Introduction
The digitalisation of medical education has fundamentally transformed how surgical skills are acquired and disseminated. Over the past decade, video-based learning (VBL) has emerged as an indispensable component of surgical training, offering trainees the opportunity to observe operative techniques repeatedly, at their own pace and independent of institutional resources.Reference Mao, Teichroeb, Lee, Wong, Pang and Pleass1, Reference Mota, Carvalho, Carvalho-Dias, João Costa, Correia-Pinto and Lima2 A systematic review by Youssef et al. demonstrated that VBL improved surgical performance in 17 of 22 evaluated studies, underscoring its efficacy as a pedagogical supplement across multiple disciplines.Reference Youssef, Aydin, Canning, Khan, Ahmed and Dasgupta3
YouTube, with more than 2.56 billion active users as of 2024, constitutes the world’s largest freely accessible repository of surgical video content.Reference Pavuloori, Lin and Mi4 Surgeons and residents worldwide routinely consult this platform when preparing for specific procedures or seeking to refine their operative technique. Studies report that up to 90 per cent of surgeons use online video content for surgical preparation, with YouTube being the preferred platform.Reference Rapp, Healy, Charlton, Keith, Rosenbaum and Kapadia5 However, the open-access nature of YouTube means that any individual or institution may upload content without peer review, formal quality control or adherence to established educational standards.Reference Shabli, Heuermann, Leffers, Kriesche, Abrams and Yilmaz6 As a result, the educational quality of surgical videos on this platform is highly variable and frequently inadequate.
The absence of a standardised, specialty-specific quality assessment tool for otolaryngological surgical videos long hampered systematic evaluation efforts. The LAParoscopic surgery Video Educational GuidelineS (LAP-VEGaS) classification, originally developed for laparoscopic procedures, has been applied in otolaryngology studies, but its non–specialty-specific criteria limit its applicability.Reference Celentano, Smart, McGrath, Cahill, Spinelli and Obermair7 To address this gap, the Young Otolaryngologists of the International Federation of Otorhinolaryngological Societies (YO-IFOS) established the IVORY guidelines (Instructional Videos in Otorhinolaryngology by YO-IFOS) in 2021 via a three-round Delphi consensus process involving 27 international experts, reaching agreement on 28 propositions covering ethics, technical aspects, case presentation, surgical procedure and organ-specific recommendations for educational otolaryngological videos.Reference Simon, Peer, Michel, Bruce, Cherkes and Denoyelle8
Building upon the IVORY framework, Mayer et al. introduced the IVORY Grading System (IVORY-GS) — the first systematic adaptation of the IVORY guidelines into a quantitative scoring tool — and applied it to parotidectomy videos on YouTube.Reference Mayer, Isik, Nachtsheim, Wolber, Hansen and Grosheva9 Subsequent studie have validated and extended this approach across a growing range of otolaryngological procedures, including stapedotomy, tympanoplasty, septoplasty, cholesteatoma surgery, endoscopic endonasal dacryocystorhinostomy and endoscopic endonasal approaches.Reference Yıldırım and Ozdilek10–Reference De La Torre, Joe and Lee14 Collectively, these studies have consistently demonstrated that the majority of procedure-specific surgical videos on YouTube fail to meet satisfactory educational standards.
Given the clinical importance of tracheostomy and the central role YouTube plays in contemporary surgical training, the educational quality of tracheostomy videos on this platform warrants systematic investigation. To the best of our knowledge, no study has yet applied the IVORY-GS or any otolaryngology-specific quality assessment tool to tracheostomy surgical videos. Accordingly, the primary objectives of the present study are twofold: first, to systematically evaluate the educational quality of tracheostomy videos available on YouTube using a modified version of the IVORY-GS modified to the procedural steps of open surgical tracheostomy; and second, to determine the statistical correlation between the cumulative IVORY-GS scores and video engagement metrics (views, likes, duration and video age) in order to establish the external validity of the assessment tool.
Materials and methods
This cross-sectional descriptive study was conducted following the methodological framework of prior IVORY-GS publications.Reference Mayer, Isik, Nachtsheim, Wolber, Hansen and Grosheva9–Reference Kilictas, Birinci and Erdivanlı11 A systematic YouTube search was performed in May 2025 using a cache-cleared browser to minimise algorithmic personalisation. The following search terms were queried independently: “tracheotomy,” “tracheostomy,” “tracheostomy surgery,” and “open tracheostomy,”. This study was exempt from institutional ethical committee review, as it exclusively analysed publicly accessible online video content and involved no human subjects, patient data or identifiable personal information.
Videos were included if they demonstrated a complete or near-complete open surgical tracheostomy performed on a human patient or cadaveric specimen and were intended for surgical education. Videos were excluded if they: (i) consisted of animation, lectures or simulation without live operative footage; (ii) demonstrated percutaneous dilatational tracheostomy (PDT), which will be addressed separately; (iii) depicted only a single operative step without showing the full procedure; (iv) featured patient testimonials, post-operative–care briefings without intra-operative content. The final sample size of 39 videos reflected the restrictive inclusion criterion requiring complete or near-complete operative footage, consistent with prior IVORY-GS publications. No a priori power calculation was performed, as this study did not test a primary hypothesis but rather aimed at descriptive quality characterisation.
The following variables were extracted for each video using a standardised form: view count, like count, video duration (minutes), upload date (converted to video age in months), uploader identity (individual vs. institutional), clinical specialty of the producer (otorhinolaryngology, general surgery, emergency medicine, etc.) and country of origin. As YouTube discontinued public access to dislike counts in November 2021, the likes/dislikes ratio was not computable and was excluded from all analyses.
The IVORY guidelines were established via international Delphi consensus to standardise the evaluation of educational surgical videos in otolaryngology.Reference Simon, Peer, Michel, Bruce, Cherkes and Denoyelle8 Four items were removed from Sections A–D of the original IVORY-GS framework and redesigned Section E to reflect the specific operative anatomy, sequential surgical steps and clinical decision points unique to open surgical tracheostomy. The following items were excluded from the scoring system on the basis of inapplicability or non-verifiability in the YouTube context, consistent with prior IVORY-GS modifications: (i) Item 9, peer review prior to publication (no formal peer-review mechanism exists for YouTube uploads); (ii) Item 12, pre-operative imaging workup (imaging is generally not necessary for tracheostomy.); (iii) Item 15, endoscope specifications (open tracheostomy does not routinely involve endoscopic instrumentation); and (iv) Item 17, pathological specimen identification (no specimen is retrieved during standard tracheostomy).
Section E was redesigned with seven tracheostomy-specific criteria addressing: (16) explicit statement of the tracheostomy indication; (17) specification of skin incision type with rationale; (18) tracheostomy tube type and size specified, with demonstration of correct tracheal placement; (19) tracheal incision level and shape clearly shown; (20) management of the thyroid isthmus demonstrated; (21) stoma fixation method and suture technique shown; and (22) tracheostomy tube securing method demonstrated. The seven tracheostomy-specific criteria comprising the redesigned Section E were derived through a structured review of the tracheostomy complication litreature rather than arbitrary selection. Each criterion was mapped to a discrete operative decision point documented as a primary determinant of procedure-related adverse events in published complication analyses. Specifically, criteria addressing tracheal incision level, thyroid isthmus management, tube type and size specification and stoma fixation technique were selected on the basis of their established associations with hemorrhage, false passage formation and accidental decannulation — the three most clinically consequential complications of open surgical tracheostomy.Reference Erickson, Katta, Sun, Shan, Lemeshow and Schofield15, Reference Umstot, Samanta, Umstot, Area, Richmond and Jarrouj16 The criterion requiring explicit statement of the tracheostomy indication was included to reflect the multidisciplinary authorship of YouTube tracheostomy content and the recognised importance of indication-specific decision-making in reducing procedure-related morbidity, as corroborated by large-scale national database analyses demonstrating that indication category is an independent predictor of complication incidence.Reference Strober, Kallogjeri, Piccirillo and Rohlfing17
The modified IVORY-GS comprised 22 items across five sections. Each item was scored on a three-point Likert scale: 0 (non-compliant), 1 (partially compliant) or 2 (fully compliant), yielding a maximum total score of 44 points. Total scores were categorised into academic grades according to the US grading system. Two experienced otorhinolaryngologists (F.A., 7 years of specialist; A.U.K., 4 years of specialist) independently evaluated all included videos using the modified IVORY-GS. Each evaluator assessed videos at separate sittings, blinded to the other’s scores. In cases of discordant ratings (defined as a difference of one or more points on any item), a consensus score was reached through comprehensive discussion between both evaluators.
Data analysis was conducted using SPSS version 26.0 (IBM Corp., Armonk, NY, USA). The normality of variable distribution was assessed with the Shapiro–Wilk test. Relationships between non-normally distributed continuous variables were evaluated using Spearman’s rank correlation analysis. Comparisons between two independent groups for non-parametric continuous variables were performed using the Mann–Whitney U-test. Statistical significance was determined within a 95 per cent confidence interval, and a p-value below 0.05 was considered statistically significant.
Results
Characteristics of the included videos
Of the 39 videos fulfilling the inclusion criteria, the median duration was 5.7 minutes (interquartile range [IQR]: 3.5–8.3; range: 1.7–23.5). Forty-six percent of videos were under 5 minutes and 43.6 per cent between 5 and 10 minutes. The median view count was 4,666 (IQR: 303–32,902) and the median like count was 60 (IQR: 8–254). Median video age at the time of the search was 47.5 months (IQR: 18.6–75.9). The majority of videos were uploaded by individual creators (n = 28; 71.8 per cent), with institutional channels accounting for 28.2 per cent (n = 11). Otorhinolaryngologists constituted the largest producer group (n = 20; 51.3 per cent), followed by national surgical academies (n = 5; 12.8 per cent) and producers of unknown specialty (n = 4; 10.3 per cent); the remaining 25.6 per cent comprised emergency medicine physicians, general surgeons, anesthesiologists, paediatric surgeons and maxillofacial surgeons. India was the predominant country of origin (n = 18; 46.2 per cent), followed by the United States (n = 8; 20.5 per cent), Italy (n = 3; 7.7 per cent) and other countries (Table 1).
Characteristics of the included YouTube tracheostomy videos (n = 39)
Table 1 Long description
Variables are summarized with two columns, Median with interquartile range and Mean plus or minus standard deviation. View count shows a median of 4,666 with an interquartile range from 303 to 32,902, and a mean of 66,187 with a standard deviation of 136,863. Like count shows a median of 60 with an interquartile range from 8 to 254, and a mean of 636.3 with a standard deviation of 1,545.1. Video duration in minutes shows a median of 5.7 with an interquartile range from 3.5 to 8.3, and a mean of 6.4 with a standard deviation of 4.2. Video age in months shows a median of 47.5 with an interquartile range from 18.6 to 75.9, and no mean value is provided. Ivory gs total score shows a median of 20.0 with an interquartile range from 13.5 to 29.0, and a mean of 21.7 with a standard deviation of 8.9.
Abbreviations: IVORY-GS, Instructional Videos in Otorhinolaryngology Grading System; IQR, interquartile range; SD, standard deviation.
IVORY-GS scores
The modified IVORY-GS had a maximum achievable total score of 44 points. The mean total score across all included videos was 21.7 ± 8.9 (median: 20.0; IQR: 13.5–29.0; range: 8–39). The highest individual score recorded was 39 and the lowest was 8.
When total scores were categorised according to the US academic grading system, no video achieved Grade A (total score ≥ 40). Only three videos (7.7 per cent) attained Grade B (high educational quality; score 35–39). Grade C (moderate quality; score 31–34) was achieved by four videos (10.3 per cent), and Grade D (low quality; score 27–30) by five videos (12.8 per cent). The large majority, 27 videos (69.2 per cent), were classified as Grade F, indicating insufficient educational quality (score < 27). Collectively, only three videos (7.7 per cent) demonstrated moderate-to-high educational quality (Grade A–B). The distribution of scores according to academic grades is presented in Table 2.
Distribution of tracheostomy videos according to IVORY-GS total score and academic grades (n = 39)
Table 2 Long description
Grades are listed with percent range, total score range out of 44, frequency in videos, and percent of videos. Grade A covers 90 to 100 percent and total scores 40 to 44, with 0 videos and 0.0 percent. Grade B covers 80 to 89 percent and total scores 35 to 39, with 3 videos and 7.7 percent. Grade C covers 70 to 79 percent and total scores 31 to 34, with 4 videos and 10.3 percent. Grade D covers 60 to 69 percent and total scores 27 to 30, with 5 videos and 12.8 percent. Grade F covers less than 60 percent and total scores less than 27, with 27 videos and 69.2 percent.
Section-level performance
Section-level analysis demonstrated considerable variation in educational quality across the five domains of the modified IVORY-GS (Table 3). Section A (Ethics) achieved the highest proportional score, with a mean of 5.74 ± 0.94 out of a possible six points (95.7 per cent), indicating near-universal compliance with ethical standards. Section B (Technical Aspects) attained a mean of 5.64 ± 2.69 out of 10 (56.4 per cent). Section C (Case Presentation) recorded a mean of 1.62 ± 1.23 out of 4 (40.4 per cent). Section D (Surgical Procedure) yielded the lowest proportional score of any section, with a mean of 2.64 ± 2.99 out of 10 (26.4 per cent), accompanied by the widest variability observed across all sections (median: 2.0; IQR: 0.0–4.5). Section E (Organ-Specific Tracheostomy Criteria) recorded a mean of 6.10 ± 3.93 out of 14 (43.6 per cent).
Section-level IVORY-GS Scores across all included videos
Table 3 Long description
Ivory gs scores are summarized by section using Max Score, Mean plus or minus SD, Median with IQR, and percent achieved. Ethics had a max score of 6, mean 5.74 with SD 0.94, median 6.0 with IQR 6.0 to 6.0, and 95.7% achieved. Technical Aspects had a max score of 10, mean 5.64 with SD 2.69, median 5.0 with IQR 4.0 to 7.5, and 56.4% achieved. Case Presentation had a max score of 4, mean 1.62 with SD 1.23, median 1.0 with IQR 1.0 to 2.0, and 40.4% achieved. Surgical Procedure had a max score of 10, mean 2.64 with SD 2.99, median 2.0 with IQR 0.0 to 4.5, and 26.4% achieved. Organ Specific Tracheostomy had a max score of 14, mean 6.10 with SD 3.93, median 6.0 with IQR 3.0 to 9.0, and 43.6% achieved. Total had a max score of 44, mean 21.7 with SD 8.9, median 20.0 with IQR 13.5 to 29.0, and 49.3% achieved.
Shapiro–Wilk testing confirmed non-normal distribution of total scores (W = 0.932; p = 0.021) and view counts (W = 0.535; p < 0.001); Spearman’s correlation was applied accordingly. Statistically significant positive correlations were identified between the IVORY-GS total score and both view count (p = 0.012) and like count (p = 0.001). No significant associations were observed with video duration (p = 0.262) or video age (p = 0.219) (Table 4).
Spearman correlation between IVORY-GS total score and video characteristics (n = 39)
Table 4 Long description
Spearman correlation results relate IVORY-GS total score to four video characteristics, with columns for Spearman rho and p-value. View count has Spearman rho 0.399 and p-value 0.012 with an asterisk marker. Like count has Spearman rho 0.498 and p-value 0.001 with an asterisk marker. Video duration in minutes has Spearman rho 0.184 and p-value 0.262. Video age in months has Spearman rho 0.201 and p-value 0.219.
* p < 0.05. Values in green shading indicate statistically significant results.
Regarding geographic origin, the single video from Australia achieved the highest country-level median (38.0), followed by Greece (30.0) and Egypt (25.0). India-originated videos (n = 18), which constituted the largest subgroup, recorded a median score of 18.5. Videos produced in the United States (n = 8) had a median of 19.0. The lowest country-level median was observed for Bangladesh (11.0) (Fig. 1).
IVORY-GS median scores and interquartile ranges by country of origin (n = 39 videos). Countries with n = 1 have no IQR. Shaded zones correspond to academic grade categories (F, D, C, B/A). IVORY-GS, Instructional Videos in Otorhinolaryngology Grading System.
Figure 1 Long description
The x-axis is labeled, IVORY-GS Total Score (maximum: 44 points). The x-axis ranges from 0 to 44. The y-axis lists countries with sample sizes: Australia (n equals 1), Greece (n equals 1), Egypt (n equals 2), Brazil (n equals 2), Italy (n equals 3), USA (n equals 8), India (n equals 18), Pakistan (n equals 1), Turkiye (n equals 1), Bangladesh (n equals 1). A vertical dashed line is labeled, Cohort median (20). Australia (n equals 1) shows a single dot at 38. Greece (n equals 1) shows a single dot at 30. Egypt (n equals 2) shows a dot at 25 with a horizontal interquartile range bar spanning 20 to 30. Brazil (n equals 2) shows a dot at 22 with a horizontal interquartile range bar spanning 21 to 23. Italy (n equals 3) shows a dot at 20 with a horizontal interquartile range bar spanning 18 to 22. USA (n equals 8) shows a dot at 19 with a horizontal interquartile range bar spanning 15 to 30. India (n equals 18) shows a dot at 18 with a horizontal interquartile range bar spanning 12 to 25. Pakistan (n equals 1) shows a single dot at 14. Turkiye (n equals 1) shows a single dot at 13. Bangladesh (n equals 1) shows a single dot at 11. Legend items shown: Interquartile range (IQR), Median IVORY-GS score, Overall cohort median (20).
Discussion
YouTube has become the world’s most widely accessed surgical video repository, used by the majority of surgeons and residents for pre-operative preparation.Reference Rapp, Healy, Charlton, Keith, Rosenbaum and Kapadia5 Its open-access architecture, however, imposes no peer review, credentialing requirements or minimum educational standards for uploaded content, resulting in a landscape of highly variable and frequently inadequate surgical instruction.Reference Javidan, Nelms, Li, Lee, Zhou and Kayssi18 The LAP-VEGaS classification was developed to address this gap in laparoscopic surgery and has since been applied in several otolaryngological video analyses.Reference Celentano, Smart, McGrath, Cahill, Spinelli and Obermair7 However, LAP-VEGaS criteria were designed for laparoscopic procedures and lack the organ-specific components — anatomical landmarks, subspecialty-relevant instrumentation and procedure-specific safety considerations — that characterise otolaryngological surgery. Recognising this limitation, the YO-IFOS established the IVORY guidelines through a structured international Delphi consensus, providing the first specialty-specific framework for evaluating educational surgical videos in otorhinolaryngology.Reference Simon, Peer, Michel, Bruce, Cherkes and Denoyelle8 Subsequently, the IVORY Grading System (IVORY-GS) was modified and applied in numerous studies, collectively contributing to its establishment as a standardised quality assessment tool for educational otorhinolaryngology video content.Reference Mayer, Isik, Nachtsheim, Wolber, Hansen and Grosheva9–Reference Kilictas, Birinci and Erdivanlı11
The IVORY guidelines acknowledge that Section E — the organ-specific component — must be tailored to the anatomical and procedural demands of each evaluated operation. For tracheostomy, the original Section E is not applicable, as it addresses otology and rhinology-specific recommendations irrelevant to airway surgery. The redesigned Section E introduces tracheostomy-specific criteria reflecting the unique operative demands of the procedure. These criteria were selected because they represent the operative decisions most directly linked to tracheostomy complications, including hemorrhage, false passage and accidental decannulation.Reference Erickson, Katta, Sun, Shan, Lemeshow and Schofield15, Reference Umstot, Samanta, Umstot, Area, Richmond and Jarrouj16 The resulting 22-item, 44-point instrument constitutes, to our knowledge, the first validated IVORY-GS modified for tracheostomy and extends the instrument’s procedural scope into the multidisciplinary domain of airway surgery.
The overall educational quality of tracheostomy videos on YouTube, as reflected in our findings, is consistent with — and, in the Surgical Procedure domain, lower than — all prior IVORY-GS publications. Across parotidectomy, stapedotomy and tympanoplasty series, 60–70 per cent of videos fall into the lowest quality category; our cohort yields a comparable proportion.Reference Mayer, Isik, Nachtsheim, Wolber, Hansen and Grosheva9–Reference Kilictas, Birinci and Erdivanlı11 This cross-procedural convergence confirms that poor YouTube educational quality is a platform-level phenomenon rather than a procedure-specific finding. What distinguishes the tracheostomy data from prior series is the exceptional underperformance of the Surgical Procedure section — the lowest proportional score across all published IVORY-GS studies. The near-complete absence of take-home messages and surgical risk communication reflects a systematic failure to translate operative footage into structured educational content, a pattern documented in cholesteatoma surgery,Reference Wu, Knoll, Bouhadjer, Remenschneider and Kozin12 neck dissection,Reference Luu, Yver, Douglas, Tasche, Thakkar and Rajasekaran19 and thyroidectomy analyses,Reference Sunba, Levin, Wu and Campisi20 confirming that this is a field-wide rather than tracheostomy-specific shortcoming. The critical deficiencies in clinical indication, isthmus management and tube placement confirmation in the organ-specific section are more contextually distinctive: they reflect the multidisciplinary authorship of tracheostomy content, where producers from non-surgical specialties are less likely to present the procedure with the anatomical and decision-making depth expected in otolaryngological education. The significant association between IVORY-GS scores and video engagement metrics is consistent with findings in the parotidectomy and tympanoplasty series,Reference Mayer, Isik, Nachtsheim, Wolber, Hansen and Grosheva9, Reference Kilictas, Birinci and Erdivanlı11 yet the modest explanatory power of this relationship reaffirms that popularity metrics cannot substitute for validated quality instruments as educational filters, and that trainees must be explicitly cautioned against using view counts or like counts as surrogates for instructional quality.Reference Pavuloori, Lin and Mi4, Reference Javidan, Nelms, Li, Lee, Zhou and Kayssi18
Systematic evidence confirms that video-based learning can improve surgical performance when content meets minimum quality thresholds,Reference Mao, Teichroeb, Lee, Wong, Pang and Pleass1 and YouTube remains the most accessible pre-operative preparation resource for the majority of residents and surgeons worldwide.Reference Rapp, Healy, Charlton, Keith, Rosenbaum and Kapadia5 For tracheostomy — a procedure associated with a complication burden approaching one-third of casesReference Erickson, Katta, Sun, Shan, Lemeshow and Schofield15, Reference Umstot, Samanta, Umstot, Area, Richmond and Jarrouj16 — the stakes of this educational reliance are particularly high. A trainee who prepares for tracheostomy using YouTube content of the quality documented in our analysis encounters material that, in most cases, provides no indication rationale, no risk communication and no post-operative guidance. The pedagogical consequence is a trainee who has observed the operative sequence but lacks the clinical reasoning, situational awareness and complication-management knowledge required for safe independent performance. This gap is further amplified by the multidisciplinary management of tracheostomised patients: post-operative stoma care is routinely delegated to nurses, respiratory therapists and non-surgical physicians, yet the absence of post-operative instructional content in the analysed videos extends the educational deficit well beyond the operating room.Reference Umstot, Samanta, Umstot, Area, Richmond and Jarrouj16 The development of peer-reviewed, societally endorsed tracheostomy video curricula represents a concrete and immediately implementable step toward closing this gap, and the IVORY-GS adaptation introduced in the present study provides a procedure-validated instrument for quality benchmarking in this effort.
Several specialty-specific initiatives are actively working to address the deficiencies of unregulated platforms such as YouTube. The Journal of Laryngology and Otology maintains a curated surgical video library, freely accessible via its dedicated Vimeo channel, featuring operative content across the breadth of otolaryngological surgery produced in alignment with editorial standards — a model that directly addresses the absence of peer review that characterises most YouTube tracheostomy content identified in the present study. Similarly, ENT on Air (entonair.com) has emerged as a dedicated global online education platform for otolaryngology, offering live surgical demonstrations with expert commentary, on-demand procedural content and structured subspecialty educational resources — features conspicuously absent from the majority of videos analysed in this study. Platforms such as Headmirror, which operates a peer-reviewed open-access surgical video atlas with subspecialty expert review prior to publication, and CSurgeries, which hosts peer-reviewed otolaryngological operative videos with accompanying structured commentary, further represent the trajectory toward quality-controlled dissemination of surgical educational content. Taken together, these emerging resources demonstrate that the limitations of YouTube as an educational platform are not inherent to online video-based surgical education but are specific to the absence of gatekeeping mechanisms — and that viable, scalable specialty-endorsed alternatives are already available and merit active promotion within ENT residency training programmes.
This study has several limitations. YouTube’s dynamic content inventory constrains reproducibility, partially mitigated by a fixed search date and cache-cleared browser. Percutaneous dilatational tracheostomy was excluded due to its distinct technical approach and warrants a separate dedicated analysis. YouTube’s removal of the public dislike counter in November 2021 precluded calculation of the likes/dislikes ratio, a metric identified as a strong quality correlate in prior IVORY-GS publications.Reference Mayer, Isik, Nachtsheim, Wolber, Hansen and Grosheva9 The instrument evaluates educational presentation quality but does not assess the technical accuracy or evidence-currency of demonstrated techniques. Finally, small subgroup sizes in specialty and geographic strata limit inferential comparison; those findings should be interpreted as descriptive and hypothesis-generating.
What is already known:
• YouTube is the most widely accessed open-access platform for surgical video education globally, yet its content is entirely unregulated and lacks mandatory peer review or quality thresholds
• The IVORY Grading System (IVORY-GS) is an established, Delphi-derived instrument for assessing the educational quality of otolaryngological surgical videos, previously validated for parotidectomy, tympanoplasty, stapedotomy and septoplasty
What this paper adds:
• This study provides the first systematic evaluation of open surgical tracheostomy videos on YouTube using a procedure-adapted IVORY-GS, introducing a validated, 22-item, 44-point scoring instrument specifically modified for tracheostomy
• The large majority (69.2 per cent) of freely available tracheostomy videos were classified as Grade F (insufficient educational quality), with the Surgical Procedure section recording the lowest proportional score across all assessed domains
• Higher IVORY-GS scores were significantly associated with greater view and like counts, yet the modest explanatory power of this association confirms that engagement metrics are insufficient surrogates for educational quality in online tracheostomy content
Conclusion
The present study demonstrates that the large majority of tracheostomy videos freely accessible on YouTube fail to meet minimum educational quality standards, with the most critical deficiencies concentrated in the domains of surgical risk communication, procedural contextualisation and organ-specific technical completeness. The tracheostomy-modified IVORY-GS introduced here constitutes the first validated procedure-specific scoring instrument for this operation and provides a directly applicable benchmark for content producers, educators and professional societies. In the era of competency-based surgical training, the development of peer-reviewed, standardised and educationally complete surgical video resources for tracheostomy is not a peripheral academic concern — it is a patient safety imperative.
Artificial intelligence (AI)-assisted language tools were used solely for grammatical editing and linguistic refinement of this manuscript. All scientific content, data interpretation and conclusions are the sole responsibility of the authors.
Funding
No funding was received for this study.
Competing interests
The authors declare no conflict of interest.
Ethics approval
This article does not contain any studies with human participants or animals. This material has never been published and is not currently under evaluation in any other peer-reviewed publication.
