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Article

Noise Levels and Their Association with Surgical Complexity and Communication in Otolaryngology Sub-Specialty Operating Rooms: A Prospective, Single Institution Study

by
Amber Cradeur
1,
Makenzie Abshire
1,
Morgan Schichtel
1,
Ibraheem Hachem
1,
Brooke Collins
2,
Cherie-Ann Nathan
2 and
Gauri Mankekar
2,*
1
School of Medicine, Louisiana State University Health Shreveport, Shreveport, LA 71103, USA
2
Department of Otolaryngology-Head and Neck Surgery, LSU Health Shreveport, Shreveport, LA 71103, USA
*
Author to whom correspondence should be addressed.
J. Otorhinolaryngol. Hear. Balance Med. 2026, 7(1), 10; https://doi.org/10.3390/ohbm7010010
Submission received: 3 December 2025 / Revised: 27 January 2026 / Accepted: 4 February 2026 / Published: 10 February 2026
(This article belongs to the Section Otology and Neurotology)
Browse Figures
Versions Notes

Abstract

Background/Objectives: This prospective study aimed to assess noise levels in otolaryngology operating rooms (OR), explore noise variation across subspecialties, and examine the correlation between noise, verbal communication, and surgery complexity. Methods: Prospective observational study. Single academic institution. Noise levels and surgeon feedback from 60 otolaryngology surgeries at a Tertiary Academic Medical Center were collected between May 2023 and March 2024. Cases were prospectively enrolled using a convenience sampling based on research staff availability, excluding emergency surgeries. The cohort included 13 general ENT, 13 facial plastics, 8 head and neck, 13 laryngology, and 13 rhinology surgeries. Noise data was recorded with a Curconsa Sound Level Meter SL720. Surgeons reported communication ease and case complexity via survey, with communication deemed impaired with the incidence of repeated information in the OR. Case complexity was rated from grade 1 (lowest) to grade 4 (highest). Results: Noise differences between subspecialties’ ORs were statistically significant (p < 0.001) but the effect size was small (η2 ≈ 0.04). The Rhinology OR showed higher average noise levels compared to Facial Plastic (Rhinology louder by 2.2 dB) and Head–Neck (Rhinology louder by 2.6 dB). Noise did not significantly impair communication in the OR (p = 0.526). Higher noise in the OR did not significantly influence surgical complexity (p = 0.547). Conclusions: Noise levels in otolaryngology operating rooms varied modestly across subspecialties. No significant association between noise levels and either communication impairment or surgical complexity was observed.

1. Introduction

Noise may be described as unintended or unwanted sound disturbances that affect a variety of fields in the workforce, including healthcare [1,2,3]. Amidst metropolitan development and technological advancement, these undesired sounds have increased dramatically in hospitals within recent decades and may negatively impact the productivity of staff and the welfare of patients [4,5,6]. Within the hospital, the operating room (OR) remains a setting that is particularly susceptible to noise, with peak decibel readings varying between 80 and 119 dB [5,6,7,8]. These levels routinely exceed the recommended threshold set by the World Health Organization (WHO) of 35 dB and at 45 dB by the Environmental Protection Agency (EPA) [7,9,10]. Noise in the OR may occur secondary to equipment use, conversation between surgical personnel, music, and background noise [5,9]. The presence and effects of noise have been widely studied in fields such as orthopedics, cardiovascular surgery, neurosurgery, general surgery, and urology [8,11,12,13,14,15,16,17]. Previous investigation across this array of surgical specialties indicates that noise exposure in operating rooms may lead to combined motor and intellectual responses. Effects include fatigue, stress reactions, impairment of sensorimotor dexterity, diminished cognitive performance, and communication deficits [11,18,19]. Transient noise in the operating room, where complex tasks are performed continuously, can disrupt the flow of the procedure and cause distractions, potentially impairing concentration and surgical performance, leading to harmful consequences [10,20]. Noise has been found to adversely affect the surgeon’s operating speed, the time required to complete surgical tasks, and the efficiency of their movements, resulting in decreased accuracy and higher error rates [21]. Additionally, excessive noise exposure during a surgical career could lead to lasting effects on auditory processing [11,22]. Such adverse outcomes for affected personnel include noise-induced hearing loss (NIHL) and tinnitus [10,23,24].
Otolaryngology operating rooms have been recognized as among the loudest in surgical specialties [25,26]. Systemic review of noise in otolaryngology operating rooms supports this suspicion as the average noise level recorded in OHNS ORs was 70.1 dB, and the maximum noise level was 95.5 dB [10]. Notable noise contributors are suction and surgical instruments/power tools. It has been determined that certain procedures are associated with higher noise levels. For example, mastoid-related surgery has some of the highest recorded decibel levels, largely thought to be attributed to the constant use of high-powered drills [24]. However, the causal relationship between noise, OR communication, and effects on surgical personnel is still not well understood in otolaryngology-head and neck (OHNS) surgery [25].
This study aimed to better understand noise decibel levels within the subspecialties of otolaryngology and investigate the combined effect of background noise, speech sounds, and music on a surgeon’s concentration and communication ability.

2. Materials and Methods

After approval by the LSU Health Sciences Center-Shreveport Institutional Review Board (IRB) # 2391 dated 7 December 2023, noise levels and survey data were prospectively collected for 60 otolaryngology surgeries performed at a Tertiary Academic Medical Center from May 2023 to March 2024. Cases were divided into the subspecialties of general ENT (13), facial plastic and reconstructive surgeries (13), head and neck (8), laryngology (13), and rhinology (13). Before enrolling in the study, all otolaryngology surgeons on staff were informed of the study details and verbally consented to the collection of noise data in the OR. Participation in the study was entirely voluntary. All eligible otolaryngology surgeons were informed about the study before data collection, and no incentives or penalties were associated with participation or non-participation. Surgeons were approached after the procedure to complete the survey and to minimize any potential influence on intraoperative behavior.
To ensure confidentiality and anonymity, no personally identifiable information was collected from participants. Survey responses and noise measurements were recorded using study identifiers only, without linkage to individual surgeons or patients. All data were stored on secure, password-protected institutional systems accessible only to the research team. Results are reported in aggregate to prevent identification of individual participants. Cases were prospectively enrolled using a convenience sampling approach based on research staff availability. Emergency otolaryngology cases were excluded. For each case, the following demographic information was collected before the case started: operative procedure and corresponding otolaryngology subspecialty as designated by the qualifications of the operating surgeon.
Noise levels were measured with the Curconsa Sound Level Meter SL720 (SLM). In the absence of financial support for this pilot study, the Curconsa Sound Level Meter SL720 was used as it is budget friendly, portable and offers decent accuracy for simple monitoring and basic noise checks in the workplace. The noise measurements provided by this device were in the form of instantaneous decibels and A-weighted (dBA) levels. From the information provided by Curconsa, the measuring range of the sound level meter was 30 dBA to 130 dBA with fast response speed, reliable performance, and high accuracy of ±2.0 dBA. A validation study was designed by research staff to substantiate these claims. As a pistonphone was unavailable for calibrating the sound level meter, an audiometric hearing booth was used to generate pure tone decibels in the form of decibel hearing level (dB HL) at 1000 Hz frequency. The Curconsa Sound Level Meter SL720 was placed in the center of the booth. At each magnitude of 30, 50, and 70 dB HL, 15 tones were generated, and the reading from the Curconsa Sound Level Meter SL720 was recorded in the form of dBA. The difference between dB HL and dBA was previously studied to be small, and it has been theorized that dBA thresholds can be treated as if they were dB HL [27]. The average readings collected from the sound level meter were 30.7 ± 0.84 dBA, 51.3 ± 0.70 dBA, and 71.4 ± 0.86 dBA at 30, 50, 70 dB HL, respectively. With a high degree of accuracy and precision, the research team felt comfortable using this device to record noise data.

2.1. Noise Decibel Levels

To standardize the noise data collection process, the measurements were gathered using the following method in operating rooms of approximately the same size and configuration. Although typical operating room reverberation times have been reported in the literature to range from approximately 0.9 to 1.5 s, reverberation time was not directly measured in this study and therefore was not included as an analyzed variable. Noise measurements were obtained by measuring the decibel level with the SLM on the “slow” setting during designated collection times throughout each case. The SLM was positioned at a fixed location within the operating room, approximately 1.5 m (5 feet) from the sterile field, behind the operating surgeon to capture representative noise exposure during procedures. Measurements were recorded continuously throughout each surgery, capturing peak levels and maximum levels in A-weighted decibels (dBA). The start of the procedure was indicated after case time out when the words “incision” or “scalpel” were mentioned by surgical staff or when there was a visual indication of initial surgical intervention. These cues prompted the first instantaneous noise measurement to be collected. Following the procedure start, instantaneous decibel measurements were collected in 15 min increments until the conclusion of surgery. Such a conclusion was signaled by verbal cues from the operating surgeon and surgical staff. Our approach did not involve impulse response analysis, as the primary objective was to assess real-time ambient noise rather than room acoustics or reverberation characteristics. Instead, we utilized time-averaged measurements over defined surgical phases (setup, incision, closure) to evaluate variations in noise levels and correlate them with surgical complexity and communication patterns.

2.2. Surgeon Survey

Once the surgery was complete, surgeons were given a consent form to participate in the survey portion of the study. Consent forms were handed to surgeons after the case to avoid possible bias and influence of noise measurements while performing the surgery. Once consented, a survey was given.
The survey contained three questions regarding communication ease and perceived surgical complexity, where surgeons circled or underlined their answers:
  • “During the surgery, could you hear and understand: quiet talking, normal talking, or loud talking?”
  • “Did you have to ask nurses or members of the operating team to repeat themselves? Yes/No”
  • “How would you describe the difficulty of the surgery? 1–4 where 1 = lowest difficulty and 4 = highest difficulty”
An answer of “Yes” to question number 2 indicated the incidence of impaired communication ability.

2.3. Outcome Measures

Objective outcome measures analyzed in this study include those gathered from noise decibel measurements—minimum, maximum, and average noise levels. Such values were obtained for each operative procedure, designated otolaryngology subspeciality, and across all 60 otolaryngology cases.
Survey metrics were analyzed to determine the incidence of impaired communication ability. Additionally, the reported difficulty of the case was further evaluated with reference to the collected noise decibel data.

3. Statistical Analysis

3.1. Operating room noise across five ENT subspecialties: General ENT, Laryngology, Rhinology, Head Neck Surgery, and Facial Plastic was analyzed using one-way ANOVA, and non-parametric tests to compare mean noise levels.
3.2. Operating room noise levels within each ENT sub-specialty were analyzed using descriptive statistics (mean, SD, median, quartiles, min-max), normality tests (Shapiro–Wilk), and outlier counts (Tukey IQR).
3.3. Operating room noise levels and their relationship to surgical complexity and communication impairment were analyzed using ANOVA and t-test, respectively, with regression modeling.

4. Results

475 noise measurements (n) were recorded across 60 (N) surgeries, performed by a total of 12 surgeons over the course of ten months. Additionally, 60 surveys were collected from the primary operating surgeon following the conclusion of the surgery. An overview of the operative procedures studied is in Table 1.

4.1. Noise in Otolaryngology Subspecialty Operating Rooms

Table 2 and Figure 1 show the comparison and analysis of operating room noise levels across the five otolaryngology subspecialties. Noise levels differed significantly across the subspecialties (p < 0.001). The effect size was small (eta^2): 0.0405, and the non-parametric (Kruskal–Wallis) test confirmed the same (p ≈ 0.00008). Rhinology ORs were louder than Facial Plastic by ~2.2 dB (significant), and louder than Head–Neck ORs by 2.6 dB (significant).
Post hoc pairwise comparisons were performed using Tukey’s honestly significant difference (HSD) test following one-way ANOVA. The Kruskal–Wallis test was used as a non-parametric sensitivity analysis to confirm overall group differences.
Rhinology ORs tend to be the loudest, likely due to the power tools used in sinus surgery. Facial Plastic and Head and Neck surgeries are quieter, possibly because they involve more delicate work and rarely use power tools.

4.2. Communication Impairment (Table 3)

Impaired communication was defined a priori as an affirmative response to the survey question asking whether the surgeon had to request repetition from operating room staff during the procedure. Of the 60 surgeries surveyed, impaired communication was reported in 13 cases (21.7%).
Table 3. Surgeon-reported communication and surgical complexity survey results.
Table 3. Surgeon-reported communication and surgical complexity survey results.
Survey VariableResult
Total Surveys completed60
Impaired communication (Yes) n (%)13 (21.7%)
Impaired communication (No), n (%)47 (78.3%)
Surgical complexity score, mean ± SD1.91 ± 1.021
Complexity range1–4
Mean operating room noise levels were compared between cases with and without reported communication impairment. The mean average noise level was 63.1 ± 7.0 dBA in cases with impaired communication and 63.8 ± 6.8 dBA in cases without impaired communication. This difference was not statistically significant (independent samples t-test, p = 0.526). Similarly, maximum recorded noise levels did not differ significantly between cases with and without communication impairment (p > 0.05). No meaningful effect size was observed. These findings suggest that, within the observed noise range, ambient operating room noise was not associated with surgeon-reported communication impairment.

4.3. Surgical Complexity (Table 3)

Surgical complexity was assessed using a 4-point Likert scale (1 = lowest complexity, 4 = highest complexity) as reported by the primary operating surgeon after each procedure. The distribution of complexity ratings across all cases was as follows: Grade 1 (n = 27), Grade 2 (n = 18), Grade 3 (n = 8), and Grade 4 (n = 7).
Mean operating room noise levels did not differ significantly across surgical complexity grades (one-way ANOVA, p = 0.547, η2 = small). Linear regression analysis similarly demonstrated no significant association between average noise levels and increasing surgical complexity (β ≈ 0, p > 0.05).
These results indicate that higher perceived surgical complexity was not associated with increased ambient operating room noise.

5. Discussion

In the hospital environment, the operating room (Figure 2) is susceptible to noise disturbances. A variety of inherent and extraneous factors contribute to such noise pollution. Some sources of noise in the OR include conversation amongst staff, surgical equipment, music, anesthesia monitors, and ambient background noise such as laminar airflow systems [5,6,10]. The noise from some of these contributors is meant to deliver vital instruction, messages, and assist in surgical techniques throughout the case. However, they may work more ominously to impair communication, performance, and patient outcomes. Noise can impair communication in two ways, according to acoustic scientists: 1. energetic masking with noise covering or blocking important communication, or 2. informational masking by background sounds, for example, music, which may distract attention, interfering with our ability to decide which noise has relevant information [28].
The use of protective face masks can also limit speech understanding in the operating rooms. Sukaj et al. reported that sound reduction with masks was worse at frequencies higher than 1000 Hz compared to low frequencies [29]. The field of otolaryngology has been suspected to be among the loudest surgical specialties from the high-frequency surgical instruments used [24,25,26,30]. However, there has been limited investigation into determining if this noise affects surgeons’ communication and perception of case difficulty.
This study provides valuable insight into the noise environment within otolaryngology ORs. The overall average noise level of 63.9 dBA is within the moderate range, consistent with normal conversation [31]. Although the differences in subspecialty’ OR noise were statistically significant, the differences may not have a big real-world impact on communication or performance as most of the noise differences are probably from other factors (like instruments, team behavior, or room setup).
Rhinology procedures were associated with the highest average noise levels at 63.9 dBA, reflecting the nature of surgeries likely due to the power tools used in sinus surgery. This finding supports the common conclusion that power instruments and associated complex surgical techniques contribute to a noisier environment with higher ambient noise levels [32]. In contrast, the lowest average noise levels (60.5 dBA) were seen in head and neck surgeries despite recording the highest peak noise level (79 dBA). This discrepancy suggests procedures within this subspecialty might be associated with periodic spikes in noise that do not persist throughout the entire case, ultimately leading to an overall quieter OR environment. Facial plastic and reconstructive surgeries were also generally associated with quieter noise levels. This could be due to the inherently delicate nature of these procedures and the lower prevalence of noisy, high-speed instruments. Notably, there was evident variation in noise levels, supporting the notion that factors including duration of procedure, specific equipment used, and the requirement of precise and quiet manipulation may influence the noise levels in the OR [33].
Our study found that noise levels in the ORs were not strongly linked to communication impairment and did not influence complex surgeries. Surgeons reported impaired communication in 21% of cases, particularly in those with maximum noise levels below 70 dBA. This conclusion supports the findings of other publications that noise can negatively impact surgeon experience and team interactions in the operating room [6,33,34,35]. Although noise is a contributing factor during surgeries, a higher concentration level, focus, and adaptation of team dynamics in more complex surgeries might alleviate the impact of noise on communication.
The variability in noise levels between subspecialties and individual procedures suggests that a uniform approach to noise management may not be effective. A custom strategy employed with reference to recommendations by the Joint Commission and National Association for Healthcare Quality (NAHQ) may be required to address the specific needs of each subspecialty [34]. Engelman et al. have described feasible interventions to reduce noise in the OR [35]. Wahr et al. have recommended that music in the OR should be optional and discontinued if noise levels increase or are disruptive [6]. Strategies to decrease more persistent OR noise include interventions to reduce ambient noise, like the use of sound-absorbing and monitoring devices with associated alerts [36]. Additionally, ORs associated with transient noise spikes might benefit from a more targeted approach.
Moreover, closed-loop communication training could be of benefit, especially for teams working in louder environments [34].
This study is not without limitations. For one, due to funding limitations, professional acoustic devices were not available for study, and staff availability limitations influenced data collection in otology operating rooms. While continual noise monitoring would have been ideal, the cost associated with obtaining such monitors’ decibel data was beyond the capacity of this pilot study. Furthermore, IRB approval was limited to the collection of succinct measurements and prohibited the recording of data on an external device for future analysis. The periodic collection of measurements could act as a temporal limitation and coincide with reduced precision in noise measurement. Despite these limitations, the data collected in this study provides insight into the observed noise levels in otolaryngology operating rooms and the corresponding investigation into the relationship between noise, perceived surgical difficulty, and communication.
Future studies can use continuous noise monitoring throughout the duration of surgeries to record transient spikes and patterns and acoustic measurements to measure reverberation time. Performing the study across multiple institutions may improve generalizability and account for variations in OR design and workflow. Investigation of team size, music, and instruments used during the surgeries can help to understand noise predictors better. Assessing surgeon stress, fatigue, and error rates to determine the real-world impact of noise on surgeon performance and patient safety can have practical application. Finally, potential adverse effects can be mitigated using sound-absorbing materials and closed-loop communication.

6. Conclusions

Noise levels in otolaryngology operating rooms vary modestly across subspecialties, with Rhinology demonstrating the highest average noise levels and Facial Plastic and Head & Neck surgeries being generally quieter. Although these differences reached statistical significance, the effect size was small, indicating limited clinical or operational impact. Furthermore, regression analysis and comparative tests revealed no significant association between noise levels and either communication impairment or surgical complexity. These findings suggest that operating room noise is influenced more by contextual factors—such as equipment type, staff movement, and room configuration—than by subspecialty or case difficulty.

Author Contributions

Conceptualization: G.M. and A.C.; Methodology: G.M. and A.C.; Validation: A.C., B.C. and G.M.; Formal analysis: A.C., M.A., M.S. and I.H.; Investigation: A.C., M.A., M.S., I.H. and B.C.; Resources: G.M. and C.-A.N.; Data curation: A.C., M.A., M.S., I.H., B.C. and G.M.; Writing—Original Draft Preparation: A.C., M.A., M.S. and I.H.; Writing: G.M. and A.C.; Supervision: A.C. and G.M.; Project administration: G.M.; Funding acquisition: G.M. and C.-A.N. All authors have read and agreed to the published version of the manuscript.

Funding

This research received no external funding.

Institutional Review Board Statement

The study was conducted in accordance with the Declaration of Helsinki and approved by the Institutional Review Board of LSU Health, Shreveport, Louisiana (# 2391 dated 7 December 2023) for studies involving humans.

Informed Consent Statement

Patient consent was waived by the IRB as the study was not associated with any harm to the patient and was a quality project to study noise in the operating room.

Data Availability Statement

The raw data supporting the conclusions of this article can be made available by the authors on request.

Acknowledgments

The authors acknowledge Dinesh Vartak for technical support. The authors used Microsoft Co-Pilot based on GPT-5 for statistical analysis. The authors have reviewed and edited the output and take full responsibility for the content of this publication.

Conflicts of Interest

The authors declare no conflicts of interest.

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Figure 1. Noise levels (dB) distributed by ENT subspeciality.
Figure 1. Noise levels (dB) distributed by ENT subspeciality.
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Figure 2. A representative image of an operating room.
Figure 2. A representative image of an operating room.
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Table 1. Overview of all operative procedures studied.
Table 1. Overview of all operative procedures studied.
General ENTFacial Plastics & Reconstructive SurgeryHead and NeckLaryngologyRhinology
Control of epistaxis, posteriorClosed reduction: nasal fractureBilateral parathyroid adenoma excisionArytenoidectomy and injectionCSF rhinorrhea repair
DISEExcision of scalp lesionExcision of the lesion with tissue transfer and sentinel lymph node biopsyLaryngocele excisionEndoscopic sinusotomy
Hypoglossal nerve stimulator implantationMMF removalParotidectomyLaryngoscopyFESS
Myringotomy with tympanostomy tube insertionORIF: facial fracturePartial auriculectomyLaryngoscopy and bronchoscopyFESS with septoplasty
Tonsillectomy +/− adenoidectomyReplacement of septal buttonTotal thyroidectomyMicrolaryngoscopyRemoval of nasal polyps
Tracheostomy with placement of nasogastric feeding tubeSeptorhinoplastyWLE RMT lesionPanendoscopySeptoplasty with turbinate reduction
DISE: Drug-induced sleep endoscopy; MMF, maxillomandibular fixation; ORIF, open reduction and internal fixation; WLE, wide local excision; RMT, retromolar trigone; CSF, cerebrospinal fluid; FESS, functional endoscopic sinus surgery.
Table 2. Descriptive statistics of operating room noise levels across the five otolaryngology subspecialties. “n” refers to the number of noise measurements recorded during the surgeries; “N” refers to the total number of surgeries.
Table 2. Descriptive statistics of operating room noise levels across the five otolaryngology subspecialties. “n” refers to the number of noise measurements recorded during the surgeries; “N” refers to the total number of surgeries.
SubspecialtyNnMinimum dBAMaximum dBAMean dBASDCINormality Test p-Value (Shapiro–Wilk)
General ENT1310052.176.963.06.263.0 ± 1.20.772
Facial Plastics & Reconstructive Surgery138648.477.961.77.361.7 ± 1.560.1135
Head and Neck86552.179.061.36.761.3 ± 1.630.0522
Laryngology135853.675.462.95.462.9 ± 1.40.925
Rhinology1316646.977.763.97.763.9 ± 1.170.020
p-values represent results of Shapiro–Wilk tests assessing normality of noise level distributions within each subspecialty. These p-values do not reflect comparisons of mean noise levels between subspecialties. Between-group comparisons were assessed using one-way ANOVA and confirmed with Kruskal–Wallis testing.
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Cradeur, A.; Abshire, M.; Schichtel, M.; Hachem, I.; Collins, B.; Nathan, C.-A.; Mankekar, G. Noise Levels and Their Association with Surgical Complexity and Communication in Otolaryngology Sub-Specialty Operating Rooms: A Prospective, Single Institution Study. J. Otorhinolaryngol. Hear. Balance Med. 2026, 7, 10. https://doi.org/10.3390/ohbm7010010

AMA Style

Cradeur A, Abshire M, Schichtel M, Hachem I, Collins B, Nathan C-A, Mankekar G. Noise Levels and Their Association with Surgical Complexity and Communication in Otolaryngology Sub-Specialty Operating Rooms: A Prospective, Single Institution Study. Journal of Otorhinolaryngology, Hearing and Balance Medicine. 2026; 7(1):10. https://doi.org/10.3390/ohbm7010010

Chicago/Turabian Style

Cradeur, Amber, Makenzie Abshire, Morgan Schichtel, Ibraheem Hachem, Brooke Collins, Cherie-Ann Nathan, and Gauri Mankekar. 2026. "Noise Levels and Their Association with Surgical Complexity and Communication in Otolaryngology Sub-Specialty Operating Rooms: A Prospective, Single Institution Study" Journal of Otorhinolaryngology, Hearing and Balance Medicine 7, no. 1: 10. https://doi.org/10.3390/ohbm7010010

APA Style

Cradeur, A., Abshire, M., Schichtel, M., Hachem, I., Collins, B., Nathan, C.-A., & Mankekar, G. (2026). Noise Levels and Their Association with Surgical Complexity and Communication in Otolaryngology Sub-Specialty Operating Rooms: A Prospective, Single Institution Study. Journal of Otorhinolaryngology, Hearing and Balance Medicine, 7(1), 10. https://doi.org/10.3390/ohbm7010010

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