sliding proximally during deployment will be suitable. After the ear tube  1118  is placed in the tympanic membrane TM, the suction shaft  1110  and/or the entire device  1100  may be retracted/pulled back, to slide the suction shaft  1110  out of the ear tube and the device  1100  out of the ear canal. 
       FIG. 22  illustrates a distal end of an alternative embodiment of an ear tube placement device  1200 . In this embodiment, the main shaft  1202  includes a camera (not visible), as with previously described embodiments. The suction shaft  1204  is curved and ends in a sharp distal tip  1208 . A stop member  1210  is disposed over the suction tube, and an ear tube  1206  is shown in position. In some embodiments, it may be advantageous to have a curved suction shaft  1204  with the ear tube placement device  1200 , as this will allow it to reach different areas of the TM with slight spins of the suction shaft  1204 . 
     Referring now to  FIGS. 23-26 , in one embodiment of an ear visualization/suction device  1300 , an optional handle angle adjustment member  1310  may be provided.  FIG. 23  shows a portion of the device  1300  without the handle angle adjustment member  1310 , illustrating a handle  1302 , with a finger loop  1306 , and a main shaft  1304 .  FIG. 24  shows the removable handle angle adjustment member  1310 , which has a straight hand rest portion  1312 , a curved portion  1314  and an attachment portion  1316  that attaches to the handle  1302 . The attachment portion  1316  may be slid over the handle  1302  into place, such that the diameter of the handle  1302  and/or a stop member along the handle  1302  helps position the attachment portion  1316 . In some embodiments, the attachment portion  1316  may be moved along the handle  1302  by the user, to any suitable location on the handle  1302 . In various embodiments, the optional handle angle adjustment member  1310  may have any number of different sizes, shapes and angles. The curved portion  1314 , for example, may have any suitable angle. In some embodiments, the curvature of the curved portion  1314  may be adjustable by the user—for example, it may be malleable. In some embodiments, the device  1300  may be provided with multiple, differently shaped handle angle adjustment members  1310 , each having a different angle, shape and/or size. 
       FIG. 25  shows a user holding the portion of the device  1300  without the handle angle adjustment member  1310 . This figure illustrates a first relative angle between the user&#39;s hand and the handle  1302 , as well as a first orientation of the main shaft  1304  of the device  1300 , relative to the hand.  FIG. 26  shows the same user&#39;s hand holding the device  1300  with the handle angle adjustment member  1310  attached. As seen here, the handle  1302  is now angled in a more upward direction, relative to the user&#39;s hand, and the main shaft  1304  of the device  1300  is angled toward the hand more than it was in  FIG. 24 . At the same time, however, the overall position of the user&#39;s hand is almost exactly the same in  FIGS. 25 and 26 . This illustrates that the handle angle adjustment member  1310  (or alternate embodiments thereof) may help a user access and visualize different parts of an ear without needing to assume awkward or uncomfortable hand positions. 
       FIGS. 27A and 27B  are diagrammatic illustrations of one embodiment of a combined ear visualization/suction device  1400 , shown in an orientation as if the device  1400  were being held in a left hand while inserted into a right ear ( FIG. 27A ) and a left ear ( FIG. 27B ). These two figures are simple representations of the device  1400 , to illustrate how a working area in an ear canal might be limited in some scenarios. For example,  FIG. 27B  shows a representation of a left ear canal LEC and an area of interest in the left ear LE. The “area of interest” may refer to an area in the ear and/or one or more structures in the ear, such as but not limited to the tympanic membrane, an area just beyond the tympanic membrane in the middle ear, an area just before the tympanic membrane, or any other suitable area and/or structure in the ear. The device  1400  is being held in the left hand of the user (hand not shown), and the angle of view is represented in the figure by an eye symbol at the distal tip  1412  of the device  1400 . The device  1400  includes a proximal bend  1410 , which allows for a working area  1420  within the left ear canal LEC. The working area  1420  can be used for passing one or more tools for performing a procedure on the left ear LE area of interest. As  FIG. 27B  illustrates, when a user holds the device  1400  in his left hand and accesses the left ear canal LEC with the device  1400 , the working area  1420  is sufficient for passing one or more tools, because it has a relatively large entry opening (the opening into the ear canal from outside the patient). 
     In contrast, referring to  FIG. 27A , when the left handed user uses the device  1400  to access a right ear canal REC to view an area of interest in the right ear RE, this embodiment of the device  1400  may cut off the entry opening of a working area  1414 , which may make it more difficult for the user to insert working tools into the ear canal REC. Although the overall size of the working area  1414  in  FIG. 27A  is approximately the same as the size of the working area  1420  in  FIG. 27B , the configuration of the working area  1414  for a left handed user in a right ear canal REC may be problematic for passage of tools. This may require the user to position his/her hand in an awkward position or insert tools through the ear canal REC in an awkward way. The same problem may occur if a person holds the device  1400  in the right hand and uses the device  1400  in the left ear canal LEC. 
       FIGS. 28A and 28B  are diagrammatic illustrations of an alternative embodiment of a combined ear visualization/suction device  1500 , shown in an orientation as if the device  1500  were being held in a left hand while inserted into a right ear ( FIG. 28A ) and a left ear ( FIG. 28B ). In this embodiment, the device  1500  includes a proximal bend  1510  and a distal bend  1520 , closer to the distal end  1522  of the device  1500 . Thus, when held in the user&#39;s left hand and inserted into the right ear canal REC, the resulting working area  1524  has a sufficiently large opening and overall width to allow for tool passage. The distal bend  1520  may be formed in any of a number of ways and may be either fixed or adjustable in various embodiments. For example, in some embodiments, a distal portion of the device  1500  may be malleable, so the user can form and adjust the distal bend  1520 . In other embodiments, the distal bend  1520  or a distal portion of the device  1500  may be rotatable. Alternatively, the view of the camera at the distal end  1522  of the device  1500  may be rotated or otherwise adjusted, for example by electronic adjustment, to allow for the desired viewing angle. 
       FIG. 28B  shows the device  1500  with the distal bend  1520  adjusted to have a different angle, designed to access the left ear canal LEC and view the left ear area of interest LE. In this scenario, the working area  1530  is also sufficiently wide to allow for tool passage. Various alternative embodiments may have any number, location and angle of bends. In one embodiment, a left-handed device and a right-handed device may be provided. 
     Referring now to  FIGS. 29A and 29B , an alternative embodiment of an ear visualization and suction device  1600  is illustrated. In various embodiments, the suction tube of an ear visualization/suction device (the side tube through which the suction device passes) may have an inner diameter ranging from about 0.6 mm to about 2.5 mm, with some embodiments having an inner diameter of about 1.1 mm or less. The main shaft (or visualization shaft) may have an outer diameter of about 2.5 mm or less. These dimensions may differ in some embodiments. In the embodiments described above, the suction shaft (i.e., the part of the device that transmits suction force to the distal end of the device) passes through the suction tube and slides up and down through the tube as it is advanced and retracted. The size of the outer diameter of the suction shaft is thus limited by the size of the inner diameter of the suction tube. In various embodiments, for example, the suction shaft may have an outer diameter ranging from about 0.6 mm to about 2.5 mm, depending on the inner diameter of the suction tube. In some embodiments, the suction shaft of the ear visualization/suction device may have an outer diameter measuring about 3 French (i.e., about 1 mm). For some ear surgery procedures, this diameter works well. In other cases, however, it might be advantageous to have a larger suction shaft diameter, to provide more suction force and/or prevent clogging of the suction device. For example, in some embodiments it might be advantageous to have a suction shaft with an outer diameter of about 5 French (i.e., about 1.67 mm). Any number of suitable sizes of suction shafts may be used in a given embodiment, again ranging from as small as about 0.6 mm outer diameter to as large as about 2.5 mm outer diameter or more. 
     If the suction shaft must pass through the suction tube, then a larger suction shaft will require a larger suction tube. Therefore, one way to provide ear visualization/suction devices with different suction diameters is to provide separate devices with suction tubes and suction shafts having different diameters, allowing the user to choose between devices for a given procedure or even to swap out devices during a procedure. Another way to allow for suction size variation is to provide one device with multiple, differently sized suction shaft components that may be swapped out on the same device. The ear visualization and suction device  1600 , shown in  FIGS. 29A and 29B  is one embodiment of an adjustable suction size device. 
     In the embodiment of  FIGS. 29A and 29B , the device  1600  includes a handle  1602 , a main shaft  1606  (or “visualization shaft”), two suction tubes  1604  extending along either side of a proximal portion of the main shaft  1606 , suction ports  1608  on either side of the handle  1602 , a suction shaft  1612 , suction tubing  1610 , a suction push rod  1616 , and a thumb depress  1614  attached to the proximal end of the suction push rod  1616 . In  FIG. 29A , solid-tipped arrows show the path of suction into the distal end of the suction shaft  1612 , into the suction tubing  1610 , which is attached to the handle  1602  via one of the ports  1608 , and then into and through the handle  1602 . In some embodiments, for example, the handle  1602  houses additional suction tubing (shown in later figures) that connects to further tubing to couple with a source of suction. In operation, the user presses the thumb depress  1614  to advance the suction push rod  1616 , which extends through one of the two suction tubes  1604 . The suction push rod  1616  advances the suction shaft  1612 . When suction is activated, as illustrated in  FIG. 29A , suction passes through the suction shaft  1612 , the suction tubing  1610 , and the handle  1602 . The suction push rod  1616  serves merely to advance and retract the suction shaft  1612 . (Retraction occurs automatically via a spring positioned over the proximal portion of the suction push rod  1616 , between the top of the handle  1602  and the bottom of the thumb depress  1614 , as described in further detail above, in regard to other embodiments.) 
       FIG. 29C  shows the suction component  1618  of the device  1600 . When coupled with the handle  1602 , the suction push rod  1616  extends from a proximal end attached to the thumb depress  1614  to a distal end attached to the suction shaft  1612  via a junction  1617 . The suction shaft  1612  includes a proximal curve, and its proximal end fits within the suction tubing  1610 . As is evident from  FIG. 29C , the outer diameter of the suction push rod  1616  is smaller than the outer diameter of the suction shaft  1612 . For example, the suction shaft  1612  may have a 5 French outer diameter in one embodiment. In alternative embodiments, the suction shaft  1612  may have any suitable diameter. As long as the suction tube push rod  1616  is sized to fit through the suction tube  1604 , the suction shaft  1612  may have any desired inner and outer diameter, according to different embodiments. In this way, the suction component  1618  and various sizes thereof may allow for the same ear visualization/suction device  1600  to be adjusted to provide multiple different sizes of suction shafts  1612 . The thumb depress  1614  may be easily removable from the proximal end of the suction push rod  1616 , for example via threaded connection or friction fit. In this way, the device  1600  facilitates changing of the suction component  1618  for a different suction component with a differently sized suction shaft  1612 . 
       FIG. 30  shows the suction component  1618  on the right and an alternative suction component  1622  on the left. The suction component  1618  was already described in reference to  FIG. 29C , but it is shown here with an alternative thumb depress  1620  and with the spring  1621 . The alternative suction component  1622  includes a suction shaft  1624 , a second alternative thumb depress  1628  with a suction port  1627 , suction tubing  1626  and a spring  1629 . The suction shaft  1624  of the alternative suction component  1622  extends through the suction tube  1604  of the device  1600 , as described in relation to other embodiments herein. In one embodiment, the suction shaft  1624  may have an outer diameter of about 3 French, while the suction shaft  1612  may have an outer diameter of about 5 French. In one embodiment, the device  1600  may be provided with both suction components  1618 ,  1622 , to allow a user to choose between the two for a procedure or to swap between the two during a procedure. One method for swapping out the suction components  1618 ,  1622  is to remove the thumb depress  1620 ,  1628  (along with the spring  1621 ,  1629 ) and slide either the suction push rod  1616  or the suction shaft  1624  distally out of the suction tube  1604 . The other suction component  1618 ,  1622  may then be loaded into the device  1600  by reversing the process. 
     Referring now to  FIGS. 31A-31C , the ear visualization and suction device  1600  is illustrated with the alternative suction component  1622  attached.  FIG. 31A  shows a proximal suction tube  1630  extending through the handle  1602 .  FIGS. 31B and 31C  are top cross-sectional views, with the handle  1602  not illustrated. As illustrated by solid-tipped arrows in  FIG. 31B , in this configuration, suction travels up the suction shaft  1624 , through the thumb depress  1628 , through the suction tubing  1626 , and then into and through the proximal suction tubing  1630  in the handle  1602 .  FIG. 31C  shows how the suction shaft  1624  extends through the suction tube  1604  and attaches to a distal shaft portion  1632  of the thumb depress  1628 . The distal shaft portion  1632  travels back and forth within a bore  1634  of the handle, with proximal movement assisted by the spring  1629 . 
     The embodiments and features illustrated in  FIGS. 29A-31C  represent merely one example of an ear visualization and suction device  1600  that provides two different suction shaft diameters. Alternative embodiments may achieve the same objective using different techniques and features. For example, in one embodiment, an ear visualization and suction device may have a larger diameter suction tube, for example allowing for passage of a 5 French (outer diameter) suction shaft. That device may also be provided with an alternative suction component having a suction shaft with a smaller outer diameter, such as 3 French. The smaller suction shaft may have a wider proximal portion that fits in the suction tube, to prevent the shaft from wiggling or jostling within the suction tube. Thus, any number of different embodiments and sizes of suction shafts may be provided as part of an ear visualization/suction device. 
     Referring now to  FIGS. 32A-32D , in one embodiment, an ear visualization and suction device  1700  may also include an irrigation component.  FIG. 32A  shows an assembled side view of the device  1700 , which includes a handle  1702 , with a finger hold  1704 , a electric cable  1706 , a proximal suction tube  1708 , an irrigation tube  1710 , a distal suction tube  1714 , a thumb depress  1712  and a suction shaft  1716 . (The main shaft is hidden behind the suction shaft  1716  in this view.) The electric cable  1706  may contain, for example, image sensor wires and LED power lines. The device  1700  includes other parts and features described in relation to other embodiments above, but these will not be described again here. In this embodiment, the suction shaft  1716 , extends through a first bore in the top of the handle  1702 , and an irrigation shaft (not visible in  FIG. 32A ) extends through a second bore. Irrigation fluid, such as saline solution, is passed through the irrigation tube  1710  and irrigation shaft so that it flows down the side of the main shaft into the patient&#39;s ear. Suction from the suction shaft  1716  may be used to evacuate the irrigation fluid. 
       FIG. 32B  shows the ear visualization and suction device  1700  with the irrigation shaft  1722  removed from the handle. As mentioned above, to use the irrigation portion of the device  1700 , the irrigation shaft  1722  is passed down into one of two bores  1720  on the top of the handle  1702 , and thus into one of the two suction tubes  1718  that extend along either side of a proximal portion of the main shaft  1717 . Either bore  1720  may be used, and the suction shaft  1716  (not shown in  FIG. 32B ) is inserted into the other bore  1720 . As evident from  FIG. 32B , the irrigation shaft  1722  is shorter than the main shaft  1717 , and it may also be shorter than the length of the two suction tubes  1718 . Thus, when irrigation fluid passes out of the distal end of the irrigation shaft  1722 , it passes along the side of the main shaft  1717  and into the ear. In alternative embodiments, the irrigation shaft  1722  may be longer or shorter than the one shown. Also visible in  FIG. 32B  is one of two handle suction ports  1724 , on either side of the handle  1702 , configured for coupling with the suction tube  1714  ( FIG. 32A ). 
       FIG. 32C  is the same side view as in  FIG. 32B , but with the irrigation shaft inserted into one of the bores  1720 .  FIG. 32D  is a top view of the same configuration of the ear visualization and suction device  1700 . 
     The above description of embodiments and features of various devices and methods is believed to be complete. The embodiments are meant to exemplary in nature, however, and not exhaustive. Thus, their description should not be interpreted as limiting the scope of the invention.