Aims: Otologists face significant ergonomic risk with a high prevalence of musculoskeletal disorders, often attributed to the use of the operating microscope. Over the past decade, the 3D-exoscope has emerged as a promising tool in otologic and lateral skull base surgery. This systematic review evaluates the impact of this technology on surgical ergonomics. Methodology: A systematic search of Medline, EMBASE, Cochrane and cited references was conducted for ergonomic assessments in otologic and lateral skull base surgery performed using the 3D-exoscope. English language papers with no publication date restrictions were considered. Exclusion criteria comprised of non-otologic or lateral skull base surgeries, studies not assessing ergonomics with the 3D-exoscope, cadaveric or model-based studies, and letters and video reports. Risk of bias was assessed using the ROBINS-I tool. Results: Seven studies were included: five classified as level 3 evidence and two as level 4 evidence. 152 procedures were assessed (59 performed exclusively with the 3D-exoscope, 28 with a combination of 3D-exoscope and another modality, 59 with the operating microscope alone, and 6 with an endoscope alone). The included studies covered a range of transmastoid and lateral skull base procedures. Objective ergonomic assessments used the Rapid Upper Limb Assessment tool, while subjective evaluations employed the NASA Task Load Index or custom questionnaires. The objective findings demonstrate a measurable postural advantage with the 3D-exoscope, corroborated by subjective reports indicating perceived ergonomic benefits. Conclusion: The collective evidence from seven studies supports the view that 3D-exoscopes improve surgical ergonomics and posture in otologic and skull base surgery. Although limited by a handful of studies with small sample size, the findings highlight the potential of this technology and the need for more extensive studies.