Escape Room Activity to Teach Head and Neck Anatomy
By the end of this activity, learners will be able to: 1. List the major structures located within the carotid sheath, infratemporal fossa, pterygopalatine fossa, and nasal cavity. 2. Define the boundaries of the infratemporal and pterygopalatine fossae and nasal cavity, including the openings that allow for continuity between them. 3. Outline the flow of blood from the arch of the aorta to the nasal cavity. 4. Identify knowledge gaps in understanding complex spaces in the head and neck. 5. Self-reflect on the use of skills necessary for successful team escape room completion.   Health care professional students commonly report having difficulty learning anatomy. They attribute some of this challenge to the following: difficulty visualizing the structures, being overwhelmed by the volume of information, and curricular design issues (e.g., limited time to learn the content and a lack of repeated exposure). Within anatomy, students rank the following areas among the most challenging to master: the head and neck, neuroanatomy, and the pelvis. – These areas contain structures that can be difficult to visualize (due to their small size) and are anatomical regions that are extremely dense in content. Creating novel educational interventions to assist students with mastering these difficult areas could improve the students’ learning experience and their comprehension of the content. To teach head and neck anatomy in an interactive way, dissections and prosections have been used. Weeks and colleagues described a head and neck anatomy curriculum using augmented reality and diagnostic imaging. Other innovative methods to teach this content previously described in the literature include art-based assignments, drawing and body painting, and 3D-printed modeling. Game-based learning, including the use of escape rooms, is occurring more often in health care professional curricula. Escape rooms have been used to teach professional students many topics, including basic concepts in vascular surgery, critical thinking in emergency medicine, and dermatology. They offer an alternative method to challenge students to apply information covered in class and foster teamwork skills while teaching important curricular content. Escape room activities place adult learners in an environment where they can be optimally engaged, requiring self-direction, problem-solving, and goal oriention. As such, escape room activities reflect the major tenets of adult learning theory as adult learners are autonomous and self-directed, interested in learning what is relevant to their personal/professional lives, interested in applying knowledge to solve problems, and goal oriented. While literature exists on the use of escape rooms to teach health care professional students, there is a dearth of research on the use of escape rooms to teach head and neck anatomy. Due to the success of game-based learning and escape rooms in professional education, we explored a head and neck escape room activity as an innovative active learning review tool to help students integrate the anatomical regions while fostering collaboration, problem-solving, and critical thinking.   All methods were approved as a retrospective exempt analysis of a curricular tool by the Institutional Review Board at Rutgers, The State University of New Jersey, on February 29, 2024 (Pro2024000291). Overview The anatomy curricula at Rutgers New Jersey Medical School (NJMS) and Rutgers School of Dental Medicine (RSDM) involved small groups discussing anatomy topics and their clinical relevance. These discussions occurred in a large room where groups could engage with the entire anatomy education team. Discussions were followed by individual and team summative assessments that reinforced learning. Afterwards, students performed dissections using human body donors. We designed the escape room activity as a flipped classroom review session for both RSDM and NJMS students. We ran a pilot of the head and neck escape room for first-year RSDM students as part of their gross anatomy and embryology course (round A). This 16-week course occurred within the first semester of the dental curriculum. Ninety-two students participated in this mandatory activity, which occurred as part of a review session following the students being taught the entire head and neck anatomy curriculum. Round A students had 45 minutes to complete the activity. We next offered the escape room to a cohort of the NJMS students as part of their neurology, psychiatry, and biostatistics course, the last course of the NJMS organ systems–based preclerkship curriculum (round B). Fifty-seven students participated in this optional activity, which occurred as an out-of-class review following the students being taught most of the head and neck anatomy curriculum. The content covered in the escape room was taught at the same level of detail for both the dental and medical students. Based on feedback from round A students and the inclusion of new elements, the time to complete the activity for round B students was increased to 60 minutes. We administered the activity in the anatomy lab at NJMS. The anatomy lab provided space for teams to work through the computer-based elements and to perform the physical challenges (e.g., structure identification on donors). Each team had six students, and all teams ran concurrently each round. Preparation Prior to Activity Before administering the activity, the escape room facilitators (three anatomy faculty and one postdoctoral fellow) discussed how it would flow and individual responsibilities throughout. The facilitators prepared the anatomy lab by identifying donors with clear prosections for the physical challenges, making skulls and pipe cleaners available, and placing a lockbox with prizes inside on each table. Based on posttest results from the pilot activity (round A), we added a physical kit for space construction to each table for round B students to help them visualize the boundaries of the infratemporal and pterygopalatine fossae. ( is a fossae kit construction guide that outlines the preparation of the space construction kits, and features printable templates for the kits. is a sample of a completed construction kit to help students visualize how to assemble the spaces.) Orientation At the start of the activity, an escape room student guide  was read aloud to the students. This guide explained to the students how to get started, general rules, and how to navigate more challenging tasks (e.g., physical space construction). Escape Room Activity Each team of students then navigated through four regions/spaces in the head and neck by working through four PowerPoints: (1) the neck, (2) the infratemporal fossa, (3) the pterygopalatine fossa, and (4) the nasal cavity . The PowerPoints were placed in Canvas (the institutional learning management system) under a newly created module in advance of the activity and remained locked until the activity began to prevent students from looking at them ahead of time. PowerPoints provided the escape room story and contained four knowledge and/or application-level questions that the teams needed to answer correctly to proceed. These questions focused on the boundaries of the spaces and the neurovascular structures within them. The PowerPoints for the infratemporal fossa and pterygopalatine fossa also prompted the students to physically construct the space using the kit on their tables. After completing the PowerPoint on a given space, students also had to complete a physical challenge  that involved the identification of structures on human body donors and skulls and helped to emphasize the continuity between the spaces (e.g., to leave the neck, students identified the arteries of the terminal bifurcation of the external carotid and where they traveled, as the maxillary artery entered the infratemporal fossa, the next space). After successfully completing each physical challenge and escaping that region/space, the teams were presented with part of a combination to unlock the lockbox. If the teams successfully escaped all four spaces in the allotted time, they could enter the code in the lockbox and claim their prize (e.g., bone-shaped pens). Assessment and Evaluation We utilized a mixed-methods analysis to determine the activity's effectiveness in achieving the educational objectives and to garner students’ opinions of it. Ten-question pretests and posttests were given before and after the escape room, respectively ( and ). These tested similar concepts but did not contain the same questions. We had students from other cohorts review the questions and provide feedback prior to their administration. A survey was also given immediately following the escape room for feedback, primarily using a 5-point Likert scale (1 = strongly disagree, 5 = strongly agree ) and open-ended questions . All data were analyzed using SPSS Version 29 (IBM) as indicated in the results.   The anatomy curricula at Rutgers New Jersey Medical School (NJMS) and Rutgers School of Dental Medicine (RSDM) involved small groups discussing anatomy topics and their clinical relevance. These discussions occurred in a large room where groups could engage with the entire anatomy education team. Discussions were followed by individual and team summative assessments that reinforced learning. Afterwards, students performed dissections using human body donors. We designed the escape room activity as a flipped classroom review session for both RSDM and NJMS students. We ran a pilot of the head and neck escape room for first-year RSDM students as part of their gross anatomy and embryology course (round A). This 16-week course occurred within the first semester of the dental curriculum. Ninety-two students participated in this mandatory activity, which occurred as part of a review session following the students being taught the entire head and neck anatomy curriculum. Round A students had 45 minutes to complete the activity. We next offered the escape room to a cohort of the NJMS students as part of their neurology, psychiatry, and biostatistics course, the last course of the NJMS organ systems–based preclerkship curriculum (round B). Fifty-seven students participated in this optional activity, which occurred as an out-of-class review following the students being taught most of the head and neck anatomy curriculum. The content covered in the escape room was taught at the same level of detail for both the dental and medical students. Based on feedback from round A students and the inclusion of new elements, the time to complete the activity for round B students was increased to 60 minutes. We administered the activity in the anatomy lab at NJMS. The anatomy lab provided space for teams to work through the computer-based elements and to perform the physical challenges (e.g., structure identification on donors). Each team had six students, and all teams ran concurrently each round.   Before administering the activity, the escape room facilitators (three anatomy faculty and one postdoctoral fellow) discussed how it would flow and individual responsibilities throughout. The facilitators prepared the anatomy lab by identifying donors with clear prosections for the physical challenges, making skulls and pipe cleaners available, and placing a lockbox with prizes inside on each table. Based on posttest results from the pilot activity (round A), we added a physical kit for space construction to each table for round B students to help them visualize the boundaries of the infratemporal and pterygopalatine fossae. ( is a fossae kit construction guide that outlines the preparation of the space construction kits, and features printable templates for the kits. is a sample of a completed construction kit to help students visualize how to assemble the spaces.)   At the start of the activity, an escape room student guide  was read aloud to the students. This guide explained to the students how to get started, general rules, and how to navigate more challenging tasks (e.g., physical space construction).   Each team of students then navigated through four regions/spaces in the head and neck by working through four PowerPoints: (1) the neck, (2) the infratemporal fossa, (3) the pterygopalatine fossa, and (4) the nasal cavity . The PowerPoints were placed in Canvas (the institutional learning management system) under a newly created module in advance of the activity and remained locked until the activity began to prevent students from looking at them ahead of time. PowerPoints provided the escape room story and contained four knowledge and/or application-level questions that the teams needed to answer correctly to proceed. These questions focused on the boundaries of the spaces and the neurovascular structures within them. The PowerPoints for the infratemporal fossa and pterygopalatine fossa also prompted the students to physically construct the space using the kit on their tables. After completing the PowerPoint on a given space, students also had to complete a physical challenge  that involved the identification of structures on human body donors and skulls and helped to emphasize the continuity between the spaces (e.g., to leave the neck, students identified the arteries of the terminal bifurcation of the external carotid and where they traveled, as the maxillary artery entered the infratemporal fossa, the next space). After successfully completing each physical challenge and escaping that region/space, the teams were presented with part of a combination to unlock the lockbox. If the teams successfully escaped all four spaces in the allotted time, they could enter the code in the lockbox and claim their prize (e.g., bone-shaped pens).   We utilized a mixed-methods analysis to determine the activity's effectiveness in achieving the educational objectives and to garner students’ opinions of it. Ten-question pretests and posttests were given before and after the escape room, respectively ( and ). These tested similar concepts but did not contain the same questions. We had students from other cohorts review the questions and provide feedback prior to their administration. A survey was also given immediately following the escape room for feedback, primarily using a 5-point Likert scale (1 = strongly disagree, 5 = strongly agree ) and open-ended questions . All data were analyzed using SPSS Version 29 (IBM) as indicated in the results.   Round A was the pilot of the escape room with RSDM students, and round B was the modified version for the NJMS students. Student Knowledge Prior to and After the Escape Room Activity Round A students ( N = 92) and round B students ( N = 57) completed both a pretest and posttest. For round A, the pretest average was 69% ( SD = 17%), and the posttest average was 70% ( SD = 19%). A Wilcoxon signed rank test showed that the escape room did not elicit a statistically significant change on posttest scores ( Z = −0.164, p = .87). For round B, the pretest average was 65% ( SD = 22%), and the posttest average was 70% ( SD = 19%). While there was a higher increase in score for round B, a Wilcoxon signed rank test showed that the escape room did not elicit a statistically significant change on posttest scores ( Z = −1.391, p = .16). The pretest and posttest were both scored out of 10 points, and the scores were compared between round A and round B participants to see if there was a significant difference between the two experiences. The average pretest scores between round A and round B were found to not be statistically different using a Mann-Whitney U test ( U = 2,437, p = .46). The average posttest scores between round A and round B were also found to not be statistically different using a Mann-Whitney U test ( U = 2,578, p = .86). The average change in score from the pretest to the posttest was also compared between round A and round B to see if there was a significant difference between the two experiences. While round B students improved 0.42 points on average ( SD = 2.22), which was higher than round A students’ average score increase ( M = 0.01, SD = 2.00), there was no statistically significant difference between the change in scores between the two courses ( t = −1.165, p = .25). Student Opinion Following the conclusion of this escape room, 87 round A students completed the postactivity survey (95% response rate). Most of the attendees (90%) indicated that they enjoyed the activity. If the escape room were run again, 49% of the class indicated they would prefer an entirely physical format, versus 47% of the class who preferred the hybrid format (i.e., with computer and physical elements). Out of those who responded, 72% of the class indicated that the escape room was best used as a review activity, whereas 18% would like to use the activity to learn the content for the first time. Most students also preferred the idea of integrating curriculum-based games into structured class time (83%), versus only 45% responding yes to offering them outside of class time. For round B, 46 students completed the postactivity survey (81% response rate). Most (97%) indicated that they enjoyed the activity. If the escape room activity were run again, 63% indicated that they would prefer the hybrid format, whereas 37% would prefer an entirely physical format. Similar to RSDM students, 72% of the NJMS respondents indicated that the escape room was best used as a review activity, while 24% would like to use the activity to learn the content for the first time. NJMS respondents were indifferent about where to integrate curriculum-based games, with 74% in favor of integrating them into structured class time and 78% in favor of offering them outside of class time. includes additional questions asked on the survey pertaining to enjoyment, utility, and stress. Students were asked to rate statements on a 5-point Likert scale (1 = strongly disagree, 5 = strongly agree ). Selected quotes from an open-ended feedback question on the survey for the round A students are listed below. • “I loved this activity! It was a great way to see what information I had understood and what concepts to go back to expand on. I think we should do these more often to test our knowledge on the information. Was fast, fun, collaborative and helpful!!” • “It was fun, engaging and a great way to integrate all the material.” Selected quotes from an open-ended feedback question on the survey for the round B students are listed below. • “I thought the physical components specifically the boxes helped me visualize where I was!!” • “I think the escape room was especially helpful to understand the courses arteries and nerves take and helped me a lot with spatial reasoning! I think this activity would also be helpful for pelvic anatomy :).” Skill Set includes additional questions asked on the survey about skills the students perceived they were encouraged to use during the activity. Students were asked to rate whether they utilized the skill on a 5-point Likert scale (1 = strongly disagree, 5 = strongly agree ).   Round A students ( N = 92) and round B students ( N = 57) completed both a pretest and posttest. For round A, the pretest average was 69% ( SD = 17%), and the posttest average was 70% ( SD = 19%). A Wilcoxon signed rank test showed that the escape room did not elicit a statistically significant change on posttest scores ( Z = −0.164, p = .87). For round B, the pretest average was 65% ( SD = 22%), and the posttest average was 70% ( SD = 19%). While there was a higher increase in score for round B, a Wilcoxon signed rank test showed that the escape room did not elicit a statistically significant change on posttest scores ( Z = −1.391, p = .16). The pretest and posttest were both scored out of 10 points, and the scores were compared between round A and round B participants to see if there was a significant difference between the two experiences. The average pretest scores between round A and round B were found to not be statistically different using a Mann-Whitney U test ( U = 2,437, p = .46). The average posttest scores between round A and round B were also found to not be statistically different using a Mann-Whitney U test ( U = 2,578, p = .86). The average change in score from the pretest to the posttest was also compared between round A and round B to see if there was a significant difference between the two experiences. While round B students improved 0.42 points on average ( SD = 2.22), which was higher than round A students’ average score increase ( M = 0.01, SD = 2.00), there was no statistically significant difference between the change in scores between the two courses ( t = −1.165, p = .25).   Following the conclusion of this escape room, 87 round A students completed the postactivity survey (95% response rate). Most of the attendees (90%) indicated that they enjoyed the activity. If the escape room were run again, 49% of the class indicated they would prefer an entirely physical format, versus 47% of the class who preferred the hybrid format (i.e., with computer and physical elements). Out of those who responded, 72% of the class indicated that the escape room was best used as a review activity, whereas 18% would like to use the activity to learn the content for the first time. Most students also preferred the idea of integrating curriculum-based games into structured class time (83%), versus only 45% responding yes to offering them outside of class time. For round B, 46 students completed the postactivity survey (81% response rate). Most (97%) indicated that they enjoyed the activity. If the escape room activity were run again, 63% indicated that they would prefer the hybrid format, whereas 37% would prefer an entirely physical format. Similar to RSDM students, 72% of the NJMS respondents indicated that the escape room was best used as a review activity, while 24% would like to use the activity to learn the content for the first time. NJMS respondents were indifferent about where to integrate curriculum-based games, with 74% in favor of integrating them into structured class time and 78% in favor of offering them outside of class time. includes additional questions asked on the survey pertaining to enjoyment, utility, and stress. Students were asked to rate statements on a 5-point Likert scale (1 = strongly disagree, 5 = strongly agree ). Selected quotes from an open-ended feedback question on the survey for the round A students are listed below. • “I loved this activity! It was a great way to see what information I had understood and what concepts to go back to expand on. I think we should do these more often to test our knowledge on the information. Was fast, fun, collaborative and helpful!!” • “It was fun, engaging and a great way to integrate all the material.” Selected quotes from an open-ended feedback question on the survey for the round B students are listed below. • “I thought the physical components specifically the boxes helped me visualize where I was!!” • “I think the escape room was especially helpful to understand the courses arteries and nerves take and helped me a lot with spatial reasoning! I think this activity would also be helpful for pelvic anatomy :).”   includes additional questions asked on the survey about skills the students perceived they were encouraged to use during the activity. Students were asked to rate whether they utilized the skill on a 5-point Likert scale (1 = strongly disagree, 5 = strongly agree ).   We developed this head and neck escape room activity as a review tool with the hope that the activity would be engaging and help the students accomplish the following: identify gaps in their knowledge, organize the anatomy of small spaces in the head and neck, appreciate how the spaces interconnect with one another, and foster critical thinking and problem-solving. Our findings demonstrate that we were successful in accomplishing our goal. Student perceptions in the postsurvey indicated that the students felt the escape room was an enjoyable and helpful review tool and study aid. Students also felt the activity required them to collaborate with their peers, problem-solve, and think critically. Research on anatomy escape rooms employed in other health professions curricula and medical curricula has featured similar reports of student enjoyment. In other health professions curricula, escape rooms have been shown to increase problem-solving and critical thinking skills. Our positive student perceptions could be partially attributed to the pedagogical approach. Medical students have reported that the use of think-pair-share activities in flipped classroom sessions enhances their learning and is a good use of their time. Flipped classroom is where students review the relevant content before class and then spend class time applying that information through various activities. Think-pair-share is where students (1) are posed a question, (2) think independently, (3) partner and discuss with a peer, and then (4) discuss with the class/larger group. The escape room included elements of flipped classroom and active learning (i.e., think-pair-share). Students came to the activity having already been taught the anatomy related to the head and neck spaces and were required to apply that knowledge to navigate the challenges within teams. Students discussed the challenges/questions amongst themselves to solve them. The challenges/questions had defined discrete answers and fostered sharing and collaboration amongst team members. After running the pilot of the activity with the round A students, we learned a great deal, which we then used to make adjustments for round B, including the total time offered, facilitator-to-student ratio, and coverage of the space boundaries. Round A students were given 45 minutes to complete the activity but rushed through elements due to time pressure. For the round B experience, we increased the time to 60 minutes in order to reduce rushing. In round A, numerous teams were waiting to perform the physical challenges with facilitators. Having a facilitator-to-student ratio of 1:12 (or one facilitator for every two teams) is closer to optimal based upon our experience, and we ran the round B escape room with this ratio. Though round A student perceptions were very favorable, the activity did not improve posttest performance (improvement on posttest of only 0.11%, not statistically significant). When we reviewed the posttest questions with the highest level of difficulty, it was apparent that students were still not able to name the boundaries of the infratemporal and pterygopalatine fossae. For the round B escape room, we added the space construction activity to aid with this spatial orientation. Though there was a greater percentage of improvement on the round B posttest (4.21%), it still was not statistically significant. After two iterations of the activity, we would improve the space construction kit instructions as students commonly made procedural errors when trying to assemble the cardboard spaces. When reviewing the escape room student guide before the start of the activity, more time should be spent explaining how to construct the spaces. As part of the instructions, a sample box should be built, allowing the students to visualize the final product and how to approach it . Though a helpful review tool and study aid, this resource also has some limitations. These limitations include its focus on specific head and neck regions, significant resource requirements, pretest/posttest discrepancies, and PowerPoint functionality. The activity requires significant resources, including the time to make the components, the number of faculty to help facilitate the sessions, the budget for supplies, and finding the time for the students to complete the activity within their schedule. Student perceptions of the activity are that it is useful as a review but would not be as useful in learning the content for the first time. Thus, additional class time or a separate session would be needed. The 10 knowledge questions on the pretest and posttest covered similar concepts but were not the same. Numerous students reported to the facilitators after the activity that the posttest was a harder assessment than the pretest. Lastly, the PowerPoints that tell the escape room story do not penalize teams for the selection of incorrect answers. This may lead to some teams clicking quickly through the PowerPoint and not having robust discussion around the questions. We will continue to explore escape rooms as a learning tool for students at NJMS. Examples of future directions include facilitating an entirely physical escape room activity as a follow-up to the hybrid one. Being completely immersed in a space may allow the students to better appreciate its boundaries and lead to better learning outcomes. Additional future directions include exploring team dynamics and peer evaluation, as well as other anatomical topics/regions known to be difficult for students, including the pelvis, neuroanatomy, and embryology.   Fossae Kit Construction Guide.docx Space Boundary Templates.pptx Sample Assembled Space Kit.pdf Escape Room Student Guide.docx Head and Neck Escape Room PP 1.pptx Head and Neck Escape Room PP 2.pptx Head and Neck Escape Room PP 3.pptx Head and Neck Escape Room PP 4.pptx Physical Challenges 1-4.docx Escape Room Pretest.docx Escape Room Posttest.docx Escape Room Survey.docx All appendices are peer reviewed as integral parts of the Original Publication.   