Introduction
The practice of otorhinolaryngology involves performing extremely precise and delicate procedures in the small and narrow spaces of the ears, nose or throat. Otorhinolaryngologists often have to maintain forced postures of the neck, back or shoulders when using otoscopes, endoscopes or microscopes and manipulating different instruments within these cavities. This entails a risk of developing musculoskeletal disorders.Reference Dabholkar, Yardi, Dabholkar, Velankar and Ghuge1
Musculoskeletal symptoms can lead to surgical fatigue syndrome, in which the surgeon's dexterity, judgment and performance may decline, with detrimental effects for both the patient and the surgeon.
There is growing concern about musculoskeletal disorders derived from surgical practice in the different surgical specialties and otolaryngology is not an exception, as evidenced by the growing number of publications on this issue in recent years. Surveys aimed at ENT professionals or those with a special dedication in a more specific field have shown a very high prevalence of musculoskeletal complaints that the respondents attribute to surgical practice.Reference Cavanagh, Brake, Kearns and Hong2–Reference Little, Deal, Zanation, McKinney, Senior and Ebert4
The first objective of this study was to determine the prevalence of work-related musculoskeletal symptoms in otolaryngology and head and neck surgery specialists and trainees in Spain and compare these results with those from other similar studies conducted so far. The second and more novel approach was to identify and measure the effect that physical exercise and the level of physical activity could have on the appearance of musculoskeletal disorders. A third aim was to establish potential associations between those musculoskeletal symptoms and demographic variables such as age, gender, body mass index, subspecialty and other variables related to workload. Finally, although work-related musculoskeletal disorders are pervasive, awareness of ergonomic principles aimed at preventing this type of discomfort is less common. The last objective of the study was to assess individual perception of the magnitude of this problem and the level of knowledge of the principles and recommendations in studies and research in the field of surgical ergonomics.
Materials and methods
The study protocol was reviewed and approved by the hospital's ethics committee (Ethical Committee, Hospital Universitario Marques de Valdecilla, Santander, Spain) and by the institutional review board.
Target population and method
A survey adapted from Cavanagh et al.Reference Cavanagh, Brake, Kearns and Hong2 was electronically distributed to the entire membership of the Sociedad Española de Otorrinolaringología (the official society of otolaryngologists in Spain).Reference Park, Lee, Seagull, Meenaghan and Dexter5 The questionnaire was sent via e-mail (google forms) and was open from September to December 2017 for a total of 12 weeks. Repeat e-mails were sent to encourage participation. All survey responses were anonymous.
In addition to the questions included in the original questionnaire, the current survey addressed other issues such as: hours of surgery in the last week or last month; hours of sports or gymnastics in the last week or last month; current smoking status; and asked, in the respondent's perception, what percentage of fellow otolaryngology surgeons suffer musculoskeletal disorders attributable to the performance of surgical interventions.
Exclusion criteria were: previous musculoskeletal disorders (not related to surgical practice), general medical conditions or previous surgery preventing surgical practice in the last year.
Survey structure
The survey was based on a questionnaire adapted from Cavanagh et al. Reference Cavanagh, Brake, Kearns and Hong2 (in turn adapted from Park et al.).Reference Park, Lee, Seagull, Meenaghan and Dexter5 This questionnaire included the following sections: (1) demographic information, which included age, gender, height and weight, handedness, years in practice, number of different types of procedures performed in a year, caseload, number of hours of exercise, and smoking habits; (2) physical symptoms; (3) ergonomics; and (4) individual perception of the magnitude of the problem.
Some questions included multiple choice answers, such as ‘what is your type of practice? (public, private, both)’; other questions included check all that apply options such as ‘if you answer yes, which of the following apply? (numbness, stiffness, fatigue, pain)’; and others allowed free-text answers to open-ended questions such as ‘when do these symptoms or discomforts affect you most?’
Statistical analysis
A descriptive analysis was performed with a calculation of the mean and median for continuous variables and percentages for categorical variables. Categorical variables are presented as the means of absolute and relative frequencies, and numerical variables are presented as the mean (standard deviation) or median (25th and 75th percentiles). Categorical variables were analysed with the chi-square test, and the numerical variables were analysed with the Mann–Whitney U test or the Kruskall–Wallis test. Analysis of variance and Fisher's exact test were used where appropriate. A p-value of less than 0.05 was considered statistically significant. The analysis was done with STATA® (version 14) statistical software.
Results
The survey was sent to 2450 otolaryngology and head and neck surgery practitioners across Spain. Four hundred and seven surgeons (58 of whom where trainees) answered the survey giving a response rate of 16.6 per cent. There were 403 total completed surveys (excluding individual perception of the magnitude of the problem). Table 1 summarises the demographic information of the respondents, prevalence of work-related musculoskeletal symptoms and their impact, and awareness of surgical ergonomics among Spanish otolaryngologists. The mean age of respondents was 44.9 years. Most responders practised in an academic setting (55.4 per cent).
Table 1. Demographic information, prevalence of work-related musculoskeletal symptoms and their impact, and awareness of surgical ergonomics among Spanish otolaryngologists
SD = standard deviation
Practice experience and musculoskeletal disorders
The average caseload was 9.82 (standard deviation (SD) = 5.4) hours per week and 28.9 (SD = 16.7) hours per month. Physicians completed a large number of minor microscopy cases: 247 ENT surgeons performed more than 25 cases a year and 114 ENT surgeons performed more than 50 cases a year. Among respondents, 62 rhinologists, 32 otologists, and 30 head and neck or skull base surgeons completed more than 50 cases of minor and major endoscopy, major microscopy and head and neck or skull base cases, respectively.
Surgical practice and musculoskeletal disorders
A total of 89.8 per cent (362) of respondents reported discomfort or physical symptoms that they attributed to surgical practice (95 per cent confidence interval, 86 to 93 per cent). Of these, the most frequent symptom reported was pain (79.6 per cent; 288), followed by stiffness (51.5 per cent; 187), fatigue (49 per cent; 178) and numbness (40.5 per cent; 147). The most affected regions were (in descending order): the back (218), the neck (177), shoulder (68) and hands (59). The symptoms were localised in 46.5 per cent of respondents. In the rest, they radiated to other parts of the body. Other complaints described by the respondents were headache, eyestrain, tingling and heaviness in the legs. Table 2 presents the pain or discomfort characteristics that the otolaryngology and head and neck surgeons attributed to their surgical practice, and these are compared with other published results of similar studies.
Table 2. Summary of studies on the prevalence of work-related musculoskeletal disorders amongst ENT surgeons worldwide showing most frequently affected body parts
*lowest and highest prevalence of symptoms by procedure type (six subgroups according to type of surgical procedure). MSD = musculoskeletal disorders; BAOHNS = British Association of Otorhinolaryngology–Head and neck Surgery; NA = not available; Nad = not addressed; ARS = American Rhinologic Society; ASPO = American Society of Pediatric Otolaryngology; AAO-HNS = American Academy of Otolaryngology-Head and Neck Surgery; BRS = British Rhinological Society; ERS = European Rhinological Society; ENT-UK = British Association of Otorhinolaryngology-Head and Neck Surgery; CSO-HNS = Canadian Society of Otolaryngology-Head and Neck Surgery; AFPRS = American Academy of Facial Plastic and Reconstructive Surgery; SUO = Society of University Otolaryngologists; SEORL = Sociedad Española de Otorrinolaringología
Most respondents reported that the discomfort was most frequent during a surgical intervention and in the hours immediately after it, followed by long surgical procedures and out-patient clinical work. Of respondents, 60.6 per cent received some type of treatment for this reason (pharmacotherapy, physiotherapy, and osteopathy or chiropractic treatment), and 93.6 per cent experienced improvement with treatment. However, the problem was solved in only 45.9 per cent of cases, and 10 surgeons required surgery. The problem limited clinical practice in 9.9 per cent of cases. The most difficult reported procedures to perform in these circumstances were septoplasty and functional endoscopic sinus surgery. Finally, the discomfort represented a current problem for 29.4 per cent.
Subspecialty and musculoskeletal disorders
There was no significant difference when the frequency of physical discomfort or the need of treatment was compared with the different subspecialties.
Physical activity and musculoskeletal symptoms
The average physical activity (exercising, stretching, sports and gymnastics) was 2.7 (SD = 2.9) and 9.3 (SD = 7.8) hours per week and hours per month, respectively. When the level of physical activity was compared with the frequency of physical discomfort, no significant difference was found.
Individual perception of the problem
This question was answered by 379 respondents. Seven participants did not answer the question correctly, and the rest left this box blank. The average perception of those who answered the question correctly was 59 per cent (SD = 25 per cent) or given as the mode was 50 per cent.
ENT practice and awareness of ergonomics
Of the respondents, 83.8 per cent did not know the recommendations from the field of surgical ergonomics. The majority of those who had some knowledge (16.2 per cent) obtained it on the internet (alternative sources were courses, lectures and by word of mouth). Of these, most had applied it to their surgical practice with very positive and satisfactory results. Finally, 94.2 per cent reported that they would appreciate more information regarding surgical ergonomics.
Musculoskeletal disorders and need for medical treatment
Demographic information, workload and physical activity were compared with the prevalence of musculoskeletal symptoms and with the need for medical treatment. This analysis showed that years of experience, workload and the majority of demographic variables were not related to a higher frequency of musculoskeletal disorders or need for treatment. The only significant variable associated with a higher rate of musculoskeletal symptoms was sex, with muscle disorders being more frequent in women (p = 0.04). Table 3 compares the data for the three groups of physicians: (1) those who reported pain or discomfort and had received medical therapy; (2) those who reported pain or discomfort and had not received medical therapy; and (3) those who did not report any pain or discomfort related to their surgical practice.
Table 3. Comparison of main data for the three physician groups
*accumulated hours in the last week/last month (p = 0.65/p = 0.85); †accumulated hours of surgical activity in the last week/last month (p = 0.32; p = 0.49)
Discussion
Four hundred and three ENT surgeons responded to our survey, and 89.8 per cent (362) reported discomfort or physical symptoms that they attributed to the surgical practice. The response rate of 16.6 per cent was acceptable and comparable to other similar studies (Table 2).Reference Dabholkar, Yardi, Dabholkar, Velankar and Ghuge1–Reference Little, Deal, Zanation, McKinney, Senior and Ebert4,Reference Mal and Costello6–Reference Ho, Hamill, Sykes and Kraft12 Online or postal surveys typically have low response rates, with a median around 20 per cent for similar surveys.Reference Rimmer, Amin, Fokkens and Lund10
It should be noted that the gender distribution in this study was even, compared with a male predominance in previous studies. This may be because the number of female doctors specialising in ENT has increased in recent decades, and female ENT surgeons currently represent about 45 per cent of the ENT population in Spain. In this study, women had a higher prevalence of musculoskeletal disorders than men, which is consistent with previous studies and probably explained not only by differences in the perception of complaints, pain or discomfort but also by a possible ergonomic disadvantage in the operating room.Reference Cavanagh, Brake, Kearns and Hong2 Female surgeons responding to the survey were significantly shorter than men (on average 1.63 cm vs 1.77 cm, respectively; p < 0.0005), and this should be considered when equipping an operating room (for instance, some operating tables are not low enough). The mean age of respondents was 44.9 years, significantly lower than the mean age for back and neck pain in the general population.Reference Manchikanti, Singh, Datta, Cohen and Hirsch13
Musculoskeletal disorders were reported by 89.9 per cent of respondents in the present study, which is slightly higher than in other studies (Table 2). The most affected body regions were similar to those reported for ENT surgeons. Looking at other studies, shoulder complaints ranged between 12.9 per cent (Cavanagh et al.) and 63 per cent (Little et al.).Reference Cavanagh, Brake, Kearns and Hong2,Reference Little, Deal, Zanation, McKinney, Senior and Ebert4 In our study shoulder complaints were reported by 18.8 per cent, which is a similar figure to that of Mal et al., who specifically addressed shoulder impingement syndrome in British otolaryngologists.Reference Mal and Costello6
Ho et al. surveyed symptom prevalence by type of surgery and found that the neck and shoulder were the most affected areas, with shoulder complaints ranging from 45.2 to 62.8 per cent depending on the procedure (microdirect laryngoscopy and bronchoscopy being the most problematic).Reference Ho, Hamill, Sykes and Kraft12 Some studies have assessed symptom frequency for a specific area (back and neck;Reference Babar-Craig, Banfield and Knight7 shoulderReference Mal and Costello6) or surgical procedure (microlaryngeal surgery;Reference Wong, Baker, Smith and Rosen8 endoscopic sinus surgeryReference Little, Deal, Zanation, McKinney, Senior and Ebert4,Reference Amin, Rimmer, Swift, White and Lund9,Reference Rimmer, Amin, Fokkens and Lund10 ). For microlaryngeal surgery, the rate of reported shoulder symptoms was only 21 per cent.Reference Wong, Baker, Smith and Rosen8 By contrast, for musculoskeletal disorders related to endoscopic sinus surgery, the rates were 63 per cent,Reference Little, Deal, Zanation, McKinney, Senior and Ebert4 50.8 per centReference Amin, Rimmer, Swift, White and Lund9 and 45 per cent,Reference Rimmer, Amin, Fokkens and Lund10 which are higher rates than in other surveys aimed at all ENT surgeon populations.
When we analysed the areas affected in surgeons with a focus on a specific type of surgery (defined as those who performed 50 or more procedures of a particular subspecialty a year), we found no significant differences compared with the rest of the respondents. However, it should be noted that only 62 (15.3 per cent), 32 (7.9 per cent) and 30 (7.4 per cent) ENT surgeons met the criterion for major microscopy, minor and major endoscopy, and head and neck and skull base surgery, respectively. In any case, there was no difference with the largest general ENT physician group. Sitting and standing position during surgery was not evaluated and was beyond the aim of this study, although it could be related to the ratio of upper vs lower limb musculoskeletal disorders.
Endoscopic sinus surgery and otological and laryngological procedures expose otolaryngology and head and neck surgery specialists to neck, shoulder and back strains.Reference Wunderlich, Jacob, Stelzig, Rüther and Leyk14 Otorhinolaryngologists have been found to spend 54 per cent of their operating time with the head bent forward, to one side or twisted.Reference Babar-Craig, Banfield and Knight7 Although a higher musculoskeletal disorder prevalence might be expected with increasing age and cumulative surgical load, this has not been demonstrated, which could be explained by the healthy worker effect.Reference Cavanagh, Brake, Kearns and Hong2 However, Bolduc-Bégin et al. found that respondents who worked more than 16 hours per week in clinic had a higher prevalence of global musculoskeletal disorders.Reference Bolduc-Bégin, Prince, Christopoulos and Ayad11
Out-patient clinical work is not often considered, but many factors might contribute to musculoskeletal disorders such as sustained or awkward postures, inappropriate writing desk setup, work break frequency, illumination, and assistance. In the present study, out-patient clinical work was the third most cited factor related to musculoskeletal discomfort after surgical practice and long surgical procedures. The prevalence of reported musculoskeletal disorders was similar for otolaryngology residents and practising otolaryngologists and consistent with published findings.Reference Wong, Grundfast and Levi15
An effort should be made to establish preventive measures and teach ergonomic skills early in training. Some corrective measures have been suggested by ENT surgeons themselves: adequate work breaks, skilled assistance, change in posture, customised workstations, use of a back rest and time management.Reference Dabholkar, Yardi, Dabholkar, Velankar and Ghuge1 Other more specific recommendations come from the fields of ergonomics, minimally invasive surgery, laparoscopic surgery and, most recently, studies on ergonomic aspects of microlaryngoscopy and endoscopic sinus surgery.Reference Matern and Koneczny16–Reference Ayad, Péloquin and Prince20
Statham et al. demonstrated that lack of arm support during microlaryngeal surgery leads to a 4-fold increase in compressive forces on vertebral disc space. The position that involves least risk for the surgeon is one in which the arms and feet are well supported, and the neck minimally flexed from 0° to 10° with respect to the vertical plane.Reference Statham, Sukits, Redfern, Smith, Sok and Rosen18 Ramakrishnan et al. reviewed the ergonomic recommendations for endoscopic sinus and skull base surgery based on scientific evidence. These recommendations cover aspects such as appropriate monitor placement, proper instrument maintenance, adjustable operating tables, correct use of pedals and upper body position.Reference Ramakrishnan and Montero17
The increasing preoccupation with ergonomics in current surgical training is reflected in the growing number of publications on the issue. Although otolaryngology and head and neck surgery practitioners in Spain have a high perception of the magnitude of the problem of musculoskeletal disorders, knowledge of surgical ergonomics is low meaning there is an urgent need for thorough ergonomics education and training. Surgeons who are aware of the implications of ergonomics are more likely to take them into account during surgery. In the present study, most of those who had some knowledge (16.2 per cent) applied it to their surgical practice with very positive and satisfactory results.
This study failed to demonstrate a relationship between factors such as age, surgical experience or workload and the development of musculoskeletal disorders. This is consistent with other surveys published in recent years that point to many potential offenders without clearly confirming their role in work-related musculoskeletal disorders. This could be explained by multifactorial aetiology, where diverse factors such as general health, physical activity, fitness, lifestyle and work style factors (e.g. postures involved in office procedures or computer work), risk-related behaviours, and cumulative exposure to risk factors may contribute to the development of symptoms.Reference Wong, Baker, Smith and Rosen8
This study has several limitations. First, there is a possibility of selection bias as physicians with an interest in ergonomics or those who have experienced musculoskeletal symptoms could have been more likely to respond to the survey. However, if we consider that those who did not respond have no musculoskeletal disorders, the number of otorhinolaryngologists in Spain with musculoskeletal disorders derived from surgical practice is still 14.5 per cent. Secondly, the multifactorial aetiology of musculoskeletal disorders constitutes a confounding factor even though the respondents reported the musculoskeletal symptoms directly related with their surgical practice. The final limitation is the small sample size, although it is larger than most of the reviewed surveys, some of which are international in scope.
We did not find a positive relationship between regular physical exercise and the absence of musculoskeletal disorders. This may be due in part to the high prevalence of musculoskeletal disorders among those who responded to the survey. If we collected data related to the practice of exercise and the presence of musculoskeletal disorders as a secondary variable, we might obtain a different result. Another possible reason is the non-specific nature of the exercise, meaning it does not act as a protective factor and may even aggravate certain symptoms or work-related musculoskeletal disorders. We believe that the best way for physical exercise to be beneficial would be through a series of physical exercises aimed at strengthening the most compromised muscle groups and would be personalised, thereby taking into account the individual's surgical and medical activity, physical condition, and any possible previous injuries or affected muscle groups. It has been shown that performing any type of physical activity prevents the appearance of musculoskeletal disorders,Reference Dabholkar, Yardi, Dabholkar, Velankar and Ghuge1 although exercises that strengthen the muscles that are most in demand during normal activity are probably the most beneficial.
We must take advantage of the knowledge and experience of rehabilitation doctors and physiotherapists who can advise on the adoption of correct postures at work, ergonomic aspects and exercises appropriate to workload.
Poor ergonomics might lead to chronic pain and fatigue. This is a significant concern not only for the surgeon's quality of life but also for healthcare delivery. Applying ergonomic knowledge may result in less illness, better surgical outcomes, high productivity and injury-free careers for surgeons. We encourage the cited articles to be read in order to spread knowledge of the ergonomics recommendations for endoscopic sinus and skull base surgery, and microlaryngeal surgery. Future studies should address the possible impact of specific surgical ergonomic changes on the intensity and prevalence of musculoskeletal disorders among otolaryngology and head and neck surgery practitioners.
• There is a high prevalence of musculoskeletal disorders among ENT surgeons in Spain, which is similar to other European and American countries
• Muscular discomfort or physical symptoms attributed to surgical practice start very early in training
• This study has failed to demonstrate an important role of physical exercise in the prevention of musculoskeletal disorders
• The most beneficial effects of exercise would be through personalised exercises to strengthen the most compromised muscle groups in each surgeon based on their surgical and medical activity
• There is an urgent need for more thorough ergonomics education and training among otolaryngologists
Conclusion
Musculoskeletal disorders are very prevalent among ENT surgeons in Spain. Although the perception of the magnitude of the problem of musculoskeletal disorders among these professionals is high, the knowledge of surgical ergonomics is very low. Accordingly, there is an urgent need for more thorough ergonomics education and training. This study has failed to demonstrate an important role of physical exercise in the prevention of musculoskeletal disorders. The reasons are unclear but might be related to the non-specific nature of the exercise.
Competing interests
None declared
