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Table of Contents
Year : 2022  |  Volume : 24  |  Issue : 3  |  Page : 131-136

Surgical exposure and competence in performing open tracheostomy: A trainees self-perception questionnaire

1 Department of Otolaryngology-Head and Neck Surgery, Faculty of Medicine, King Abdulaziz University, Jeddah, Saudi Arabia
2 Department of Otolaryngology-Head and Neck Surgery, Faculty of Medicine, King Saud University, Riyadh, Saudi Arabia

Date of Submission25-Jul-2022
Date of Acceptance10-Aug-2022
Date of Web Publication24-Sep-2022

Correspondence Address:
Dr. Faisal Zawawi
Department of Otolaryngology, Head and Neck Surgery, King Abdulaziz University Jeddah
Saudi Arabia
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/sjoh.sjoh_35_22

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Background: Advancements in airway procedures and intensive care medicine have resulted in a reduction in open tracheostomy (OT) performed annually which could affect the training of residents. The aim of this study is to highlight the otolaryngology-head-and-neck surgery (OHNS) trainees' perception of their surgical exposure and competency in performing OT. Methodology: A cross-sectional questionnaire-based study (using a 22-item previously validated, peer-reviewed, and published questionnaire) conducted from June 2019 to February 2020 of OHNS residents training in multiple hospitals in the two metropolitan cities. Results: The response rate was 54% (which represents n = 67 out of 125 in both cities). There were 35 juniors (52.2%) and 32 seniors (47.8%). Thirty (44.8%) residents estimated that there are ≤50 tracheostomies/year in their hospital. Only 6% of the residents reported scheduled teaching regarding OT, and only one-third (34.3%) were actually aware of the different types of cannulas and postoperative care. Conclusion: The reason behind the lower confidence of trainees is likely multifactorial, and requires restructuring of the training program to improve the confidence of graduating trainees.

Keywords: Competency, confidence, open tracheostomy, otolaryngology, self-assessment, trainees

How to cite this article:
Kanawi HM, Alamoudi HA, Munshi SZ, Almatrafi ST, Marzouk YI, Aboalfaraj A, Zakzouk AS, Marzouki HZ, Zawawi F. Surgical exposure and competence in performing open tracheostomy: A trainees self-perception questionnaire. Saudi J Otorhinolaryngol Head Neck Surg 2022;24:131-6

How to cite this URL:
Kanawi HM, Alamoudi HA, Munshi SZ, Almatrafi ST, Marzouk YI, Aboalfaraj A, Zakzouk AS, Marzouki HZ, Zawawi F. Surgical exposure and competence in performing open tracheostomy: A trainees self-perception questionnaire. Saudi J Otorhinolaryngol Head Neck Surg [serial online] 2022 [cited 2023 Jan 30];24:131-6. Available from: https://www.sjohns.org/text.asp?2022/24/3/131/356932

  Introduction Top

Open tracheostomy (OT) is one of the first procedures taught to otolaryngology-head-and-neck surgery (OHNS) residents and it is possibly one of the most common procedures they will perform. It is estimated that approximately 100,000 tracheostomies were made in the USA from 2000 to 2004 (population size 288.4 million in 2002, US Census Bureau).[1] Tracheostomy is a procedure performed by making a surgical incision in the trachea to save the airway and it is used frequently in patients requiring accessory airways and/or prolonged ventilator support.[2]

It is a lifesaving procedure in emergent situations. However, it can be electively performed if ventilation is adequate, and the airway is secured.[3]

The rates of mortality and morbidity are inversely proportional to the performance of the surgical procedures, and proficient performance relies on well-directed knowledge to increase the confidence level and ability to provide appropriate care to the patients.[4] Recent reports from both the United States and Taiwan showed a decrease in the number of tracheostomies performed by junior surgeons due to concerns about inadequate training.[5] Another study conducted in Anchorage, Alaska in 2012, concluded that many chief residents have graduated with insufficient exposure to airway emergencies, thus with minimal experience, which reflects the need for improving the training program.[6] Subsequently, residents' readiness to perform OT independently is still doubtful, as reported by a study of residency programs in another country.[3]

Self-beliefs have played a role in the performance of the practitioner in various specialties.[7] The level of competence achieved by the residents was previously evaluated either by the number of procedures performed or by their program director's (PD) evaluation; however, residents themselves have not been questioned to determine their self-perception of surgical competency, which might be consistent with the PD's evaluation.[8]

To the best of the author's knowledge, there is not enough research available to evaluate the quality of the OHNS residency program in terms of surgical exposure to OT, performance competency, and adequacy of knowledge.

Therefore, our goal is to highlight the OHNS trainees' perspective of their surgical exposure and competency in performing OT.

  Methodology Top

This study was approved by the institutional review board (protocol # 150–19).

This is an observational cross-sectional multicenter study conducted from June 2019 to February 2020 among multiple hospitals in the two largest cities in Saudi Arabia (Jeddah and Riyadh), targeting the two largest universities, King Abdul-Aziz University and King Saud University. Informed consent was obtained from all participants before enrolment to the study.

Otolaryngology-head-and-neck surgery residency program in Jeddah and Riyadh

This is a 5-year residency joint program held among multiple hospitals. Each resident must rotate every 6 months to a different hospital. The first 3 years are classified as juniors, and the last 2 years are classified as seniors.

The first postgraduation year (PGY-1) rotates in different specialties and starts practicing OHNS from PGY-2 to PGY-5.

Trainees are expected to pass the promotion exam (written and oral exam) at the end of every year before moving to a more advanced level.

Juniors must pass the Part 1 Exam during any year in their first 3 years to pass to the senior level, and at the end of the PGY-5, they take the board exam (Part 2 Exam) to be qualified as senior specialists.


OHNS trainees in Jeddah and Riyadh were approached and asked to participate in this study. The exclusion criteria were OHNS residents in their PGY-1 and OHNS trainees outside Jeddah and Riyadh.

The authors visited the hospitals in Jeddah city to distribute the questionnaire in person and to increase the response rate. To approach the trainees in Riyadh city, we sent an electronic questionnaire by email to the participants combined with a reminder every 10 days over 2 months.

It was filled out voluntarily, and consent was obtained from all participants after they were informed about the study objective and response confidentiality [Table 1].
Table 1: Characteristics of participants, according to the level of residency (n=67)

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A validated previewed and published subjective-themed electronic questionnaire consisting of 22 items was used.[3] It was categorized into four sections. The first section included demographics; the second section inquired about the estimated burden of OTs and percutaneous tracheostomy (PT) in the responder's hospital; the third section had questions about surgical experience and the estimation of personal capability in performing OT; and the fourth part was about whether they had previous training in OT and the need for further training, exposure to complications, and familiarity with cannula types.

The main aim of this study was to assess the trainees' perspective of their performance level during the OT operation, so many of these questions may seem highly subjective.

Statistical analysis

A Microsoft Excel spreadsheet was used to record the data. All statistical analyses were descriptive. Comparative statistical analysis was carried out to determine if there was any correlation between research variables using the mean and standard deviation for continuous variables and Fisher's exact and Pearson Chi-square tests for categorical variables. P ≤ 0.05 were deemed significant. Data were analyzed using IBM SPSS Statistics for Windows, version 21.0 (Armonk, NY, USA: IBM Corp., 2012).

  Results Top

Sixty-seven trainees out of 125 filled out and returned the questionnaire, with a response rate of 54%. Of these, 38 were from Jeddah and 29 were from Riyadh (38 out of 47 in Jeddah and 29 out of 78 in Riyadh). They were 35 juniors and 32 seniors with a mean age of 28.1 years.

The tracheostomy case volume

The reported volume of tracheostomies (OTs/PTs) is shown in [Table 2]. Most residents (44.8%) estimated that the number of tracheotomies performed per year in their hospital was fewer than 50. Of the total tracheostomies performed, 61.2% estimated that the percentage of pediatric tracheostomies was <5%/year per institution, which only equals 2–3 tracheostomies per year/institution. It was also reported that OHNS trainees did most of the OT cases, whereas PT cases were done mostly by intensivists and infrequently by otolaryngologists.
Table 2: Estimated burden of tracheostomies, according to the level of residency (n=67)

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Surgical experience

The trainees reported that their confidence in performing OT when they first started the residency program was low, which improved as they progressed in their training. Of the trainees who responded to the questionnaire, 55.2% had faced life-threatening complications during at least one of the tracheostomies.

A total of 65.6% of the seniors had good exposure, and 56.3% of them had received teaching regarding OT. Their confidence level was correlated with these two factors (exposure and teaching) [Table 3].
Table 3: Training for open tracheostomy, according to the level of residency (n=67)

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Open tracheostomy education

When asked about the educational activities about tracheostomies, 50.7% reported receiving some form of tracheostomy education, with the majority of the education (94%) not in the form of a scheduled session. Only 34.3% of the respondents felt they were adequately aware of the various types of cannulas and postoperative management. Education was mostly given in the form of senior trainees educating junior trainees, and only 11.9% was given by the attending consultant on service.

  Discussion Top

OHNS residency programs tend to place emphasis on advanced surgeries during the training years, and because of that, some of the routine procedures, for example, tracheostomy, could be easily overlooked. This study highlights that our OHNS residency program still needs further improvements. Alongside the low exposure to OT training that our trainees faced, there is an inherent weakness in the teaching system. However, their confidence level was progressively improved as they move to a more advanced level of residency, which is expected because with a more advanced level, the more exposure and more active participation in surgeries, the better their surgical skills.

Many training programs are moving toward competency-based education evaluation. This involves the trainees achieving certain milestones before progressing from one level to another. Nevertheless, for trainees to reach certain milestones, trainees need caseloads and organized educational schedules to ensure that they reach the expected milestones.

Although confidence and comfort levels are subjective, they are important factors that every trainee should achieve at the end of their training. For that reason, many programs have started using subjective self-assessment tools to evaluate residents' abilities. Therefore, using validated scales to highlight surgical exposure among trainees in performing OT is beneficial and has been recommended.[3]

Airway-related concerns are responsible for many of the consultation referrals to OHNS, which makes mastering the basic airway procedures mandatory for every physician practicing OHNS.[9] However, the outcomes of these types of procedures and the related rates of mortality and morbidity rely highly on the caregiver's confidence level, and this confidence can be gained from adequate knowledge and sufficient exposure.[4] In our results, we noticed that the majority of the estimated total number of performed OTs in each institution was fewer than 50 OTs per year, which reflects a low exposure. This could be a consequence of an overall decrease in the performance of surgical airways and tracheostomies due to advancements in intensive care medicine.[10] Moreover, the literature showed that recently, there has been a decrease in OT exposure by OHNS trainees, as described in a previously published study in 2017, which estimated only eight tracheotomies are performed per resident each year.[3] This is supported by a study conducted in a tertiary referral center in central Pennsylvania, which showed a decline in OT performance by OHNS trainees from 44% in 2000 to only 25% in 2013.[11] This decreasing number was explained by the participation of the general surgery department in performing OT.[11]

The lack of experience and knowledge is a serious obstacle among our seniors to becoming confident since as previously mentioned, senior residents are already in their PGY-4 or PGY-5, which gives them a maximum of 1 year before becoming board certified, despite 15 out of 32 seniors having low confidence regarding such a basic procedure [Table 4]. This may be explained by different factors, either insufficient teaching or inadequate exposure [Table 5]. As we noticed, the more exposure and teaching they had, the more confidence they gained; on the other hand, less exposure and teaching resulted in a lower confidence level.
Table 4: Surgical experience, according to the level of residency (n=67)

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Table 5: Surgical experience, according to seniority (n=32)

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On the other hand, junior residents cover most of the on-call shifts, making them the frontline physicians to manage airway emergencies.[6] For that reason, it is crucial to become competent in performing basic airway interventions.[12] According to our juniors, only 13 out of 35 (37.1) are actually confident in their ability to perform an OT [Table 4], which could be explained by low exposure, low received teaching, or decreased scheduled teaching (16 {45,7%}, 17 [48.6%], and 34 [97.1%], respectively). Our results are consistent with a previous similar study that concluded that training for OT in OHNS residency programs is not well structured.[3] We ended up with comparable numbers [Table 6], including the number of residents who participated in both studies (67 vs. 69).
Table 6: Comparison between our study and Muallem-Kalmovich et al. study[3]

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We notice that the overall current confidence level of our residents is lower than previously published studies regarding OT performance. This may be explained by the low exposure level and teaching received as previously mentioned or by the infrequency in our scheduled teaching program and the relatively lower exposure of OT per year in each institution [Table 6]. Despite the slightly higher reported confidence level and exposure in other articles, the literature consistently supports a systematic deficiency in OT education, making it a universal educational issue rather than a country-or program-specific issue.

Despite the era of declining exposure regarding OT, training programmers should be concerned about improving the quality of teaching and training to graduate a well-trained and confident surgeon. To improve the clinical skills and competency of trainees, high-fidelity simulation scenarios and didactic sessions are needed.[5] Other areas to focus on include direct supervision by the surgeon of the trainees,[6] the trainees performing the surgery as the primary operator,[13] and more frequent evaluation and feedback to the trainees in a well structure format.[3],[13],[14],[15]

There are a few limitations to this study. First, it relied entirely on residents' self-evaluation of whether they are competent enough to perform OT independently or not, which can be highly subjective, and the number of cases seen is highly variable between centers. Furthermore, the survey nature of this cross-sectional study has an inherent recall bias. Nevertheless, the variability among the responses was not wide, which reassures the authors that the results highlighted are valuable.

  Conclusion Top

The reason behind the lower confidence of trainees is likely multifactorial and requires further studies to understand them properly. Future research should focus on the value of structuring educational milestones, in this case for OT, to improve the skills of trainees with the aim of graduating confident and competent surgeons.


  1. OHNS residents do not feel as confident as they should in performing OT. This is neither a center specific nor a country-specific issue
  2. The main reasons for the residents' low confidence are likely due to the reduced number of OT tracheostomies performed per institution and the lack of organized didactic teaching around tracheostomies and tracheostomies care
  3. Training programs should focus on high-fidelity simulation training to raise the confidence level of trainees.

Compliance with ethical standards

None of the authors have any conflict of interest or received financial compensation for anything pertaining to this research and publication.

All participants signed an informed consent form before participating in the survey.

This study did not include any human or animal biological samples.

Data source

The data source is available upon request.

Main Points

1- This questionnaire-based study highlights the lack of standardization of education surrounding tracheostomy

2- Despite being one of the most common procedures performed most trainees did not receive scheduled teaching and most of the education they received was not by the attending surgeon, but rather by their senior trainees

3- These were some of the main factors that resulted in a reduced sense of confidence in the management of tracheostomy

4- The finding of this study is similar to another study which used the same questionnaire in a different country, highlighting that this issue is not country specific but likely that many international programs need to assess their trainees' self-perception and confidence when performing what is considered a routine surgery.

Financial support and sponsorship


Conflicts of interest

There are no conflicts of interest.

  References Top

Russo CA, Merrill CT, Friedman B. Procedures with the most rapidly increasing hospital costs, 2000-2004: Statistical brief #28. 53 In: Healthcare Cost and Utilization Project (HCUP) Statistical 54 55 Briefs. Rockville Bookshelf (Bethesda, MD, USA).  Back to cited text no. 1
Lesko D, Showmaker J, Ukatu C, Wu Q, Chang CW. Declining otolaryngology resident training experience in tracheostomies: Case log trends from 2005 to 2015. Otolaryngol Head Neck Surg 2017;156:1067-71.  Back to cited text no. 2
Muallem-Kalmovich L, Pitaro J, Asaly A, Kessler A, Eviatar E, Shteiner M, et al. Open tracheostomy training: A nationwide survey among otolaryngology-head and neck surgery residents. Eur Arch Otorhinolaryngol 2017;274:4035-42.  Back to cited text no. 3
Agarwal A, Marks N, Wessel V, Willis D, Bai S, Tang X, et al. Improving knowledge, technical skills, and confidence among pediatric health care providers in the management of chronic tracheostomy using a simulation model. Pediatr Pulmonol 2016;51:696-704.  Back to cited text no. 4
Cheng PC, Cho TY, Hsu WL, Lo WC, Wang CT, Cheng PW, et al. Training residents to perform tracheotomy using a live swine model. Ear Nose Throat J 2019;98:E87-91.  Back to cited text no. 5
Andrews JD, Nocon CC, Small SM, Pinto JM, Blair EA. Emergency airway management: Training and experience of chief residents in otolaryngology and anesthesiology. Head Neck 2012;34:1720-6.  Back to cited text no. 6
Maschuw K, Osei-Agyemang T, Weyers P, Danila R, Bin Dayne K, Rothmund M, et al. The impact of self-belief on laparoscopic performance of novices and experienced surgeons. World J Surg 2008;32:1911-6.  Back to cited text no. 7
Chadwick KA, Dodson KM, Wan W, Reiter ER. Attainment of surgical competence in otolaryngology training. Laryngoscope 2015;125:331-6.  Back to cited text no. 8
Carr MM. Improving the otolaryngology consultation service in a teaching hospital. Laryngoscope 2001;111:1166-8.  Back to cited text no. 9
Levitan RM. Myths and realities: The “difficult airway” and alternative airway devices in the emergency setting. Acad Emerg Med 2001;8:829-32.  Back to cited text no. 10
Patel HH, Siltumens A, Bess L, Camacho F, Goldenberg D. The decline of tracheotomy among otolaryngologists: A 14-year review. Otolaryngol Head Neck Surg 2015;152:465-9.  Back to cited text no. 11
Awad Z, Pothier DD. Management of surgical airway emergencies by junior ENT staff: A telephone survey. J Laryngol Otol 2007;121:57-60.  Back to cited text no. 12
Bruijstens L, Titulaer I, Scheffer GJ, Steegers M, van den Hoogen F. Emergency front-of-neck airway by ENT surgeons and residents: A dutch national survey. Laryngoscope Investig Otolaryngol 2018;3:356-63.  Back to cited text no. 13
Gofton WT, Dudek NL, Wood TJ, Balaa F, Hamstra SJ. The ottawa surgical competency operating room evaluation (O-SCORE): A tool to assess surgical competence. Acad Med 2012;87:1401-7.  Back to cited text no. 14
Al-Qahtani KH, Alkhalidi AM, Islam T. Tool for assessing surgical tracheostomy skills in otolaryngology residents. B-ENT 2015;11:275-80.  Back to cited text no. 15


  [Table 1], [Table 2], [Table 3], [Table 4], [Table 5], [Table 6]


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