Planetary Health in Otolaryngology: A Call to Depollute Care

Abstract

Planetary health is a framework that emphasizes the interdependence between human and environmental health. Principles of planetary health are increasingly relevant to Otolaryngologists, who both contribute to climate change and face its consequences for their patients’ health. This commentary applies these principles to Otolaryngology-Head and Neck Surgery, offering recommendations at 3 levels of change: the individual Otolaryngologist, the institution, and the broader system. These recommendations are grounded in 3 principles: reducing demand for care through health promotion and disease prevention, ensuring appropriateness of care by addressing overuse and underuse, and reducing healthcare pollution through adoption of circular economy principles. By embracing planetary health as a guiding principle, Otolaryngologists can reduce their footprint while advancing patient and community health.

Graphical Abstract

This is a visual representation of the abstract.

Key Messages

1. Otolaryngologists both contribute to climate change and manage its health impacts in their patients.

2. The 3 principles of planetary healthcare can be applied to Otolaryngology-Head and Neck Surgery: reducing healthcare demand through improved health and outcomes, ensuring appropriate care, and reducing healthcare pollution by applying circular economy principles.

3. Each principle can be enacted at the individual, institutional, and system levels.

Introduction

Planetary health is a framework that describes the relationship between human health and environmental health. ¹ Concern for the connection between human and environmental health is growing as the impact of climate change on health becomes harder to ignore. Within Otolaryngology, there are numerous relevant trends: rising temperatures and changes in weather patterns increase the load and spread of allergens, driving up rates of allergic rhinitis; ² rising temperatures amplify wildfire risk, with wildfire smoke linked to a higher incidence of respiratory diseases and associated exacerbations; ³ and chronic exposure to air pollution is associated with increased incidence of head and neck cancers in adults. ⁴ These examples illustrate how environmental degradation is already changing the health of our patients and shifting clinical practice.

In Canada, healthcare systems and their supply chains generate 33 million tons of greenhouse gases (GHGs) each year. ⁵ Within the healthcare system, perioperative services are significant sources of GHG emissions, due in part to the energy intensity of operating rooms (ORs) and reliance on single-use disposables. For example, a coblation tonsillectomy procedure, on average, generates 205 kg CO₂ equivalents (CO₂e) per case. ⁶ Given the high volume and resource intensity of Otolaryngologic procedures, reducing the footprint of our specialty can culminate in a significant environmental impact.

Despite the specialty’s footprint, many Otolaryngologists are unaware of their potential role in climate and environmental change, as well as opportunities for improvement. A national survey of Canadian Otolaryngologists reported that while 86% of respondents believe in climate change, only 46% view sustainability practices as important in the OR, and only 20% ‘strongly agree’ that ORs contribute to climate change. ⁷ This disconnect highlights a critical gap between environmental concerns and actionable awareness. In reality, while Otolaryngologists contribute to climate and environmental change, we also have the potential to mitigate our footprint.

MacNeill et al ¹ proposed a 3-part framework for improving healthcare sustainability or practicing ‘planetary healthcare’: (1) reducing healthcare demand through health promotion, disease prevention, and good chronic disease management; (2) ensuring appropriate care through avoidance of healthcare overuse and underuse; and (3) reducing pollution from healthcare delivery with a focus on adopting circular economy principles. This commentary extends the planetary healthcare framework to Otolaryngology-Head and Neck Surgery (OHNS). We draw on illustrative examples from the OHNS and perioperative sustainability literature to demonstrate actionable opportunities within each planetary healthcare principle. Our recommendations target 3 levels of change: the individual Otolaryngologist, the institution, and the broader system. The objective of this paper is to motivate and equip our colleagues to evaluate their approach to surgical care through a planetary healthcare lens.

Reducing Demand for Health Services

Addressing the root causes of ill health can make communities healthier and improve the sustainability of healthcare by reducing demand for services.

Individual Practice Level

Many conditions managed by Otolaryngologists, such as head and neck cancers, chronic rhinosinusitis, recurrent otitis media and hearing loss, are amenable to upstream prevention and can reduce the need for more resource-intensive care. For example, it has long been known that smoking is a significant risk factor for head and neck cancers and that it also adversely affects postoperative outcomes. ⁸ Compared to non-smokers, surgical patients who smoke have compromised wound healing, higher rates of ICU admission, and a higher incidence of postoperative infections. ⁸ Even a short period of tobacco abstinence before surgery can mitigate some postoperative risks; thus, Otolaryngologists should actively counsel patients on modifiable risk factors, such as tobacco use, to improve outcomes and reduce downstream demand for health services. Beyond tobacco, noise exposure is a major modifiable risk factor for hearing loss. While occupational noise exposure is regulated in most jurisdictions, recreational exposure from personal listening devices is not. The European Union mandates a default output limit of 85 dB(A) on personal audio devices; users can override this limit, but only after the device displays a warning about potential hearing damage. ⁹ In North America, a similar consumer-protection framework is not in place, placing the onus on Otolaryngologists to counsel patients on safer listening practices and advocate for similar legislation domestically.

When resource-intensive treatment such as surgery is needed, Otolaryngologists can minimize their environmental impact by optimizing patient care and implementing Enhanced Recovery After Surgery (ERAS) protocols to minimize the risk of postoperative complications and associated care requirements. ¹⁰ Within OHNS, ERAS programs have been associated with reduced length of stay, complication rates, and hospital costs. ¹⁰

Institution Level

With the support of their colleagues and institutions, Otolaryngologists can improve access to care and reduce healthcare underuse related to systemic inequities. Screening initiatives can detect pathologies at an early stage to avoid the resource use and poor outcomes associated with treatment of advanced disease. Screening must, however, be thoughtfully and appropriately implemented, or else the resources required for widespread screening may exceed the resource savings of early detection. For example, while the US Preventive Services Task Force does not support oropharyngeal carcinoma screening by primary care physicians in asymptomatic adults, targeted screening of high-risk populations may be appropriate. ¹¹ In Vancouver’s Downtown Eastside neighborhood, vulnerably housed people are at higher risk for advanced disease due to healthcare disparities and barriers to access. In response, OHNS residents at the University of British Columbia established head and neck outreach clinics. This collaborative effort between residents, staff, and the institution identified concerns that might otherwise have been neglected: 64% of patients presented with specific otolaryngologic issues, and 28% had abnormal head and neck examinations. ¹²

System Level

Otolaryngologists and their professional societies can advance population-level interventions for disease prevention by engaging with policymakers and supporting public education campaigns. Human papillomavirus (HPV) vaccination is a potential area of advocacy, as it is highly effective for primary prevention of head and neck cancers, but community uptake remains suboptimal. Based on 2024 estimates, the national HPV vaccination completion rate for 17-year-olds in Canada was only 64%, despite a vaccination target of 90% by 2025. ¹³ Certain high-risk populations, such as the LGBT+ community, continue to have low HPV vaccination rates. In an Ontario survey conducted between 2018 and 2019, only 27.3% of men who have sex with men reported having received the HPV vaccine, highlighting the need for targeted advocacy efforts. ¹⁴

Appropriateness of Care

Appropriate care means balancing healthcare demand with supply by eliminating overuse and underuse. ¹ Healthcare overuse includes care that does not improve patient outcomes or exposes patients to unnecessary risks. Conversely, underuse is the failure to provide necessary care, which can lead to missed opportunities for early disease treatment with less resource-intensive options.

Individual Practice Level

To reduce overuse, Otolaryngologists should evaluate whether investigations or treatments will meaningfully change patient management before ordering them. The Choosing Wisely recommendations provide OHNS-specific guidance to identify and eliminate low-value care. Beyond guideline-based tools, shared decision-making (SDM) for elective procedures may also reduce healthcare overuse. SDM promotes a patient-centered decision-making process that tends to improve decision quality and decrease decision conflict. ¹⁵ The literature on SDM and surgical utilization is heterogeneous, but there is a trend toward well-informed patients choosing elective surgery less often. ¹⁶ Otolaryngologists can use SDM to make their care more patient-centered while potentially reducing avoidable care. An example of SDM in OHNS occurs in the management of chronic rhinosinusitis (CRS). Many options for CRS exist (eg, steroids, biologics, surgery), including the option of no active treatment. SDM is critical to align treatment decisions with patients’ preferences to avoid over- or undertreatment. ¹⁵ The American College of Allergy, Asthma and Immunology, in partnership with The American Rhinologic Society, provides online tools that review treatment options for CRS and help guide SDM. ¹⁷

Institution Level

Geographic inequities can drive underuse, with patients living in rural and remote communities systematically disadvantaged by their travel burdens. Institutions should consider access, quality, equity, and environmental impacts when implementing programs of care. A Halifax-based OHNS service established a head and neck cancer clinic in the neighboring province of Prince Edward Island using existing clinical infrastructure. Instead of patients traveling to Halifax, the Otolaryngologist traveled to Prince Edward Island and provided some aspects of care locally. The clinic saved up to 144 kg of CO₂e per patient per visit in avoided travel, while improving access to cancer care for patients in Prince Edward Island. ¹⁸ As an alternative to local care provision, hospitals can provide structures that enable Otolaryngologists to utilize telemedicine, which also obviates the need for patient travel and may reduce the healthcare footprint.

While satellite clinics and telemedicine can be effective clinical adjuncts, it is important to acknowledge their limitations. Implementation of clinics can be resource-intensive, and some Otolaryngologic conditions are inherently ill-suited to telemedicine. The Otolaryngologist should work collaboratively with their institution to promote appropriate access to care without compromising quality.

Another driver of institutional overuse is inadequate coordination between providers, which can lead to duplicated investigations and unnecessary patient visits. ¹⁹ Institutions can promote multidisciplinary coordination by ensuring electronic medical records are accessible to providers within the same institution and to providers in other healthcare networks. Facilitating multidisciplinary consultations on the same day also improves care coordination and reduces emissions from repetitive patient travel. ²⁰

System Level

Even with physician and institutional efforts to make care appropriate, systemic drivers of overuse and underuse remain powerful determinants of practice. Clinical practice guidelines can serve to standardize care and curtail over- and underuse, but they can also codify inappropriate care, such as over-screening for cancer. The Korean Thyroid Imaging Reporting and Data System (TI-RADS) has a lower threshold for fine-needle aspiration than the American College of Radiology TI-RADS. ²¹ From 1993 to 2011, South Korea’s aggressive thyroid screening program led to a 15-fold increase in diagnoses but no corresponding decrease in mortality. ²² Excessive screening strains healthcare system resources and inflates the environmental footprint while exposing patients to potentially unnecessary care. Otolaryngologists should periodically review the best available evidence and local outcomes to confirm that guidelines remain effective for patients and cost-beneficial for the system.

Circular Economy

The majority of healthcare emissions arise from the purchased goods used in the delivery of care, including pharmaceuticals, medical devices, and other products. ⁵ These supply chain emissions arise in part due to increasing reliance on single-use disposables in many healthcare systems. ²³ A more sustainable approach to material resource use is a ‘circular economy’ in which product lifespans are maximized through the purposeful design of durable, reusable products that are maintained through strategies such as repair, repurposing and eventual recycling. ²³

Individual Practice Level

Otolaryngologists can reduce their environmental footprint through mindful resource use in both clinic and operative settings. For example, single-use gloves are often donned unnecessarily for contact with intact skin or other circumstances in which the risk of exposure to bodily fluids is negligible. Appropriately using gloves only during at-risk patient encounters necessitating their use can divert materials away from landfills. ²⁴ Similarly, surgical pick lists, procedure packs, and instrument trays may contain items that are routinely opened but not used. Identifying and eliminating these items reduces unnecessary waste from procedures. ²⁵ When resource use is necessary, the preferential use of reusable over single-use medical devices (SUMDs) can reduce emissions and waste. For example, while reusable flexible laryngoscopes are associated with more GHG emissions during manufacturing than single-use laryngoscopes, their total lifecycle GHG emissions are less than those of single-use alternatives. ²⁶

Institution Level

Institutions can reduce their footprint through their procurement policies. Prioritizing reusable and reprocessable devices in purchasing decisions can reduce the institution’s footprint while signaling demand for lower-impact products. ¹⁹

The choice of care setting also has environmental implications. When appropriate, procedures should be performed in minor procedure rooms (MPRs) rather than ORs. Compared to ORs, MPRs may have a smaller sterile field, which translates into less waste; more streamlined instrument trays, which reduce instrument reprocessing; and a smaller clinical team, which decreases the consumption of single-use personal protective equipment. ²⁷ At a Canadian tertiary care children’s hospital, switching adenoidectomy with bilateral myringotomy and tubes from the OR to an MPR reduced OR waste by 57.6%. ²⁷

Institutions can extend product lifespans through repurposing and recycling programs. Repurposing can extract maximum value from items that would otherwise be discarded. For example, expired sutures can be repurposed for medical education, and expired OR items (eg, surgical gowns, towels, plastic trays) can be donated to community groups. ²⁸ When repurposing is not feasible, recycling is a last resort for diverting material away from landfills or incineration. Hospitals should implement recycling programs for OR waste, as approximately 20% of the operative waste from OHNS procedures is recyclable. ²⁹ Even when disposal is unavoidable, the environmental footprint of waste can be minimized through proper waste segregation, such as ensuring non-hazardous items are not processed through resource-intensive hazardous waste processing.

System Level

System-level action is needed to enable circular economy practices within OHNS. Otolaryngologists should appeal to regulatory bodies for more transparent reporting of emissions, higher environmental standards for healthcare infrastructure, and policies that discourage the introduction of SUMDs when reusable alternatives exist. ¹⁹ Planetary health principles and best practices should be integrated into OHNS training and continuing professional development to sustain these changes.

At present, there is no requirement for device manufacturers to justify bringing SUMDs to market when quality reusable alternatives exist, and there is an increasing trend toward disposability. Otolaryngologists and their professional societies should resist these trends, urging manufacturers to focus their research and development efforts on improving the quality and availability of reusable products. Manufacturers should also be encouraged to adopt take-back programs to facilitate the responsible repurposing, recycling, or disposal of devices.

When SUMDs are used, their lifespans can be extended through reprocessing; however, regulatory barriers remain a significant obstacle. In Canada, policies and guidelines on reprocessing SUMDs remain unclear, and manufacturers are also not obligated to provide reprocessing guidance. ³⁰ There should be a collaborative effort between industry, consumers, and regulators to develop clear guidance on reprocessing SUMDs, making this practice feasible for Otolaryngologists, institutions, and manufacturers.

Conclusion

We call on Otolaryngologists to recognize planetary health as a core dimension of healthcare quality and a professional responsibility, and to act in their capacity as clinicians, institutional leaders, and a profession to depollute Otolaryngologic care. This commentary identifies actionable opportunities at the individual, institutional, and system levels to promote planetary health within OHNS (Table 1).

Table 1.

Summary of Recommendations for Planetary Health in OHNS.

Individual practice level	Institution level	System level
Reducing demand for health services
Counsel on modifiable risk factors such as tobacco use and noise exposure. Optimize patients for surgery, such as through ERAS protocols, to reduce postoperative complications.	Allocate resources for preventive services (eg, smoking cessation counseling, vaccination education). Establish outreach clinics for underserved populations to detect OHNS pathologies at earlier stages.	Advocate for population-level disease prevention, such as increasing HPV vaccination uptake. Support public education campaigns on modifiable risk factors for OHNS pathologies.
Ensuring appropriate care
Consult Choosing Wisely recommendations to identify and eliminate low-value care. Engage in shared decision-making with patients to align care with patient values.	Support telemedicine infrastructure for appropriate OHNS patient encounters. Support satellite clinic initiatives to reduce travel-related emissions and to improve access to care. Coordinate multidisciplinary care and ensure EMR interoperability to reduce resource overuse and patient travel.	Periodically review clinical practice guidelines with a view to preventing overuse and ensuring screening and diagnostic thresholds remain evidence-based. Develop and regularly update shared decision-making tools to aid patient decision-making.
Circular economy
Audit surgical pick lists and procedure packs to reduce the number of opened but unused items. Reduce unnecessary resource consumption, such as glove use. Preferentially select reusable over single-use medical devices where available and clinically appropriate. Segregate waste appropriately to prevent non-hazardous items from entering resource-intensive disposal streams.	Shift appropriate cases from operating rooms to minor procedure rooms to reduce operative resource use. Utilize single-use medical device reprocessing programs when regulatory frameworks permit. Implement recycling and repurposing programs to extend product lifespans. Adopt environmentally preferable procurement policies; prioritize reusable and reprocessable devices in institutional purchasing.	Resist industry trends toward single-use medical devices (SUMDs) and require demonstration of clinical need before adopting new SUMDs. Advocate for manufacturer take-back programs to divert material from landfills. Appeal for clearer regulatory frameworks for SUMD reprocessing. Develop professional society positions on planetary healthcare in OHNS to guide individual and institutional practice. Integrate planetary health into OHNS training curricula and continuing professional development.

Abbreviation: OHNS, Otolaryngology-Head and Neck Surgery.

Many of the examples in this commentary are drawn from the Canadian healthcare context. We recognize that practices, opportunities, and barriers vary substantially across countries and systems. The specific recommendations outlined in this commentary may not be directly transferable to all settings. However, the underlying principles are applicable across healthcare systems, even as their practical implementation will need to be adapted.

We also acknowledge that there are barriers to implementing these recommendations, including competing clinical priorities for Otolaryngologists, upfront costs for institutions to establish infrastructure for reuse, and variable regulatory environments across healthcare systems. Nevertheless, many of the individual-level recommendations in this commentary, such as addressing modifiable risk factors with patients or auditing surgical pick lists, require minimal institutional support and can be immediately adopted. For institutional and system-level change, collaboration between stakeholders will be essential.

This call to action recognizes that Otolaryngologists are uniquely positioned to advocate for change in the provision of head and neck surgical care. Otolaryngologists have a professional responsibility to consider planetary health in the provision of high-quality care.