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Key points
This prospective single-center study provides rare intraoperative ergonomic data in otolaryngology, using repeated Rapid Upper Limb Assessment (RULA) measurements across real head and neck operations rather than relying only on retrospective symptom reporting.
Across 80 procedures and 970 intraoperative observations, medium-to-high ergonomic risk was common in both trainees and attending surgeons. Pain increased with case difficulty, and ergonomic risk worsened as operative time lengthened, particularly among surgeons aged 40 years and older.
Postoperative discomfort was not trivial: nearly one-third of procedures prompted intraoperative position changes, and a smaller but clinically meaningful subset caused distraction, breaks, or perceived interference with performance.
The finding that larger glove size correlated with higher pain scores suggests that surgeon ergonomics is shaped not only by procedure type and duration, but also by operator anatomy and likely equipment fit.
Background
Musculoskeletal pain is increasingly recognized as an occupational hazard of surgical practice. Otolaryngology may be especially vulnerable because surgeons frequently work in narrow operative corridors, maintain sustained neck flexion or rotation, abduct the shoulders during fine motor tasks, and perform prolonged static postures while relying on visual magnification, headlights, microscopes, or endoscopes. These biomechanical stresses accumulate over time and may contribute to acute discomfort, chronic pain syndromes, reduced operative endurance, missed work, and early retirement.
Prior literature across surgical disciplines has consistently shown high rates of work-related neck, back, shoulder, and upper extremity symptoms. However, much of that evidence has been based on surveys or retrospective reporting. Those studies are valuable for estimating burden but are less precise in linking specific intraoperative postures to immediate symptoms. For otolaryngology in particular, prospective observational data collected during active operations remain limited.
This gap matters clinically. Surgeon discomfort is not simply a wellness issue; it may affect concentration, stamina, and technical consistency, especially in long or high-complexity cases. From a systems perspective, ergonomics also intersects with workforce sustainability, trainee education, operating room design, and device engineering. Against that backdrop, the present study by Oh and colleagues addresses a timely question: how often do otolaryngology surgeons work in ergonomically risky positions during routine practice, and which factors are associated with pain?
Study design and methods
Design and setting
Oh et al conducted a prospective cross-sectional study at a single academic institution between August 2024 and March 2025. The study included otolaryngology surgeons actively performing head and neck operations during the study period.
Participants
Seventeen surgeons participated: 12 residents or fellows and 5 attending physicians. The mean age was 35.6 years, with a standard deviation of 10.6 years. Five participants were female and 12 were male.
Procedures and assessments
The investigators observed 80 operations and collected 970 intraoperative RULA scores. RULA is a validated observational ergonomic tool that grades postural risk in the neck, trunk, and upper limbs, incorporating factors such as arm position, wrist posture, muscle use, and load. Scores typically range from 1 to 7, with higher scores indicating greater ergonomic concern and stronger need for intervention.
The study’s primary outcomes were preoperative and postoperative numeric pain scores on a 0 to 10 scale and intraoperative ergonomic risk as measured by RULA. Secondary measures included baseline Neck Disability Index and Oswestry Low Back Disability scores, which are established instruments for assessing functional impact from neck and low back symptoms.
Analytic approach
The investigators used mixed-effects modeling to explore associations between pain or RULA scores and demographic and procedural factors. Variables examined included surgeon age, sex, weight, training level, glove size, case difficulty, procedure type, and operative duration.
Key findings
High ergonomic risk was frequent across routine otolaryngology practice
Among attending physicians, 143 of 386 RULA observations, or 37%, fell into the medium-to-high risk range of 5 to 7. Among residents, 249 of 584 observations, or 43%, were in that same range. These figures indicate that ergonomically concerning postures were not isolated events limited to unusually difficult operations. Rather, they were common across everyday surgical activity and affected both experienced surgeons and trainees.
The trainee-attending comparison is noteworthy. While one might expect more experienced surgeons to adopt more favorable posture, the study suggests that ergonomic strain remains prevalent even after years in practice. This may reflect structural features of otolaryngology surgery that are difficult to avoid without redesign of workflow, equipment, or operative setup.
Pain increased with case difficulty
In mixed-effects modeling, greater case difficulty was associated with higher pain scores. This is clinically intuitive but important to quantify. More difficult cases often involve longer static positioning, more demanding visualization, more intense concentration, and less opportunity to shift stance or reset posture. The finding supports the idea that ergonomic countermeasures should be targeted not only to long cases but also to technically complex ones.
Larger glove size was associated with greater pain
One of the more interesting observations was the association between larger glove size and higher pain scores. The abstract does not provide a mechanistic analysis, so interpretation should be cautious. Still, several plausible explanations exist. Hand size may affect instrument grip, wrist angle, pinch force, and compatibility with standard tool dimensions. If instruments are designed around a limited range of hand sizes, surgeons at either end of the anthropometric spectrum may be forced into suboptimal hand or forearm positions. The present finding raises a practical human-factors question: are otolaryngology instruments adequately adapted to operator anatomy?
Operative duration worsened ergonomic risk, especially in older surgeons
RULA scores increased with operative duration, and this relationship was particularly evident among surgeons aged 40 years and older. This pattern is highly relevant to workforce longevity. Static muscle loading and cumulative fatigue are known drivers of progressive postural deterioration. Age-related changes in joint mobility, muscle endurance, or preexisting degenerative symptoms may amplify that effect.
This does not imply that older surgeons are less capable; rather, it underscores that ergonomic load accumulates over a career and that preventive measures should begin early, not only after symptoms become chronic.
Several procedures caused immediate functional consequences
Postoperative surveys showed that in 23 of 80 procedures, or 28.8%, surgeons changed position intraoperatively because of discomfort. Seven procedures, or 8.8%, involved distraction due to pain. Two procedures, or 2.5%, required a break, and in one procedure, or 1.3%, pain was reported to interfere with surgical performance.
These rates matter because they move the discussion beyond mild soreness. Even if most episodes did not overtly compromise surgery, distraction and posture changes can affect focus, efficiency, and fatigue. For a profession that values precision and consistency, even infrequent performance interference warrants attention.
What was not associated with pain
No significant associations were found between pain scores and surgeon weight, sex, age, training level, procedure length, or procedure type. These negative findings are useful. They suggest that ergonomic burden may be more strongly influenced by posture quality, case complexity, task demands, and person-equipment interaction than by broad demographic categories alone.
At the same time, the absence of significant associations should not be overinterpreted. The study was small, and some relationships may have been missed because of limited statistical power.
Clinical interpretation
The central message is straightforward: otolaryngology surgeons frequently work in ergonomically risky postures, and those exposures are accompanied by measurable acute pain even during routine operative care. This is not merely a quality-of-life issue. Over time, repetitive exposure to neck, shoulder, wrist, and back strain may contribute to cumulative disability, lost productivity, or shortened careers.
For clinicians and department leaders, the study supports a shift from passive awareness to active prevention. Basic ergonomic habits remain underemphasized in many training environments, where operative success understandably receives priority over body mechanics. Yet poor postural habits adopted during residency may persist for decades. Embedding ergonomic teaching into surgical education could therefore have high long-term value.
The study also highlights an equipment problem. Standardized operating room tools and furniture often assume a narrow range of body dimensions and may not adequately support differences in hand size, stature, reach, or visual setup preferences. Adjustable tables, monitor positioning, arm supports, loupes with favorable declination angle, and instrument handle redesign are practical areas for intervention.
Strengths of the study
This study has several notable strengths. First, it was prospective, reducing some of the recall bias that affects retrospective discomfort surveys. Second, it captured repeated intraoperative RULA observations across actual cases, producing a more granular picture of ergonomic exposure than a single post hoc questionnaire can provide. Third, it paired observational ergonomic metrics with preoperative and postoperative pain ratings, allowing a closer link between posture and immediate symptom burden.
Another strength is inclusion of both trainees and attending surgeons. That broadens relevance across the professional lifespan and suggests that ergonomic risk is not confined to one level of experience.
Limitations and cautions
Several limitations should temper interpretation. The study was conducted at a single academic institution with only 17 surgeons, which limits generalizability. Practice patterns, case mix, equipment availability, and operating room setup may differ substantially across institutions.
The sample size also reduces power for subgroup analyses, especially for sex-based or specialty-specific comparisons. The abstract does not detail the distribution of case types within head and neck surgery, nor does it provide effect sizes or confidence intervals for the modeled associations, which makes it difficult to judge the magnitude and precision of observed relationships.
RULA is a practical and widely used ergonomic assessment tool, but like any observational measure it simplifies a complex biomechanical reality. It may not capture all dynamic aspects of surgery, such as torque, repetitive micro-movements, grip force, or lower-extremity strain. The study also focuses on acute pain and intraoperative risk, not long-term outcomes such as chronic disability, imaging abnormalities, missed work, or career attrition.
Finally, the cross-sectional design can identify associations but cannot establish causation. For example, the glove size finding is intriguing, but it should be treated as hypothesis-generating until replicated.
How this fits with the broader literature
The findings align with a growing body of evidence showing high rates of work-related musculoskeletal symptoms among surgeons. Surveys in otolaryngology and other procedural fields have documented frequent neck, back, and upper-extremity complaints, often attributed to prolonged standing, awkward postures, and poorly fitted equipment. Minimally invasive and microscope-based procedures have also been associated with substantial physical strain.
Importantly, this study advances the field by moving from symptom prevalence to real-time measurement of ergonomic exposure. That is a meaningful methodological step. Occupational hazards are easier to address when they can be quantified during the task itself.
Implications for practice
For individual surgeons
Surgeons should consider ergonomics a component of operative preparation, not an afterthought. Practical measures include optimizing table height before incision, minimizing neck flexion, aligning monitors to eye level, alternating stance when feasible, and using scheduled microbreaks during longer cases. Early reporting of recurrent pain may help prevent progression to chronic injury.
For residency and fellowship programs
Training programs could incorporate formal ergonomic curricula, including posture coaching in the operating room, simulation-based instruction, and routine review of equipment setup. Because poor habits become entrenched early, education during residency may have disproportionate long-term benefit.
For hospitals and device manufacturers
This study supports investment in adjustable operating room infrastructure and user-centered device design. Instrument handles, microscope and monitor configurations, and table systems should accommodate a wider range of anthropometric profiles. The association between glove size and pain gives additional urgency to this issue.
For researchers
Future studies should evaluate whether specific interventions reduce pain and postural risk. Priorities include multicenter designs, larger cohorts, wearables or motion-capture methods for objective biomechanical analysis, and longitudinal follow-up for disability and career outcomes. Randomized or stepped-wedge implementation studies of ergonomic training, microbreak protocols, or redesigned tools would be especially valuable.
Conclusion
Oh and colleagues show that ergonomic strain in otolaryngology is common, measurable, and clinically relevant. Medium-to-high intraoperative ergonomic risk affected a substantial proportion of cases, pain increased with case difficulty, and posture worsened as procedures lengthened, particularly among surgeons aged 40 years and older. The observed link between larger glove size and greater pain further suggests that ergonomics is shaped by person-equipment fit as much as by procedure characteristics.
For a specialty built on precision in confined anatomy, surgeon biomechanics deserve the same systematic attention given to operative technique and technology. The practical message is clear: ergonomic awareness, structured training, and equipment redesign are not optional wellness extras. They are necessary steps to protect surgeon performance, health, and career longevity.
Funding and registration
The abstract does not report a funding source or a ClinicalTrials.gov registration number.
References
1. Oh J, Kumar K, Li M, George J, Berryman P, Cheong D, Machiorlatti M, Patel R. Quantifying Ergonomic Risk Among Otolaryngology Surgeons. JAMA Otolaryngology–Head & Neck Surgery. Published April 30, 2026. PMID: 42060274. https://pubmed.ncbi.nlm.nih.gov/42060274/
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