Noninvasive middle ear imaging using optical coherence tomography (OCT) presents some unique challenges for real-time, clinical use in humans. We present results from a two-dimensional/three-dimensional OCT system built to assess the imaging requirements of clinical middle ear imaging, and the technical challenges associated with them. These include the need to work at a low numerical aperture, the deleterious effects of transtympanic imaging on image quality at the ossicles, sensitivity requirements for clinical fidelity of images at real-time rates, and the high dynamic-range requirements of the ear. We validated the system by imaging cadaveric specimens with simulated disorders to show the clinical applicability of the images. We also provide additional insight into the likely role of OCT in clinical otology.