Environmental impact of single-use plastics in common ENT procedures: a prospective analysis of waste generation and carbon emissions in an Australian hospital

Introduction

Paediatric ear, nose and throat (ENT) surgery highlights a fundamental environmental contradiction in healthcare: large quantities of single-use plastic are employed to maintain sterility in operative fields that inherently harbour approximately 10⁸ bacteria per gram of tissue, rendering absolute sterility biologically unattainable (1). The futility of achieving sterility is well documented, as throat cultures often remaining positive even after chlorhexidine preparation (2). Unlike cardiac or neurosurgical procedures, where strict sterility is essential to prevent catastrophic infections, ENT procedures involve inherently contaminated fields—raising the possibility that extensive sterile barriers may reflect ’sterility theatre’ rather than evidence-based infection control. Tonsillectomy, adenoidectomy, and ventilation tube (grommet) insertion are among the most common paediatric surgeries, with nearly 90,000 procedures performed annually in Australia (3). Despite their frequency, no randomised trials have demonstrated that sterile barriers reduce infections in these ENT procedures (4). Meanwhile, other specialties have safely adopted reduced-barrier protocols: urologists employ ‘green draping’ for cystoscopy (5), and dermatologists use clean rather than sterile gloves in simple cutaneous procedures, achieving equivalent outcomes with dramatically less waste (6). This evidence vacuum in ENT perpetuates potentially unnecessary waste generation on a massive scale, positioning ENT to build on the evidence-based de-escalation of excessive sterile precautions.

While the clinical equipoise for reduced sterile barriers in ENT grows increasingly apparent, the environmental imperative adds urgency to this re-evaluation. Australian healthcare contributes 7% of national carbon emissions (7), with operating theatres identified as disproportionate contributors. Tonsillectomies have been demonstrated to have an average carbon footprint of 7.5 kg carbon dioxide (CO₂) emission per operation in the United Kingdom (8-10). No Australian data has quantified the actual waste burden from our highest-volume ENT procedures.

Challenging established sterility protocols faces significant institutional, medico-legal, and cultural barriers. However, the convergence of environmental crisis, the absence of supporting evidence, and successful precedents from other specialties creates both an opportunity and an obligation for ENT to lead surgical sustainability reform. Is healthcare prioritising surgical tradition over environmental responsibility and evidence-based practice? This study provides the first prospective audit of single use plastic waste in paediatric tonsillectomy, adenoidectomy, and grommet insertion at an Australian centre. This paper aimed to quantify single-use plastic waste (kg) and estimated carbon emissions (kg CO₂) from paediatric tonsillectomy, adenoidectomy, and grommet insertion procedures at an Australian district hospital.

Methods

This prospective cross-sectional audit was conducted at Maitland Hospital, a 241-bed regional public hospital in the Hunter New England Local Health District, New South Wales (NSW), Australia, from 1 July to 31 December 2024. The hospital performs paediatric ENT operating lists 1–2 times per week, which is representative of surgical volumes at similar metropolitan district hospitals across NSW. All seven ENT surgeons in the department participated. The study was approved as a quality improvement audit by the Hunter New England Human Research Department Committee (Approval #20251016-125). Informed consent was not applicable as no human participants were involved in this study. The study is reported according to the STROBE reporting guidelines (available at https://www.theajo.com/article/view/10.21037/ajo-25-1-75/rc).

Paediatric patients undergoing tonsillectomy, adenoidectomy, and/or grommet insertion during the study period were included, comprising both day-case and overnight admissions. Exclusion criteria included combined procedures with non-ENT specialties and procedures abandoned after induction.

Single-use items were defined as manufacturer-designated disposable products discarded after one patient use. A standardised collection protocol was developed through pilot testing in June 2024. The process involved:

• Pre-operative: all opened packaging from sterile supplies retained;
• Intra-operative: designated waste bags for plastic items only, separate from clinical waste;
• Post-operative: items sorted by polymer type [polypropylene, polyethylene, polyvinyl chloride (PVC), mixed plastic] using manufacturer package labelling;
• Weighing: digital scale (±1 g precision) calibrated daily; items weighed immediately post-procedure;
• Recording: standardised log sheets documenting procedure type, item categories, polymer types, and weights.

Composite materials containing partial plastic were included if >50% plastic by composition.

Excluded items included metals, paper products, and biological waste.

As part of quality control, five data collectors underwent standardised training and competency assessment. Inter-rater reliability was assessed using duplicate measurements of a subset of 15 procedures, with agreement quantified using Cohen’s kappa. Weekly audits ensured protocol adherence, and discrepancies were resolved through team consensus.

Statistical analysis

Carbon emission calculations: CO₂ equivalents were calculated using published emission factors, with a range of literature highlighting variability in emissions. An average factor of 3.0 kg CO₂/kg of polypropylene was used for the calculation (11-14). Uncertainty was estimated at ±20% based on literature variability. Water bottle equivalents used 0.31 kg CO₂ per 1 L bottle for context (Carbon Cloud Climate Registry) (15,16).

Descriptive statistics [mean, standard deviation (SD), 95% confidence interval (CI)] were calculated for waste by procedure type. Sample-size statistical analysis indicated that 113 or more measurements were required to achieve a 95% confidence level that the true value was within ±8% of the measured value.

Normality was assessed using Shapiro-Wilk tests. Between-group comparisons used one-way ANOVA. Analyses performed using SPSS v28.0 with significance at P<0.05.

Surgical supplies and draping protocols are standardised across Hunter New England Local Health District hospitals. While these findings likely represent NSW public hospital practice, variation may exist in private facilities and interstate due to different supply contracts and protocols.

Results

Study population

During the six-month period, 115 consecutive paediatric ENT procedures were performed with complete waste data collection (100% capture rate). Patient demographic data was not captured, as it had no direct relationship to the waste. No procedures met exclusion criteria. Inter-rater reliability between raters was high (κ=0.89, 95% CI: 0.84–0.94).

Plastic waste generation

Mean plastic waste varied significantly between procedure types. A one-way ANOVA was conducted to compare the average plastic waste produced amongst isolated middle ear ventilation tube insertion (grommets), tonsillectomy/adenoidectomy/grommets insertions (TAG), adenoidectomy/grommet insertion (A + G) and tonsillectomy/adenoidectomy (T +/− A) procedures. The analysis showed a significant difference in waste across the surgery subtypes, F=42.86, P<0.00001. Plastic waste increased with procedure complexity. Combination procedures (TAG and A + G, n=58) generated 1.5 kg (SD 0.23), representing 36% more waste than isolated grommet insertion (1.1 kg, SD 0.11) and 25% more than tonsillectomy/adenoidectomy procedures (1.2 kg, SD 0.15). Refer to Table 1.

Major contributors, based on item numbers, included gloves (N=488, 31.5%), sterile drapes (N=294, 19.0%), packaging (286, 18.5%), gowns (N=262, 16.9%), suction tubing (N=117, 7.6%), and miscellaneous items, including suction adaptors and plastic devices (N=102, 6.6%). It was difficult to assess the exact percentage of plastic composition for each item; plastic ingredients and composition were recorded. Waste composition analysis revealed that the most common plastic ingredients were polypropylene, polyethylene, polyurethane, PVC, and mixed plastics across the recorded items.

Overall, the total CO₂ emissions from surgical plastic waste in these 115 operations amounted to 459.9 kg over six months. To contextualise this impact, a real-life comparison was made using the carbon footprint of a 1-litre plastic water bottle, estimated at 0.31 kg CO₂ per bottle (11). This equates to approximately 1,484 plastic 1-litre water bottles over six months, or an average of 13 bottles per patient. Refer to Figure 1.

Figure 1 Visual representation of the amount of plastic waste generated in 1L water bottles for the insertion of grommets.

Discussion

This Australian-first audit of paediatric ENT surgical waste revealed that common procedures generate 1.1–1.5 kg of single-use plastic per case, producing 460 kg CO₂ over six months at a single centre. Extrapolating to Australia’s 90,000 annual paediatric ENT procedures suggests a national footprint of more than 100 tonnes of plastic waste and 300 tonnes of CO₂ annually from just three procedure types.

Our findings are supported by recent studies demonstrating that common ENT procedures generate substantial and largely avoidable plastic waste. An Australian audit of tonsillectomy identified a total of 2.1 kg of waste per case, with approximately 15% unused, translating to an estimated 95 tonnes of solid waste and 1.18 million kg CO₂ emissions annually in Australia (17). As in our study, the dominant contributors were sterile packs, drapes, gowns, and gloves, indicating that barrier precautions drive the majority of environmental impact. Interventional studies in adenotonsillectomy show that redesigning surgical packs and eliminating routine drapes and gowns can reduce waste by more than 60% (18). These data closely mirror the magnitude of waste observed in our audit and confirm that current ENT practices have environmental impacts.

Surgical waste is a notable contributor to the environmental impact of healthcare systems worldwide (19). Operating rooms are resource-intensive environments that generate substantial waste, including single-use plastics, packaging, and unused supplies (8,20). The widespread adoption of single-use disposables has exacerbated this issue, underscoring the need for sustainable practices. There is consistent evidence that disposable plastic instruments and consumables are a major contributor to the environmental footprint of surgery. Life-cycle analyses have shown that single-use devices generate higher carbon emissions than reusable or hybrid alternatives (9,11). The Royal Australasian College of Surgeons has a position statement that identifies climate change as one of the 21st century’s biggest global health threats (19,21). Transitioning to environmentally sustainable solutions, such as reusable materials and optimised resource utilisation, is critical to addressing the ecological challenges posed by modern surgical practices.

In our study the majority of this waste in these procedures is utilised in attempting to achieve sterility in operative fields where bacterial colonisation is not merely present but overwhelming. ENT surgical sites are inherently contaminated before, during, and after procedures. The biological impossibility of achieving sterility in these fields is well established: bacterial cultures remain positive throughout ENT procedures regardless of the chosen antimicrobial method (22,23).

A global survey of paediatric otolaryngologists demonstrated marked variation in barrier use across procedures and regions, with many surgeons already omitting patient drapes and gowns for ventilation tube insertion and airway procedures without reported safety concerns (24). In contrast, adenotonsillectomy remains highly reliant on single-use barriers despite similarly contaminated operative fields. Cost and infection prevention policies were the most commonly cited barriers to sustainable practice (24). This reinforce that ENT barrier practices are driven primarily by tradition and institutional policy rather than procedure-specific microbiology or outcome data, and that the specialty is well positioned to lead evidence-based reductions in single-use plastics without compromising patient safety.

A Cochrane review on surgical drapes found no evidence of benefit across all surgical types and identified no randomised control trials specifically investigating this issue in ENT-specific procedures (4,25). Current surgical site infection rates in ENT range from 1–4% (26), yet we lack data on whether these rates would differ with reduced barrier protocols, as successfully implemented in other surgical specialties (27-29). The unique microbiology of ENT operative sites, with bacterial loads exceeding those of other ‘contaminated’ surgical fields, makes extrapolation from other specialties problematic, yet no trials have addressed this directly.

An example of successful waste reduction includes urologists implementing ‘green draping’ protocols for cystoscopy, eliminating leg drapes, top drapes, and gowns, demonstrating non-inferior infection rates while diverting 165 pounds of waste per 240 cases (5). Dermatologists have adopted non-sterile gloves for minor procedures following meta-analyses of over 11,000 cases showing equivalent infection rates (2.0%) between sterile and clean techniques (6,30). Even in clean-contaminated fields, evidence challenges convention: a large randomised control trial in colorectal surgery found no difference in surgical site infections rates between disposable and reusable gowns and drapes (31). These studies demonstrate that evidence-based reduction in barrier precautions can maintain patient safety while substantially reducing environmental impact. ENT is ideally positioned to follow this evidence-based approach yet remains constrained by tradition rather than data.

Despite compelling environmental and biological rationales, multiple barriers impede practice change. Medico-legal concerns persist despite the absence of litigation linking infection to barrier choice in ENT. Institutional inertia favours the status quo, with infection control committees applying universal precautions across all surgical specialties regardless of operative field sterility. Supply chain contracts often combine ENT supplies with other surgical specialties to reduce hospital costs, while also allowing suppliers to monopolise supply chains, thereby limiting procurement flexibility. Cultural factors, including surgeon training traditions and nursing preferences, reinforce current practices. There are no ENT-specific infection prevention guidelines from governing bodies that guide clinicians and hospitals. This prevents systemic change across the specialty. Without professional society endorsement or randomised trial evidence, individual institutions remain reluctant to pioneer change, perpetuating environmentally harmful practices lacking evidence-based justification. Future studies are required to help underpin this change in our current healthcare systems.

This study has several limitations. First, our single-centre design at one regional hospital may not capture variation across institutions. There is potential variability in hospital surgical packing, and therefore in the surgical plastic waste generated between hospitals. Second, we measured only intraoperative plastic waste, excluding pre- and post-operative waste, thus potentially underestimating the total environmental impact. Third, carbon calculations relied on standard emission factors for polypropylene (3 kg CO₂/kg) and did not account for manufacturing location, transport, or disposal methods, which could vary by ±15%. Finally, all procedures followed existing standard sterility protocols; this audit was not designed to compare infection rates between different barrier approaches, which would require a randomised controlled trial. Despite these limitations, this study provides crucial baseline data, the first from Australia, quantifying the environmental burden of current ENT surgical practices and establishing the foundation for future intervention trials.

These findings highlight important opportunities for improving evidence-based practice. Randomised controlled trials are needed to compare infection rates between current protocols and reduced-barrier approaches in ENT. This would provide crucial guidance, potentially starting with low-risk procedures like grommet insertion. Professional bodies could develop ENT-specific infection-prevention guidelines that account for the unique microbiology of our operative fields. Institutions should consider implementing waste-monitoring systems to track their environmental impact and progress toward sustainability. Procurement departments can explore arrangements that recognise ENT’s distinct requirements and pressure suppliers to develop more environmentally friendly materials and purchase packages. Finally, multi-centre collaborations could establish national baseline data and pilot carefully designed waste reduction interventions. Through measured, evidence-based steps, ENT can contribute to healthcare sustainability while maintaining our primary commitment to patient safety.

Conclusions

This first Australian audit quantified substantial plastic waste from paediatric ENT procedures, 1.1–1.5 kg per case, generating 460 kg CO₂ over six months at a single centre. Critically, this waste stems from applying maximum sterile barriers to operative fields where sterility cannot be achieved or maintained. The absence of evidence that such barriers reduce infections in contaminated-field surgery, combined with successful reduced-barrier protocols in analogous specialties, highlights an important opportunity for practice re-evaluation. Professional societies and institutions should support carefully designed trials testing reduced-barrier approaches in ENT, advancing both environmental sustainability and evidence-based practice while maintaining our fundamental commitment to patient safety.

Acknowledgments

We would like to acknowledge the ENT Department of John Hunter Hospital including consultants Dr. Toby Corlette, Prof. Kelvin Kong and Dr. Johnson Huang.

Footnote

Reporting Checklist: The authors have completed the STROBE reporting checklist. Available at https://www.theajo.com/article/view/10.21037/ajo-2025-1-75/rc

Data Sharing Statement: Available at https://www.theajo.com/article/view/10.21037/ajo-2025-1-75/dss

Peer Review File: Available at https://www.theajo.com/article/view/10.21037/ajo-2025-1-75/prf

Funding: None.

Conflicts of Interest: All authors have completed the ICMJE uniform disclosure form (available at https://www.theajo.com/article/view/10.21037/ajo-2025-1-75/coif). The authors have no conflicts of interest to declare.

Ethical Statement: The authors are accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved. The study was approved as a quality improvement audit by the Hunter New England Human Research Department Committee (Approval # 20251016-125). Informed consent was not applicable as no human participants were involved in this study.

Open Access Statement: This is an Open Access article distributed in accordance with the Creative Commons Attribution-NonCommercial-NoDerivs 4.0 International License (CC BY-NC-ND 4.0), which permits the non-commercial replication and distribution of the article with the strict proviso that no changes or edits are made and the original work is properly cited (including links to both the formal publication through the relevant DOI and the license). See: https://creativecommons.org/licenses/by-nc-nd/4.0/.

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