Ergonomic analysis of microlaryngoscopy

Ergonomics in facial plastic and reconstructive surgery

PURPOSE OF REVIEW

Understanding effective ergonomic interventions is crucial for enhancing occupational health and career longevity. There is a paucity of clear ergonomics guidelines in facial plastic and reconstructive surgery (FPRS), placing practitioners at high risk of work-related musculoskeletal disorders (WMSDs) and their consequences.

RECENT FINDINGS

There is mounting evidence that FPRS specialists are at increased risk of WMSDs as compared with the public and other surgical specialties. Numerous studies have demonstrated that implementation of ergonomics principles in surgery decreases WMSDs. Furthermore, WMSDs are reported as early as the first year of surgical residency, marking the importance of early intervention.

SUMMARY

Fatigue and physical injuries among surgeons occur more often than expected, particularly during complex, extended procedures that necessitate maintaining a constant posture. FPRS procedure often place surgeons into procrustean positions. Thus, integrating ergonomic practices into the practice of FPRS is essential for reducing WMSDs.

Don't Just Stand There. Rethinking the Ideal Body Posture for Otorhinolaryngologists

Surgeons have a high rate of work-related musculoskeletal injuries; an area that has received little attention. These injuries result in surgeons performing less efficiently, needing to take time off work, suffering higher rates of burnout, and may ultimately lead surgeons to retire earlier than planned. Otorhinolaryngologists are at particular risk for work-related musculoskeletal injuries. Beyond the clinician, sustaining such injuries can negatively impact patient safety. Ergonomic interventions have been used effectively to reduce work-related musculoskeletal injuries in other professions, yet not in surgery. With traditional teachings of ideal body postures to avoid injury and manual handling training being re-evaluated, it is important to explore evidence based interventions for reducing work-related musculoskeletal injuries in otorhinolaryngologists. New research encourages us to shift the focus away from the traditional one-size-fits-all approach to ergonomics and toward postural recommendations and education that promote a dynamic, individualized approach to avoiding sustained, static and awkward postures.

Female Surgical Ergonomics in Otolaryngology: A National Survey Study

OBJECTIVE

To assess the nature and impact surgical ergonomic challenges experienced by female otolaryngologists.

STUDY DESIGN

National survey study.

SETTING

Female otolaryngology residents, fellows and attendings recruited via social media posting and email distribution.

METHODS

We distributed a survey study to female otolaryngologists throughout the United States. The height and glove size of participants reporting difficulties with equipment and instruments were compared to those not reporting difficulties.

RESULTS

Ninety-six female otolaryngologists participated in our study, comprised of 43% residents, 10% fellows, and 47% attendings. Ninety percent of participants reported difficulties using equipment and 77% of participants reported difficulty with instruments, the most common being nasal endoscopic instruments (28%). The vast majority of participants reported pain during and (or) after the operation (92%). Head and neck (53%) and rhinology (44%) were identified as particularly challenging specialities, but only 25% of participants reported that ergonomics affected their career plans. Participants felt that adjustable equipment (60%), a variety of sizes of instruments (43%), and more discussion around ergonomics (47%) would help. Respondents reported adjusting the operating room to accommodate their size took extra time (44%) and was a mental burden (39%). Participants reporting difficulties with operating room equipment were significantly shorter than those without difficulties (64 inches vs 67 inches, P = .037), and those reporting difficulties with instruments had a smaller median glove size (6 vs 6.5, P = .018).

CONCLUSION

Surgical ergonomics represent a challenge for female otolaryngologists, particularly those with smaller hands and shorter height. Partnering with industry, we must address the needs of an increasingly diverse workforce to ensure that all surgeons can operate effectively and comfortably.

Musculoskeletal disorders risk assessment methods: a scoping review from a sex perspective

The evidence points to differences in the impact of musculoskeletal disorders (MSD) in males and females due to different exposure to risk factors and inherent characteristics. To identify risks associated with MSDs, ergonomic assessment is carried out by applying various methods. The aim of this scoping review was to determine to what extent ergonomic assessment methods consider sex-related factors and if they were found to do so, to determine the extent of this consideration. A total of 31 papers on 32 ergonomic assessment methods were analysed in the review. Of these 32 methods, only 6 considered sex as an assessment parameter or when interpreting the results. The results revealed that the limited consideration given to the sex factor in ergonomic methods, together with the different impacts of MSDs and their consequences according to a person's sex, supports the importance of including sex factors in ergonomic assessment methods. Practitioner summary: This scoping review determined to what extent ergonomic assessment methods consider sex-related factors and if they do so, to establish the extent of such consideration. Of the 32 methods analysed, only 6 considered a person's sex. The results revealed that only a limited consideration is given to the sex factor in ergonomic methods.

Female Surgical Ergonomics in Otolaryngology: A Qualitative Study

OBJECTIVE

To explore the surgical ergonomic challenges experienced by women in otolaryngology, identify specific equipment that is ergonomically challenging, and assess the impact of suboptimal ergonomics on female otolaryngologists.

METHODS

We performed a qualitative study using an interpretive framework rooted in grounded theory. We performed semi-structured qualitative interviews of 14 female otolaryngologists from nine institutions at various stages in training and across subspecialties. Interviews were independently analyzed by thematic content analysis by two researchers and inter-rater reliability was assessed via Cohen's kappa. Differing opinions were reconciled via discussion.

RESULTS

Participants noted difficulties with equipment including microscopes, chairs, step stools, and tables as well as difficulty using larger surgical instruments, preference for smaller instruments, frustration with lack of smaller instruments, and a desire for a larger spectrum of instrument sizes. Participants reported neck, hand, and back pain associated with operating. Participants suggested modifications to the operative environment, including a wider variety of instrument sizes, adjustable instruments, and more focus and attention on ergonomic issues and the range of surgeon physiques. Participants felt that optimizing their operating room set-up was an additional burden on them, and that lack of inclusive instrumentation affected their sense of belonging. Participants emphasized positive stories of mentorship and empowerment from peers and superiors of all genders.

CONCLUSION

Female otolaryngologists face unique ergonomic challenges. As the otolaryngology workforce becomes increasingly diverse, it is important to address the needs of a diverse set of physiques to avoid inadvertently disadvantaging certain individuals.

LEVEL OF EVIDENCE

N/A Laryngoscope, 133:3034-3041, 2023.

Unpacking the Broad Landscape of Intraoperative Stressors for Clinical Personnel: A Mixed-Methods Systematic Review

Purpose

The main goals of this mixed-methods systematic review are to identify what types of intraoperative stressors for operating room personnel have been reported in collected studies and examine the characteristics of each intraoperative stressor.

Methods

With a systematic literature search, we retrieved empirical studies examining intraoperative stress published between 2010 and 2020. To synthesize findings, we applied two approaches. First, a textual narrative synthesis was employed to summarize key study information of the selected studies by focusing on surgical platforms and study participants. Second, a thematic synthesis was employed to identify and characterize intraoperative stressors and their subtypes.

Results

Ninety-four studies were included in the review. Regarding the surgical platforms, the selected studies mainly focused on minimally invasive surgery and few studies examined issues around robotic surgery. Most studies examined intra-operative stress from surgeons' perspectives but rarely considered other clinical personnel such as nurses and anesthetists. Among seven identified stressors, technical factors were the most frequently examined followed by individual, operating room environmental, interpersonal, temporal, patient, and organizational factors.

Conclusion

By presenting stressors as multifaceted elements affecting collaboration and interaction between multidisciplinary team members in the operating room, we discuss the potential interactions between stressors which should be further investigated to build a safe and efficient environment for operating room personnel.

Ergonomics in Otolaryngologic Surgery: A State of the Art Review

OBJECTIVE

Otolaryngology is a surgical field with a high degree of ergonomic risk. The use of head-mounted lighting, loupe magnification, endoscopes, and microscopes is inherent to the field, coupled with repetitive fine motor movements in a constrained anatomic field as well as static, ergonomically unfavorable postures. We seek to review the otolaryngologic literature on ergonomics, including prevalence, severity, and interventions in decreasing work-related musculoskeletal pain.

DATA SOURCES

Data were derived from clinical peer-reviewed primary literature as well as information provided by residency programs and presented at national and international meetings.

REVIEW METHODS

A comprehensive review was performed by 3 independent reviewers utilizing an electronic database literature search through PubMed, Embase, and Cochrane Library. Search terms included combinations and variations of the following concepts: ergonomics, surgery, otolaryngology, work related musculoskeletal disorders, chronic cervical pain, musculoskeletal, posture, surveys, microsurgery, endoscopic surgery. Strict objective criteria for inclusion were not used due to the inherent heterogeneity in articles and lack of rigorous empirical evidence.

CONCLUSIONS

Chronic musculoskeletal pain is prevalent among otolaryngologic surgeons, with many procedures producing high ergonomic risk. Most studies evaluating interventions to decrease ergonomic risks demonstrate promising results, but standardization in methods and outcome reporting is needed.

IMPLICATIONS FOR PRACTICE

Literature shows that musculoskeletal pain begins in training, and there is a paucity of information related to ergonomic risk in otolaryngology residency curriculums. Work-related musculoskeletal disorders related to poor workplace ergonomics have the potential to limit career longevity and lead to physician burnout. Interventions to mitigate this risk are effective and tend to be well received by physicians.

Prevalence, characteristics, contributing factors, work sector, and impact of work-related musculoskeletal disorders among otorhinolaryngology practitioners in Saudi Arabia: A cross-sectional study

BACKGROUND: Otorhinolaryngology practitioners are known to be susceptible to work-related musculoskeletal disorders (WMSDs), but the incidence of WMSDs in Saudi Arabia has not been documented. OBJECTIVES: This study aimed to establish the prevalence, characteristics, contributing factors, work sector, and impact of WMSDs among otorhinolaryngology practitioners in Saudi Arabia. METHODS: A cross-sectional survey was conducted on 104 otorhinolaryngology practitioners in Saudi Arabia using a six-component questionnaire. Descriptive statistics, prevalence, percentages, and chi-square tests were used for data analysis. RESULTS: The response rate was 65.3%. The reported 12-month incidence of WMSDs was 72.7%. The neck region (67.3%) was the most common site of disorders, followed by the shoulder (49%). The elbow and hip (10.5%) regions were the least commonly affected regions. WMSD prevalence was related to gender, with men more affected than women (neck, shoulders, low back); age, with younger otorhinolaryngology practitioners more affected than older ones (neck, shoulder); work sector, with greater prevalence in government than other sectors (neck); and sub-specialty, with general otolaryngology reporting the highest WMSD frequency, followed by otology and neurotology (neck, shoulder, low back, upper back, knees). Most otorhinolaryngology practitioners experienced two to four episodes of neck, shoulder, and low-back WMSDs. The most significant risk factor for WMSDs was sustained posture for long periods of time (61.5%). The most common strategy implemented against WMSDs was modifying the practitioner’s position during treatment (58.6%). CONCLUSIONS: WMSDs among otorhinolaryngology practitioners in Saudi Arabia are very common, with the neck and shoulders regions most often involved. Improved professional skills and an understanding of the principles of ergonomics can prevent the initial development of WMSDs in otorhinolaryngology practitioners.

Application of the rapid upper limb assessment tool to assess the level of ergonomic risk among health care professionals: A systematic review

BACKGROUND: Work-related musculoskeletal disorders (WMSDs) and ergonomic risk factors are widespread problems in the healthcare sector. OBJECTIVE: The primary objective of this review is to evaluate the application of the Rapid Upper Limb Assessment (RULA) tool in various healthcare professionals and to assess the level of ergonomic risk among them. METHODS: The databases MEDLINE, EMBASE, CINAHL, LILACS, SCIELO, DOAJ, PubMed, and PEDro were searched with terms associated with ergonomics, assessment, health care providers, risk factors, workplace, and RULA. We reviewed the literature from 2000 to 2020, including studies assessing RULA’s effectiveness for evaluating the WMSD’s and ergonomic risk in health care practitioners. We excluded the studies which were not open access and freely available. RESULTS: Overall, 757 records were screened; of these 40 potential studies, 13 different healthcare professionals were identified as eligible for inclusion. In most studies, the RULA tool was established as an effective tool in application and evaluating the level of the ergonomic risk among them. CONCLUSIONS: The RULA tool assessed the high ergonomic risk levels in dental professionals and low ergonomic risk levels in professionals working in the pharmacy department, clearly suggesting potential changes in work postures were necessary to prevent or reduce these risk factors.

A systematic review of biomechanical risk factors for the development of work-related musculoskeletal disorders in surgeons of the head and neck

BACKGROUND

Previous studies have shown high rates (47-72%) of self-reported work-related musculoskeletal disorders (WRMDs) in surgeons of the head and neck. Physical requirements in the workplace, individual factors (e.g. poor posture, obesity) and psychosocial factors have been identified as risk factors. Establishing biomechanical risk factors may help prevent further development of WRMDs in this population.

OBJECTIVE

The purpose of this critical review was to source studies that identified the biomechanical risk factors for WRMDs in this surgical sub-specialty.

METHODS

Searches were conducted of Medline, CINAHL, and AMED databases from 1980 until September 2018.

RESULTS

A total of 182 article were identified. Exclusion criteria lead to 163 full-text articles being screened, generating a total of 6 articles for review. The aims of the included studies varied significantly. Surgeons spend the majority of operating time in static, asymmetrical positions. Surgical loupes/headlamps significantly increased cervical spine loading. Articulated surgical arm supports provided optimal ergonomic conditions. Performing surgical operations with the surgeon in standing or sitting had no effect on task performance or demand. Physical fatigue was also measured in both positions.

CONCLUSIONS

A combination of equipment-based and patient/surgeon position-based factors predispose surgeons to biomechanical risk factors. Studies of greater methodological quality are required.

Surgical ergonomics for urologists: a practical guide

Poor ergonomics in the operating room can have detrimental effects on a surgeon's physical, psychological and economic well-being. This problem is of particular importance to urologists who are trained in nearly all operative approaches (open, laparoscopic, robotic-assisted, microscopic and endoscopic surgery), each with their own ergonomic considerations. The vast majority of urologists have experienced work-related musculoskeletal pain or injury at some point in their career, which can result in leaves of absence, medical and/or surgical treatment, burnout, changes of specialty and even early retirement. Surgical ergonomics in urology has been understudied and underemphasized. In this Review, we characterize the burden of musculoskeletal injury in urologists and focus on various ergonomic considerations relevant to the urology surgeon. Although the strength of evidence remains limited in this space, we highlight several practical recommendations stratified by operative approach that can be incorporated into practice without interrupting workflow whilst minimizing injury to the surgeon. These recommendations might also serve as the foundation for ergonomics training curricula in residency and continuing medical education programmes. With improved awareness of ergonomic principles and the sequelae of injury related to urological surgery, urologists can be more mindful of their operating room environment and identify ways of reducing their own symptoms and risk of injury.

The effectiveness of ergonomics interventions in reducing upper limb work-related musculoskeletal pain and dysfunction in sonographers, surgeons and dentists: a systematic review

The aim of this systematic review was to summarise the effects of ergonomics interventions on work-related upper limb musculoskeletal pain and dysfunction, and on productivity in sonographers, surgeons and dentists. A total of 31 studies were included. All studies reported effects on upper limb pain. Nine studies reported effects on dysfunction and only two studies reported effects on productivity. Moderately strong evidence in reducing upper limb pain was found for instigation of microbreaks into long duration surgical procedures, and the use of wider, lighter handles in dental instruments. Moderate evidence was also found for use of prismatic glasses and favourable positioning in reducing upper limb pain. Weak, inconsistent or no evidence was found for all other ergonomics interventions in reducing upper limb pain and dysfunction and increasing productivity. The lack of high quality research, particularly in sonographers and in the outcome of productivity, should be addressed. Practitioner summary: This systematic review investigates the effectiveness of ergonomics interventions on upper limb pain, dysfunction and productivity in sonographers, dentists and surgeons. Instigation of microbreaks during long duration procedures and the use of wider, lighter instrument handles were most effective in reducing upper limb work-related pain. Abbreviations: ANOVA: analysis of variance; CLS: conventional laparoscopic surgery; DMAIC: define, measure, analyze, improve and control; GRADE: grading of recommendations, assessment, development and evaluations; HD: high definition; PRISMA: preferred reporting items for systematic reviews and meta-analyses; PROSPERO: The International Prospective Register of Systematic Reviews; RCT: randomised control trial; SILS: single incision laparoscopic surgery; VITOM: video telescopic operative microscope; WNSWLHD: Western New South Wales Local Health District; WMSD: work related musculoskeletal disorder.

Work-Related Musculoskeletal Symptoms in Otorhinolaryngology-Head and Neck Surgery Residents

Objectives

Work-related musculoskeletal disorders in Saudi Arabia are not often reported in the literature. This study aimed to identify musculoskeletal symptoms among otorhinolaryngology residents in Saudi Arabia.

Methods

This cross-sectional survey-based study was conducted in May 2018 and included residents registered in the Saudi Otorhinolaryngology-Head and Neck Surgery Board Training programme, Riyadh, Saudi Arabia. The Nordic Musculoskeletal Questionnaire was used to assess musculoskeletal symptoms in addition to demographic and occupational factors, including operating position and the average number of operating hours.

Results

A total of 45 residents (response rate: 68.2%) completed the survey, including 33 males (73.3%) and 12 females (26.7%). Most residents (91.1%) reported at least one musculoskeletal symptom. The most commonly reported musculoskeletal over the previous 12 months were shoulder complaints (64.4%) followed by neck complaints (60%). In the short term (i.e. within seven days preceding the survey), neck complaints were more common than shoulder complaints (28.9% versus 20%). Lower back complaints were the most common cause of activity limitation (24.4%) followed by shoulder complaints (13.3%), while those with neck complaints reported it as a cause for visiting a physician (8.9%). Hip and thigh complaints were significantly more frequent among residents with operation times of eight hours or more compared to those who operating for less than eight hours (42.9% versus 5.9%; P = 0.021).

Conclusion

A high incidence of shoulder, neck and lower back complaints was found in this study. Residency is an ideal time in an otorhinolaryngologist’s career to implement programmes in ergonomic best practices before bad habits are developed.

Musculoskeletal Risks: RULA Bibliometric Review

The objective of this study was to reveal RULA method applications in terms of the knowledge, country, year and journal categories. The search was performed using the "Web of Science Core Collection". The period from 1993 to April 2019 was selected. Eight hundred nine results were obtained, of which 226 were used. The largest number of publications was determined to be in the fields of industry and health and social assistance, which coincides with the OWAS and Standardized Nordic Questionnaire methods. By country, the USA stands out for its greater number of research studies and categories that are encompassed. By date, 2016 was the year when more studies were carried out, again coinciding with the Standardized Nordic Questionnaire. By journal, "Work-A Journal of Prevention Assessment and Rehabilitation" is highlighted, as it is for the REBA method as well. It was concluded that RULA can be applied to workers in different fields, usually in combination with other methods, while technological advancement provides benefits for its application.

Evaluation of 2 Low-cost High-definition Video Systems for Venous Anastomosis

Background. A literature review of the use of video systems for magnification has suggested that so far, this novel magnification system has only been used to perform arterial anastomoses. The aim of this study was to evaluate the use of 2 low-cost methods of video-assisted magnification in microvascular venous anastomosis in rats. Methods. Thirty rats were randomly divided into 3 matched groups according to the magnification system used: the microscope group, with venous anastomosis performed under a microscope; the camcorder system group, with the procedures performed under a high-definition Handycam HDR-XR160; and the Photographic camera group, for which procedures were performed with an EOS Rebel T3i photographic camera. In both video system groups, a magnification system was connected to a 42-in. television by an HDMI cable. We analyzed weight, venous caliber, total surgery and anastomosis time, patency immediately and 14 days postoperatively, number of stitches, and histological analyses. Results. There were no significant differences between the groups in weight, venous caliber, or number of stitches. Anastomosis under the video systems took longer. Patency rates were similar between the groups, except for the photographic system group that has a lower patency rate at 14 days. The histological analyses were similar in all groups. Conclusion. It is possible to perform a venous anastomosis in rats through video system magnification, with a satisfactory success rate comparable with that for procedures performed under microscopes; however, the kind of video system has a great influence on the final patency.

The Ipswich Microbreak Technique to alleviate neck and shoulder discomfort during microscopic procedures

Neck and shoulder disorders are a considerable health problem amongst frequent microscope users. We aimed to investigate the neck and shoulder discomfort experienced during prolonged microscopic activity and to assess the benefits of minibreaks. A prospective crossover study was performed on 17 healthy volunteers sitting still while looking down a bench with and without the Ipswich Microbreak Technique (IMT). We used a subjective measure of time to fatigue and pain in the neck and shoulder regions as well as objective readings from a surface electromyogram (sEMG). The IMT delayed the sensation of pain in the neck and shoulder region while reducing the overall sEMG muscle activation. In conclusion, IMT is a useful strategy in reducing and delaying the pain in neck and shoulder from prolonged working under the microscope. This technique can be incorporated in other activities that involve a sustained stationary position.

The Current State of Surgical Ergonomics Education in U.S. Surgical Training: A Survey Study

OBJECTIVE

The aim of this study was to characterize the current state of surgical ergonomics education in the United States.

BACKGROUND

The burden of work-related musculoskeletal disorders (MSDs) in surgeons is high and no overarching strategy for redress exists. Twelve distinct specialties describe an unmet need for surgical ergonomics education (SEE). This study aimed to define the current state of SEE in U.S. surgical training programs.

METHODS

We performed a descriptive analysis of a 20-item questionnaire of ACGME-certified program directors from 14 surgical and interventional medical specialties. Formal SEE was defined as any organized education module that reviewed the occupation-specific burden of common work-related MSDs and described a framework for prevention via occupation-specific applied ergonomics. Program directors were queried regarding SEE provision, characteristics, and perceived trainee attitude toward the education.

RESULTS

Questionnaires were received from 130 of 441 (29.5%) program directors. Two (1.5%) provided formal SEE and 33 (25.4%) provided informal SEE, which consisted of unstructured intraoperative directives and isolated lectures. Two programs previously provided SEE but discontinued the effort due to lack of an evidence-based framework and instructors. Trainees appeared to think that learning surgical ergonomics skills was a worthwhile time investment in 100% and 76.7% of current formal and informal SEE, respectively.

CONCLUSION

SEE is rarely provided in any capacity (25.4%), let alone in a consistent or evaluable fashion (1.5%). Impediments to sustainable SEE include lack of an evidence-based framework for education and instructors. An evidence-based, reproducible, and accreditation council-compliant SEE module would be a valuable resource for the surgical and interventional medical communities.

Work-related musculoskeletal symptoms in otorhinolaryngology and their relationship with physical activity. A nationwide survey

OBJECTIVE

The main 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 to measure the effect that physical exercise could have on muscular discomfort.

METHOD

A cross-sectional survey was administered between September and December 2017 to practising otolaryngologists.

RESULTS

Four hundred and three ENT surgeons responded, with a median age of 44.9 years, and 89.8 per cent reported discomfort or physical symptoms that they attributed to surgical practice. More female surgeons reported musculoskeletal symptoms (92.8 per cent vs 87.1 per cent; p = 0.04). When the level of physical activity was compared with the frequency of physical discomfort, no significant difference was found.

CONCLUSION

This study has shown a high prevalence of musculoskeletal disorders among ENT surgeons in Spain but has failed to demonstrate an important role of physical exercise in the prevention of musculoskeletal disorders.

Estimation of surgeons' ergonomic dynamics with a structured light system during endoscopic surgery

BACKGROUND

The purpose of this study was to use motion capture to collect body posture information during simulated endoscopic sinus surgery interventions performed by both specialists and residents in standing and sitting positions and to analyze that information with the validated Rapid Upper Limb Assessment (RULA) tool, which allows calculation of a risk index of musculoskeletal overload.

METHODS

Bilateral endoscopic sinus surgery was performed in 5 cadaver heads by 2 residents, and 4 practicing rhinologists. Musculoskeletal symptoms were evaluated before and after the dissection. Full-body postural data were collected with the help of Kinect and a .NET WPF (Windows Presentation Foundation) software application to record images of the surgical procedures, and then analyzed with the RULA tool to calculate a risk score indicative of the exposure of the individual surgeon to ergonomic risk factors associated with upper extremity musculoskeletal disorders.

RESULTS

All subjects reported physical discomfort after nasal endoscopic procedures. An overall similar RULA score was obtained by the residents and the practicing rhinologists. The RULA score was slightly lower for the sitting position than for the standing position, mostly due to a lower score in group B (neck, trunk, and leg); however, the RULA score for group A (arm and wrist analysis) was higher, denoting a higher risk for the upper back and arms.

CONCLUSION

Significant musculoskeletal symptoms were reported after an endoscopic operation by both the resident and the practicing otolaryngologists. All surgeons obtained a high RULA score, meaning that urgent changes are required in the task.

The Swansea Floating Endoscopic Assistant: A Surgical Handling Aid

Endoscopic sinus surgery is a rapidly advancing area of Otolaryngology. Operations can be lengthy and are often performed by a single surgeon. Repetitive movements can also lead to muscular fatigue. To mitigate against this, we regularly deploy two retractable Flexi™ compact leads, one bigger than the other connected together and suspended from the theatre operating light arm using velcro ties. The leads are then wrapped around the endoscope using a cotton crepe bandage, in a double loop with a reef knot. The larger lead attaches to the focus/zoom adjustment part of the endoscopic camera, and the smaller lead attaches to the scope 20 cm from the tip allowing the scope to float when suspended, with a slight downward tilt towards the patient. The mechanical effect this produces allows an advantageous reduction in the scope’s weight from 404 g un-suspended, to 65 g with the setup described. This subsequently reduces stress on the elbows, shoulders neck and lumbar spine. The Swansea Floating Endoscopic Assistant adheres to basic ergonomic principles and has the potential for application in other areas of Otorhinolaryngology and Skull Base Surgery.

Using motion capture technology to measure the effects of magnification loupes on dental operator posture: A pilot study

BACKGROUND

Motion analysis has great potential for quantitatively evaluating dental operator posture and the impact of interventions such as magnification loupes on posture and subsequent development of musculoskeletal disorders.

OBJECTIVE

This study sought to determine the feasibility of motion capture technology for measurement of dental operator posture and examine the impact that different styles of magnification loupes had on dental operator posture.

METHODS

Forward and lateral head flexion were measured for two different operators while completing a periodontal probing procedure. Each was measured while wearing magnification loupes (flip up-FL and through the lens-TTL) and basic safety lenses.

RESULTS

Operators both exhibited reduced forward flexion range of motion (ROM) when using loupes (TTL or FL) compared to a baseline lens (BL). In contrast to forward flexion, no consistent trends were observed for lateral flexion between subjects.

CONCLUSIONS

The researchers can report that it is possible to measure dental operator posture using motion capture technology. More study is needed to determine which type of magnification loupes (FL or TTL) are superior in improving dental operator posture. Some evidence was found supporting that the quality of operator posture may more likely be related to the use of magnification loupes, rather than the specific type of lenses worn.

Ergonomics in microsurgery

There is a growing body of evidence to suggest that surgeon posture while operating contributes to cervical musculoskeletal strain, discomfort, and chronic pain. Microsurgeons may be particularly susceptible to this risk due to persistent neck flexion, long periods of static posture, and the use of heavy, high-power loupe magnification. Several techniques are thus presented that may help in obviating the cervicospinal repercussions of performing microsurgery.

Effects of prolonged microscopic work on neck and back strain amongst male ENT clinicians and the benefits of a prototype postural support chair

Musculoskeletal pain is a common occupational hazard experienced by surgeons. Ear, nose and throat (ENT) surgeons are predisposed to neck and back pain due to regular prolonged microscopic work. We conducted a prospective pilot study to investigate the effects of sustained microscopic work on the neck and back, its correlation to surgical experience and to assess the benefits of a prototype postural support chair (PSC) amongst 10 male, ENT clinicians. We used a subjective measure of time to fatigue and pain for the neck and back as well as objective readings from a surface electromyogram (sEMG). We found that an increase in surgical experience correlated with the time taken to experience fatigue and pain in the neck and back. This was corroborated by our sEMG findings. The PSC significantly delayed the sensations in the neck and also eliminated the difference seen amongst the varying seniority of clinicians.

Work-related musculoskeletal symptoms amongst Otolaryngologists and Head and Neck surgeons in Canada

The first objective of this study was to identify work-related musculoskeletal symptoms and determine their prevalence in the practice of Otolaryngology and Head and Neck surgery in Canada. The second objective was to establish potential associations between those musculoskeletal symptoms and variables related to demographic status of the surgeons, their workload and work ergonomics. This study was designed as a Canadian census on work-related musculoskeletal symptoms amongst Otolaryngologist and Head and Neck surgeons. The census was a self-administered electronic survey. It was distributed to all Otolaryngologists and Head and Neck surgeons members of either the Canadian Society of Otolaryngology-Head and Neck Surgery or the Association of Oto-rhinolaryngology-Head and Neck Surgery of Quebec. The questionnaire contained three sections: demographic and workload-related data, identification of work-related musculoskeletal symptoms and evaluation of working ergonomics. The response rate was 23%. Ninety seven percent (97%) of respondents experienced some physical symptom in one or many regions of their body. Seventy-four percents (74%) of respondents noted an exacerbation of their musculoskeletal symptoms by work. Musculoskeletal symptoms limited the daily activities of 45% of respondents while 23% think that their occupational longevity will be diminished by these limitations. The prevalence of work-related musculoskeletal disorders is high among otolaryngologists and its impact on the surgeon's personal and professional life is high. There is a need to improve ergonomics in the clinical and operative room settings and to educate surgeons on ergonomic principles.

Optimizing Positioning for In-Office Otology Procedures

Objective

Surgeons often report musculoskeletal discomfort in relation to their practice, but few understand optimal ergonomic positioning. This study aims to determine which patient position—sitting versus supine—is ergonomically optimal for performing otologic procedures.

Study Design

Observational study.

Setting

Outpatient otolaryngology clinic setting in a tertiary care facility.

Subjects and Methods

We observed 3 neurotologists performing a standardized simulated cerumen debridement procedure on volunteers in 2 positions: sitting and supine. The Rapid Upper Limb Assessment (RULA)—a validated tool that calculates stress placed on the upper limb during a task—was used to evaluate ergonomic positioning. Scores on this instrument range from 1 to 7, with a score of 1 to 2 indicating negligible risk of developing posture-related injury. The risk of musculoskeletal disorders increases as the RULA score increases.

Results

In nearly every trial, RULA scores were lower when the simulated patient was placed in the supine position. When examined as a group, the median RULA scores were 5 with the patient sitting and 3 with the patient in the supine position ( P < .0001). When the RULA scores of the 3 neurotologists were examined individually, each had a statistically significant decrease in score with the patient in the supine position.

Conclusion

This study indicates that patient position may contribute to ergonomic stress placed on the otolaryngologist’s upper limb during in-office otologic procedures. Otolaryngologists should consider performing otologic procedures with the patient in the supine position to decrease their own risk of developing upper-limb musculoskeletal disorders.

Effect of alternative video displays on postures, perceived effort, and performance during microsurgery skill tasks

Physical work demands and posture constraint from operating microscopes may adversely affect microsurgeon health and performance. Alternative video displays were developed to reduce posture constraints. Their effects on postures, perceived efforts, and performance were compared with the microscope. Sixteen participants performed microsurgery skill tasks using both stereo and non-stereoscopic microscopes and video displays. Results showed that neck angles were 9-13° more neutral and shoulder flexion were 9-10° more elevated on the video display than the microscope. Time observed in neck extension was higher (30% vs. 17%) and neck movements were 3x more frequent on the video display than microscopes. Ratings of perceived efforts did not differ among displays, but usability ratings were better on the microscope than the video display. Performance times on the video displays were 66-110% slower than microscopes. Although postures improved, further research is needed to improve task performance on video displays.

A study of phonomicrosurgical arm support postures using a magnetic motion tracking system

OBJECTIVES/HYPOTHESIS

To study the different arm support postures used in phonomicrosurgery by using a magnetic-based phonomicrosurgery instrument tracking system (MPTS). Through quantitative motion parameter data collected from four arm support postures (elbow support [ES], forearm support [FS], forearm and hand support, and no support), phonomicrosurgical operation postures were analyzed and compared.

STUDY DESIGN

Prospective cohort study.

METHODS

Seven subjects operated on phonomicrosurgical simulation cutting tasks with four arm support postures while being monitored by MPTS. The motion parameters, including operation time, path length, depth perception, and motion smoothness were analyzed. The subjects' cutting quality was also calculated.

RESULTS

With the FS, the nondominant hand showed improved S, better D, and shorter P (P < 0.05). Better motion control in the dominant hand resulted from ES posture (P < 0.05). Better operation quality was associated with increased motion control in the nondominant hand.

CONCLUSIONS

Forearm support resulted in higher steadiness and shorter surgical path in the nondominant hand. In the dominant hand, ES resulted in increased steadiness, shorter surgical path, and better D. The effect of both gravity and wrist dexterity on movement control should be considered when selecting proper arm supports.

LEVEL OF EVIDENCE

4.

Prevalence and risk factors for musculoskeletal problems associated with microlaryngeal surgery: a national survey

OBJECTIVES/HYPOTHESIS

Microlaryngeal surgery (MLS) presents ergonomic challenges to surgeons and potential risks for developing musculoskeletal symptoms (MSSx). This study describes prevalence and risk factors of MLS-associated MSSx.

STUDY DESIGN

Cross-sectional survey.

METHODS

A questionnaire was administered to members of the American Academy of Otolaryngology-Head and Neck Surgery. Outcome measures related to surgeon demographics, training, MLS experience, operating room setup, experience of MSSx in relation to MLS, treatment sought, and practice changes due to MSSx.

RESULTS

Response rate was 9.2% (n = 476); 83% reported musculoskeletal symptoms during MLS, and 21% reported rest breaks during MLS. Taking breaks was independently associated with back support lack (odds ratio [OR] = 2.08) and surgery lasting >30 minutes (OR = 1.68). Areas most commonly affected were neck, upper back, shoulder, and lower back. Ten percent reported treatment for MLS-related MSSx. Some respondents reported major practice changes due to MSSx, including fewer cases, ceasing to perform MLS, applying for disability, and early retirement.

CONCLUSIONS

Musculoskeletal symptoms are common (83%) among surgeons performing microlaryngeal surgery. Findings suggest multiple factors may contribute to development of MSSx in otolaryngologists. Risk factors for MSSx and taking breaks during surgery include average case operating time >30 minutes and absence of back support. Previous studies have identified neck flexion and lack of arm support as associated with risk of musculoskeletal injury. This study demonstrates that MSSx related to surgery do occur in otolaryngologists, and that poor surgical ergonomics may play a role. Surgeons should consider proper support and positioning during MLS to protect their health.

Ergonomic considerations in endoscopic sinus surgery: lessons learned from laparoscopic surgeons

BACKGROUND

Endoscopic sinus procedures are increasingly common, and more technically difficult procedures are being undertaken to provide patients with minimally invasive alternatives to traditional open surgical techniques. However, such endoscopic approaches have increasing physical demands on the surgeon. The aim of this review is to summarize current literature on surgical ergonomic principles as they relate to endoscopic sinus and skull base surgery and focus on future needs for our specialty.

METHODS

Literature review was performed of surgical ergonomics and, particularly, laparoscopic ergonomic principles.

RESULTS

Existing ergonomic principles for laparoscopic surgery can be applied to endoscopic sinus and skull base surgery and can be expected to offer benefits in terms of surgeon fatigue, physical discomfort, and task efficiency.

CONCLUSION

Increasing surgeon awareness will allow for many basic ergonomic principles to be applied to endoscopic sinus and skull base surgery. Although many simple changes can be immediately made, there is a clear need for further study and abundant room for innovation.

Job Analysis Techniques for Distal Upper Extremity Disorders

Distal upper extremity (DUE) work-related musculoskeletal disorders (WMSDs) are among the most costly injuries suffered in industry today. These WMSDs are reported in both office (computer use) and manufacturing environments. Job physical exposure analysis techniques for DUE WMSDs range from simple checklists to quantitative models. A summary of literature review of biomechanical, physiological, psychophysical and epidemiological bases for job physical exposure risk factors for DUE WMSDs is provided. Several job analysis methods suitable for manufacturing environments are reviewed and discussed. A comparative analysis of Rapid Upper Limb Assessment (RULA), Threshold Limit Value for Hand Activity Level (TLV for HAL), and the Strain Index is provided along with results from validation studies and advantages and disadvantages of each method. Three examples from industries are provided to demonstrate applications of RULA, TLV for HAL, and the Strain Index. Last, issues with current job analysis methods when a worker rotates to different jobs and/or when a job consists of several tasks are discussed as well as the need for more robust models to account for these variations in physical exposure in real-world environments.