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This study aimed to identify limitations and challenges associated with existing instruments and techniques used in totally endoscopic ear surgery (TEES).Otologic instruments, traditionally developed for two-handed surgery with operating microscopes, are not necessarily optimized for the TEES environment. Better understanding of technical challenges and the limitations of current instrumentation may allow advances in instrument design for TEES surgery.This cross-sectional study employed a mixed-methods nine-question survey that was distributed internationally to surgeons with an interest in TEES. Respondents were asked to classify their TEES experience and instrumentation used, rate their need for better instrumentation to address six TEES-related challenges using visual analog scales, and comment on how to modify or develop new instrumentation.With 51 respondents, we quantified a need for better instruments to address the following 6 potential TEES challenges ordered from greatest to least need: 1) reaching structures visualized by the endoscope, 2) dissection and removal of cholesteatoma, 3) cutting and/or removing bone, 4) bleeding control, 5) keeping the endoscope lens clean, 6) moving and positioning a graft into the intended place. The majority of surgeons perceive a need for improved instrumentation to address each challenge. Challenges 1) and 2) were associated with significantly greater need than the others (p < 0.05, Wilcoxon method for nonparametric pairwise comparisons).In addition to highlighting and quantifying some of the common TEES challenges, these findings provide valuable insight into the design requirements for developing improved surgical instrumentation and techniques.