ª 2013 by the American College of Surgeons

Published by Elsevier Inc.

LETTERS

Effect of Noise on AuditoryProcessing in the Operating Room

Anthony R MacLean, MD, FRCSC, FACS,Elijah Dixon, MD, FRCSC, FACS,Chad G Ball, MD, FRCSC, FACS

Calgary, AB, Canada

We read with interest the article by Way and colleagues1

on the effect of noise on auditory processing in theoperating room (OR). Unfortunately, we have severalconcerns about this study.First, we must challenge Dr Way’s methodology. It

appears as though the authors intentionally designed thestudy to show that music is detrimental to communica-tion. Their SPIN-R was presented at 70 dB SPL, butthe OR noise and music combined to approach74.2 dB SPL. Even if 74.2 dB is the average noise levelfound in their local ORs, attempts at communicationin this environment would never be softer than the back-ground noise. We believe that no matter where you setthe baseline noise threshold, if the SPIN-R is presentedat a lower level, it must surely affect comprehension.The authors do mention the Lombard effect in theirdiscussion, but don’t account for it in their study design,which we believe is a critical flaw. This concept is essentialto communicating in any environment where backgroundnoise is prominent.Second, it is interesting that in the high predictability

scenario (Fig. 4), there is essentially no visible drop offin performance with the addition of music, despite thestated “significant difference.” Perhaps the authors cancomment on how the flat line from noise to noise plusmusic becomes significant.Third, limiting testing to surgeons is likely a suboptimal

manner to assess the true effects of noise on auditory pro-cessing in the OR. More specifically, the effects of noiseaffect all staff in the OR rather than just the surgeon(ie, nurses and anesthesiologists). In this day and age,miscommunication can be mitigated by a routine andorganized briefing or timeout. When new informationneeds to be provided during the course of a procedure,it should, of course, be provided in a clear, strong voice.This may even require briefly turning off music and/orstopping concurrent conversations.Furthermore, music has previously been shown to have

many beneficial effects in the OR environment. Music

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decreases stress,1 enhances concentration, can improvemotor skill performance,2,3 and often diminishes patientanxiety.4-7

In summary, suggesting that music is dangerous in theOR environment based on the data from this study ismisleading. As surgeons who enjoy the multiple benefitsof music in the OR, we hope that appropriate music isencouraged in this unique and focused setting.

REFERENCES

1. Way TJ, Long A, Weihing J, et al. Effect of noise on auditoryprocessing in the operating room. J Am Coll Surg 2013;216:933e938.

2. Allen K, Blascovich J. Effects of music on cardiovascular reac-tivity among surgeons. JAMA 1994;272:882e884.

3. Conrad C, Konuk Y, Werner P, et al. The effect of definedauditory conditions versus mental loading on the laparoscopicmotor skill performance of experts. Surgical Endosc 2010;24:1347e1352.

4. Makama JG, Ameh EA, Eguma SA. Music in the operatingtheatre: opinions of staff and patients of a Nigerian teachinghospital. African Health Sci 2010;10:386e389.

5. Chetta HD. The effect of music and desensitization on preop-erative anxiety in children. J Music Ther 1981;18:74e87.

6. Stevens K. Patients’ perceptions of music during surgery.J Advanced Nursing 1990;15:1045e1051.

7. Ni CH, Tsai WH, Lee LM, et al. Minimising preoperativeanxiety with music for day surgery patients - a randomised clin-ical trial. J Clin Nursing 2012;21:620e625.

Disclosure Information: Nothing to disclose.

Reply

T Justin Way, MD, Ashleigh Long, PhD,Jeff Weihing, PhD, Rosalind Ritchie, MD,Raleigh Jones, MD, Matthew Bush, MD,Jennifer B Shinn, PhDLexington, KY

The authors appreciate the concerns raised by DrsMacLean, Dixon, and Ball in their recent letter regardingour investigation, “Effect of noise on auditory processingin the operating room.”1 This investigation, as clearlystated in the manuscript, was intended to be a preliminaryinvestigation that attempted to replicate as closely aspossible listening performance in the operating room.

ISSN 1072-7515/13/$36.00

http://dx.doi.org/10.1016/j.jamcollsurg.2013.08.008

Vol. 217, No. 6, December 2013 Letters 1155

We respectfully disagree with the statement and sugges-tion that we intentionally designed a study that woulddemonstrate that music is detrimental to communication.The levels at which the stimuli were presented were basedon numerous measurement of the various stimuli (speech,operating room [OR] noise, and music) and not based onarbitrary levels that were chosen in order to decrease perfor-mance. Based on feedback from many OR staff membersacross institutions and studies, it is not always the case that“communication in this environment would never be softerthan the backgroundnoise.” In fact, it has been observed thatthis is indeed often the case. Although theoretically, theLombard effect should be initiated in these types of environ-ments, there is no way to guarantee that this is the case.With respect to the second concern raised regarding

Figure 4, the statistics indicate that performance was signifi-cantly worse on the high predictability sentences whencomparing quiet to music testing conditions; however, therewas not a significant difference between OR noise andmusictesting conditions, as stated in the article (p¼ 0.10). There-fore, there was the flat line between the latter 2 conditions.This was not the case for the low predictability sentencesbecause the OR noise and music testing conditions weresignificantly different (p < 0.001), and the figure demon-strates this downward slope. There was also a significantdifference between the high predictability and low predict-ability stimuli when music was introduced. The fact thatperformance for high predictability stimuli was relativelyconsistent between the OR noise and music testing condi-tions supports the fact that the stimuli were not created insuch a way as to negatively affect results in the music condi-tion. If this were indeed the case, as suggested, both high andlow predictability results would have seen an even greaterdecline in performance in the music testing condition.We agree with the third concern that more staff should

be evaluated beyond just surgeons. This was noted in thediscussion and indicated as a future direction of the study.We also agree that there are numerous studies that reportthe benefit of music to patients to reduce the anxiety.However, with that said, the particular studies that DrsMacLean, Dixon, and Ball present suggest that music beused preoperatively to ease anxiety and not intraopera-tively. Surgeon cardiovascular measures and performancemeasures may benefit from music, as Allen and colleaguesreport; however, they do not address communication,which was the purpose of our study. There are essentiallyno recent articles to our knowledge that report beneficialeffects of music on intraoperative communication.This is not the only study to raise concern for dangerous

distractions in the operating room. Not all distractions arecontrollable; however, the presence and the volume of musicin theOR can be controlled.We recommend that a review of

a recently published article by Lee and associates2 be consid-ered. In their investigation, more than 2,000 surgeons weresurveyed regarding the impact on patient outcomes causedby internal distractions and external environment distractions(one of which was music in the operating room). Of thoserespondents, 15% reported at least 1 “preventable intraoper-ative complication” because of an external OR environmentdistraction. This is a sobering finding and it is worthy forall surgeons to consider their intraoperative environment.The benefits of music in the OR and the potential risk

of miscommunication should be evaluated and ultimately,each surgical team must decide on what environment willbe the most conducive to safe and efficacious outcomes fortheir patients. This study was intended to report our find-ings with support of other peer reviewed articles, but didnot intend to dictate what is best for all surgeons and staff.We thank Drs MacLean, Dixon, and Ball for theircomments and concerns and encourage them to conducttheir own independent investigation into this matter.

REFERENCES

1. Way TJ, Long A, Weihing J, et al. Effect of noise on auditoryprocessing in the operating room. J Am Coll Surg 2013;216:933e938.

2. Lee JY, Lantz AG, McDougall EM, et al. Evaluation of poten-tial distractors in the urology operating room. J Endourol 2013Aug 1. [Epub ahead of print].

Dilated Distal Esophagus: OptimalPosition for Magnetic SphincterAugmentation

Reza Asari, MD, Martin Riegler, MD,Sebastian F Schoppmann, MD

Vienna, Austria

Due to the symptoms and the cancer risk among thosewith Barrett’s esophagus, gastroesophageal reflux disease(GERD) impairs the life quality and productivity ofpatients.1 Magnetic sphincter augmentation (MSA) repre-sents a novel laparoscopic method for surgical GERDtreatment.2 The highly important study by Bonavinaand colleagues,2 which was published in a recent issue ofthe Journal of the American College of Surgeons, reports1.2- to 6-year follow-up data after MSA implant. Normal-ization of esophageal acid exposure paralleled improve-ment of symptoms and life quality in approximately90% to 93% of the patients in the absence of protonpump inhibitor therapy. The MSA had to be removedin only 3 patients. So, when performed in experienced