Eye-tracking differences between expert and novice gaze in otolaryngology: a systematic review

Introduction

Eye-tracking technology has been broadly utilised to evaluate visual attention during complex tasks and has been applied across multiple domains including psychology and clinical performance (1-3). This tool provides an objective framework through quantitative analysis of gaze parameters, including fixation (regions of interest, duration and count) and saccades (count, amplitude), providing an indirect proxy for cognition and decision-making (3,4). Observed differences are more accurately interpreted within individual procedural contexts (5-7).

In the medical field, eye-tracking has been used to describe distinct visual strategies between experts and novices. In Radiology, for instance, variations in fixation count and saccade amplitude have been observed between consultants and trainees in interpreting X-rays (8). Similarly, in surgery, experienced surgeons employ more stable and efficient gaze patterns than novices when interacting with laparoscopic instruments and screens (9,10). Eye-tracking also demonstrates potential educational applications, as prior studies have shown that exposing surgical trainees to expert gaze pattern—either through real-time projection of a supervising surgeon’s gaze onto a monitor or gaze-guided training interventions—can reduce errors and improve operative performance when compared with conventional instructions (11,12).

These findings are pertinent to surgical training, where reduced operative exposure and increasing procedural complexity require supplementary educational tools. Otolaryngology presents relatively distinct ergonomic and visual challenges for training and skill acquisition, including dependence on endoscopic and microscopic views, constrained operative fields and limited tactile feedback. Efficient yet stable visual strategies are therefore paramount to effective and safe performance (13). Despite the growing adoption of eye-tracking across surgical disciplines, its application in Otolaryngology remains to be thoroughly understood.

The aim of this systematic review was to assess the published literature on expert and novice eye-tracking in Otolaryngology Head and Neck Surgery, with a focus on the implications for surgical training and performance assessment.

Methods

A comprehensive literature search was conducted using PubMed, EMBASE, Scopus, and the IEEE Xplore databases from their inception until January 2026. The study is reported according to the PRISMA reporting guidelines (available at https://www.theajo.com/article/view/10.21037/ajo-2026-1-0013/rc). The focus of this search was on studies employing eye-tracking technology to assess gaze movements and parameters in the context of Otolaryngology procedures and education, specifically relating to Otology, Rhinology, Laryngology, and Head and Neck Surgery. The full search strategy is provided in Appendix 1. No prospective registration was undertaken for this systematic review. Studies were included if they were conducted in English and utilised eye-tracking technology with healthcare professionals or trainees to evaluate surgical or diagnostic tasks in Otolaryngology. Studies were excluded if eye-tracking was not used to assess clinical task performance in Otolaryngology. Studies that lacked sufficient methodology details on gaze parameters were also excluded. Duplicate records were removed prior to screening.

Articles were screened by two authors independently (G.R.B. and K.O.), both Otolaryngology trainees, and the reference lists of selected articles were further explored to identify additional relevant publications. Any disagreements between the two authors were resolved through consultation with the senior author, a fellowship-trained rhinologist/anterior skull base surgeon (N.S.). The data extracted from the selected articles included author names, publication year, participant demographics, specific tasks assessed, gaze parameters evaluated, and a summary of the findings related to gaze and movement patterns in surgical or diagnostic settings. Risk of bias of all included studies was assessed using the Joanna Briggs Institute (JBI) Critical Appraisal Checklist for Analytical Cross-Sectional Studies.

Gaze parameters are all generally measured in milliseconds (ms) and defined as follows. Fixation duration measures the length of a single gaze on a certain region of interest (ROI), representing moment-to-moment visual attention (3). Conversely, dwell time represents the total duration of fixation(s) spent on a ROI, reflecting distribution of overall attention to that ROI across a task (3). Saccade counts were defined as the number of rapid eye movements between fixation points (4). Quiet eye (QE) duration defines the final sustained fixation on a ROI immediately prior to executing a critical motor action, typically within three degrees of visual angle for at least 100 ms (14).

Due to substantial heterogeneity in study design, including differences in eye-tracking hardware, experimental tasks, gaze metrics, and definitions of expertise, meta-analysis was not performed. Instead, findings were synthesised using qualitative analysis.

Results

Results of the PRISMA search protocol are shown in Figure 1. The search identified 2,195 records, of which six eye-tracking studies, published between 2014 and 2026, were ultimately included in this analysis. One study on comparison of eye-gaze patterns between expert and novice Speech Pathologists in their interpretation of video fluoroscopy swallow studies was excluded as it was only a conference abstract. Two studies comparing eye movements in diagnosing oral mucosal diseases were excluded as the study population involved dentists. Six studies were further omitted as they investigated the visual attention of general lay participants toward facial or neck appearances affected by surgery, congenital anomalies or medical devices. A study on clinical airway procedures in neonatal intensive care was excluded as it primarily assessed situational awareness rather than gaze strategies between experts and novices.

Figure 1 PRISMA flow chart diagram.

The studies included demonstrated a generally low to moderate risk of bias in reporting domains according to the JBI checklist as shown in Table 1. However, all studies possessed inherent limitations due to simulation-based study design, small sample sizes, and varying expertise definitions.

Research on eye-tracking in Otolaryngology was subdivided into two major domains: training and assessment. The training domain was defined as the use of eye tracking to develop and improve knowledge or skill acquisition of participants. The assessment domain was described as the use of eye tracking metrics to objectively determine surgical performance. Most of the included studies, except one, were involved in the assessment domain. Only one study involved both surgical training and assessment.

The eye-tracking devices were broadly categorised into three modalities: head-mounted, remote, and microscope-fixed. The distribution of these modalities can be seen in Table 2. Head-mounted eye-tracking devices include wearable headsets and glasses with inward-facing cameras. Remote devices are systems that involve an eye-tracking camera situated in front of the subject, typically beneath a screen the user views. An embedded eye-tracking system incorporates binocular eye monitoring technology fixed within the viewing apparatus of a microscope or robotic operating console. The included studies had an equal distribution between utilising remote and head-mounted devices. All research groups conducted their studies in simulated environments.

The six eye-tracking studies had heterogenous task design and gaze parameters, as summarised in Table 3. Commonly reported parameters included fixation duration, fixation count and saccade counts. The gaze metrics reported by the included studies are summarised by subspecialty below.

Rhinology

Berges et al. (13) showed that experts demonstrated significantly fewer fixation counts (6.3±4.08 vs. 16.25±11.73; P<0.0001), shorter fixation durations (3,860±3,050 vs. 9,810±6,540 ms; P<0.0001) and fewer saccade counts (~4–5 vs. ~8–9 saccades per task, P<0.0001) than novices in visualising and touching all nine anatomical targets in functional endoscopic sinus surgery (FESS) in random sequence. Although mean differences were reported, the authors did not provide a standardised effect size (e.g., Cohen’s d), which would allow comparison of the magnitude of the difference between groups.

With regards to duration, Niederhauser et al. (15) reported that proficient residents displayed longer average fixation duration than their less proficient counterparts [97 ms; 95% confidence interval (CI): 47–148; P<0.001] in performing steps of functional ethmoidectomy on cadavers. Ahmidi et al. (16) demonstrated minimal correlation between eye movement and endoscope motion (0.06 vs. −0.001 for trainees), and trainees often fixated outside of task-relevant screen areas.

Otology

Anschuetz et al. (17) compared gaze metrics of participants performing both type I underlay tympanoplasty and a piston prosthesis placement task in stapedotomy for both two-dimensional (2D) and three-dimensional (3D) endoscopic ear surgery on cadaveric models. In the 2D condition, consultants overall had longer fixation durations than residents (340 ms; 95% CI: 0–700) but significantly fewer fixation counts (16.1±3.9 vs. 22.4±4.3; P<0.05) and saccades (26.4±5.1 vs. 38.2±6.5; P<0.05). In the 3D environment, fixation durations reduced and equalised to approximately 0.5 s for both groups, with only a marginal change for residents across the two visual modalities.

Within the 2D arm, fixation duration was longer during stapedotomy than tympanoplasty for consultants (340 ms; 95% CI: 0–700), and shorter in residents performing stapedotomy compared to tympanoplasty (−240 ms; 95% CI: −360 to −120).

Laryngology

During diagnostic flexible laryngoscopy, experts and novices shared their initial fixation onto the trachea, regardless of the pathology presented. In unilateral vocal fold palsy (UVFP), experts exhibited longer fixation duration on the paralysed vocal fold (1,040±310 vs. 730±280 ms; P<0.05) and the glottic gap (15.7%±4.9% vs. 9.3%±3.7%; P<0.05). In right UVFP with arytenoid hooding, experts preferentially looked at the left vocal cord, whereas novices spent a larger proportion of their visual attention on the right arytenoid. Expert-novice distinction was also apparent in fixation duration of the left arytenoid in these cases (0.57% ± 0.98% vs. 3.80 % ± 4.61%; P=0.034). Diagnostic accuracy was significantly lower in novices than experienced surgeons (P=0.04) (18).

Head and Neck surgery

During thyroidectomy, Harvey et al. (14) observed that highly experienced surgeons demonstrated significantly longer QE durations on the recurrent laryngeal nerve (RLN) (2,407±559 vs. 844±228 ms; P<0.001). Experts also spent a significantly higher QE on the ligament of Berry compared to less experienced surgeons (25.2% vs. 4.4%, P=0.0008).

Discussion

Application of eye-tracking technology in Otolaryngology Head and Neck Surgery lends valuable insight into the perceptual organization across each subspecialty. Despite the small number of studies, an emerging pattern across subspecialties is evident in which expertise is linked to focused gaze on task-relevant regions, more efficient visual sampling and minimal gaze dispersion. Although fixation duration varies with task demands, experienced surgeons display structured allocation of visual attention according to procedure-specific complexity. For Ear, Nose and Throat (ENT) surgeons, these findings imply that visual strategy is a quantifiable aspect of surgical expertise that may be amenable to structured assessment and training.

Rhinology

Across the steps of FESS, eye-tracking studies suggest that experts minimise unnecessary scanning and allocate their visual attention to task-relevant anatomical landmarks, as shown by minimal fixation counts and saccades overall. Notably, fixation duration patterns were not uniform across all rhinologic tasks. While Berges et al. (13) reported shorter gaze duration in experts during target identification, Niederhauser et al. (15) demonstrated that more proficient trainees displayed longer durations when performing functional ethmoidectomy. This contrast likely reflects varying task demands: shorter gazes may indicate rapid orientation on search tasks, whereas longer and stable fixations may represent data-rich sampling during complex procedural steps. Prior eye-tracking studies support that gaze metrics correlate with workload and task complexity and therefore should be interpreted within procedural context (19).

Ahmidi et al. (16) further added that expert eye motion was weakly coupled to endoscope movement, whereas novices showed a more screen-driven gaze with frequent off-target views. This finding supports the notion of anticipatory gaze control, in which experienced surgeons anticipate ahead to future task-relevant anatomical landmarks rather than reacting to immediate visual stimuli (20). Similar strategies have been employed by expert laparoscopic surgeons, who preferentially fixate on key reference points, such as port insertion sites, and critical anatomical regions, including the infundibulum and cystic duct junction, to guide hand-eye coordination in surgery (21,22).

Otology

The narrow and deep operative field in Otology further demonstrates the significance of adapting visual strategies to surgical demands and task complexity. Interestingly, Otology consultants had longer fixation durations in 2D endoscopic surgery than residents (17). Despite longer fixation durations, consultants exhibited fewer fixation counts and saccades than novices, representing expert visual efficiency and reduced cognitive overload. The phenomenon of prolonged fixation duration, however, was not seen in 3D environments, likely due to the improved depth perception and anatomical view as preferred by the majority of the participating surgeons. In this context, fixation duration may reflect task-related visual attention, as shown by longer gaze period in both experts and novices in performing the stapedotomy than the tympanoplasty task, which involved graft placement within a wider operative field and thereby lower fine motor demands.

Distinct to experts in other ENT subspecialties, consultants demonstrated longer fixation duration, likely reflecting the heavier visual demand in the absence of stereoscopic cues rather than erratic expert visual behaviour. In the limited operating field of the middle ear, experts may need to prolong their gaze to account for lack of depth perception and reconstruction of spatial maps. This derivation is corroborated in Neurosurgery, whereby experts under surgical microscopes demonstrated longer fixation durations and more linear gaze paths (23). In Otology and Neurosurgery, targeted fixation on significant ROIs may represent meticulous visual attention.

Laryngology

In diagnostic flexible laryngoscopy for UVFP, experts and novices alike initially orient to the trachea as a common spatial anchor but subsequently differ in strategy. Experts concentrated their gaze on ROIs encoding dynamic function, such as the paralysed vocal fold and the glottic gap, rather than across multiple static structures as seen in novices’ (18). This mirrors established approaches to evaluating UVFP in the literature that prioritises evaluation of phase symmetry and closure patterns over isolated structural inspection (24).

The distinction between expertise levels becomes more apparent in analysing UVFP with arytenoid hooding. Novices tend to focus their gaze on the visually prominent arytenoid, potentially overlooking functional cues. Experts, on the other hand, re-direct their attention toward the contralateral vocal fold to assess compensatory motion and infer glottic competence despite partial obscuration. Comparably, in thoracic surgery, expert surgeons devoted a larger proportion of gaze time on dynamic anatomical landmarks, such as the lung hilum and pleural space, during video-assisted thoracoscopic surgery (VATS) (25). This gaze behaviour reflects adaptive visual sampling, where experienced surgeons prioritise essential dynamic landmarks to resolve diagnostic uncertainty.

Head and Neck surgery

Evidence for expert visual strategies in Head and Neck surgery remains preliminary and only derived from cadaveric thyroidectomy models. Experienced surgeons demonstrated prolonged QE on high-risk anatomical structures, such as the RLN and Berry’s ligament (14). Given that QE is an indirect proxy of final gaze prior to executing an operative step, the above finding likely represents deliberate spatial stabilisation during the most critical phase of the dissection, particularly at Berry’s ligament where the RLN is most susceptible to damage. Novices, on the other hand, exhibited a scattered gaze pattern with frequent shifts between non-critical structures and surgical instruments, suggesting less stable spatial anchoring during high-risk dissection.

Parallel to above findings, expert surgeons in open inguinal hernia repair demonstrated longer dwell times on the operative site during critical phases, such as mesh application and closure, while junior surgeons had scattered gaze attention often away toward the sterile field to identify instruments (26). While these parallel findings suggest that careful and focused fixation on high-risk regions may be a feature of surgical expertise, further studies on a broader range of Head and Neck procedures are required prior to drawing more firm conclusions given the variation in cognitive, anatomical and technical demands.

Summary of key findings

• Distinctions between novices and expert surgeons were observed in all key gaze parameters, including fixation counts, fixation duration and QE metrics. The direction of effect size varied with task complexity.
• Experts demonstrated more efficient visual search behaviour during orientation tasks.
• Experts consistently displayed more focused visual strategy on task-relevant ROI throughout all ENT subspecialties.
• Procedural context matters: briefer fixation duration during non-critical tasks (e.g., identifying anatomical landmarks) reflects efficient gaze behaviour, whereas longer fixation may represent deliberate data sampling in tasks with depth constraints or higher technical demands.
• All studies were completed in simulated surgical environment, limiting extrapolation to real-world operative conditions.
• Significant methodological heterogeneity currently hinders quantitative analysis.

Limitations

Despite the consistency of observed differences between experts and novices, interpretation of available eye-tracking evidence in Otolaryngology is currently restricted to few studies of small participant cohorts with unbalanced expert-novice recruitment, thereby limiting statistical power and generalisability of findings. As all included studies were performed in simulated environment on cadaveric models, they may not replicate the cognitive stressors of live operative conditions do, including time pressures, bleeding, team interactions and complication risks, and might indirectly impact on the degree of visual attention allocated to each task presented (3,16,22). Substantial heterogeneity was observed across studies, including variability in hardware specifications, task design, and gaze parameters. In addition, definitions of expertise widely ranged from medical students to consultants, limiting cross-study comparability.

Future directions

Given the uncertainty of whether these observed expert and novice differences are carried into real-world cognitive demands of live operative conditions, future research should aim to mitigate these limitations by applying workflow-safe eye trackers into live surgical performance. Another key aspect for future research is the standardisation of both expertise definitions and eye-tracking study design across literature to allow for quantitative analysis. Current literature inconsistently defines expert and novice based on level of training, years of experience or subjective classification, limiting cross comparability. The utilisation of objective and reproducible criteria, such as validated procedural competency scores [e.g., Objective Structured Assessment of Technical Skills (OSATS)] and case volume thresholds, would better ensure uniform grouping of participants and permit meta-analysis.

In parallel, standardisation of study design and reporting is essential. Future studies should aim to homogenize task selection, ROI using consistent surgical anatomical landmarks, and core gaze metrics (fixation count, fixation duration, saccades and QE) in a uniform fashion with appropriate effect sizes and units. Establishing a standard reporting framework, particularly a consensus-derived minimum or core dataset, for eye-tracking studies would be a critical step toward reducing methodological heterogeneity and improving generalisability across subspecialties. Moreover, incorporating eye-tracking data with tool motion data could supplement current knowledge of surgical metrics, offering a more holistic assessment of aptitude (13). This multimodal approach would also address the complexity of surgical performance, recognizing that expertise is a combination of cognitive, perceptual, and motor skills.

The convergence of findings across subspecialties provides a potential platform to explore translation onto surgical education. In practical terms, gaze-based feedback systems could supplement current training curricula by emphasizing expert-defined visual priorities during critical surgical steps. Operative phase-linked visual parameters can help analyse trainees’ scan paths across exposure, identification, and dissection of critical anatomical structures, providing targeted feedback based on expert-defined heatmaps. Longitudinal studies could help establish gaze-based learning curves, whereby residents achieve levels of visual efficiency that correlate with surgical proficiency and readiness for operative independence. Incorporating these findings into training curricula could educate trainees to adopt expert gaze patterns and expedite skill attainment. It needs to be recognised that, although eye-tracking provides a surrogate for visual attention, gaze parameters do not directly correspond to cognition or decision-making. Measured differences between experts and novices likely represent task-specific gaze behaviour rather than pure cognitive strategies. Collectively, eye tracking is a promising adjunct to not only assess but also dynamically optimise trainee performance.

Conclusions

This systematic review demonstrates consistent and reproducible differences in gaze behaviour between expert and novice surgeons across Otolaryngology subspecialties. These differences reflect task-specific visual strategies characterised by experts demonstrating efficient search behaviour during orientation tasks and more sustained fixation on task-relevant anatomical landmarks during critical procedural steps. While current evidence is limited to simulated environments, eye-tracking represents a promising objective adjunct for assessing visual aspects of surgical expertise and supporting gaze-guided surgical training. Future validation in live operative environments is required before clinical implementation.

Acknowledgments

The authors applied ChatGPT (OpenAI, version 5.2) for language editing and readability enhancement. The authors reviewed and verified the accuracy of the final version of the manuscript, including the authenticity of all references.

Footnote

Reporting Checklist: The authors have completed the PRISMA reporting checklist. Available at https://www.theajo.com/article/view/10.21037/ajo-2026-1-0013/rc

Peer Review File: Available at https://www.theajo.com/article/view/10.21037/ajo-2026-1-0013/prf

Funding: None.

Conflicts of Interest: All authors have completed the ICMJE uniform disclosure form (available at https://www.theajo.com/article/view/10.21037/ajo-2026-1-0013/coif). N.S. reports the following conflicts of interest: grants or contracts from Passe and Williams, Microsoft, CRC-P, RHRF, Avant, RBWH, and ResMed; royalties or licenses from Springer; consulting fees from GSK, Sanofi, Optinose, Nasus, and ResMed; payment or honoraria for lectures, presentations, or educational events from GSK, ResMed, and Oticara; support for attending meetings and/or travel from GSK; patents planned, issued, or pending with Optinose; and participation on a Data Safety Monitoring Board or Advisory Board for Optinose and participation on a Data Safety Monitoring Board or Advisory Borad for Optinose and AdraCard. The other authors have no conflicts of interest to declare.

Ethical Statement: The authors are accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved.

Open Access Statement: This is an Open Access article distributed in accordance with the Creative Commons Attribution-NonCommercial-NoDerivs 4.0 International License (CC BY-NC-ND 4.0), which permits the non-commercial replication and distribution of the article with the strict proviso that no changes or edits are made and the original work is properly cited (including links to both the formal publication through the relevant DOI and the license). See: https://creativecommons.org/licenses/by-nc-nd/4.0/.

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