Laryngology Fellowship Guidelines

The American Laryngological Association (ALA), as the senior society representing the subspecialty of laryngology, has developed guidelines for developing and implementing postgraduate training in laryngology. The main focus of these guidelines is to provide a resource for new physicians and residents considering further training in laryngology or for those physicians considering offering a fellowship in advanced training in laryngology. Fellowship directors who have implemented these recommended guidelines for training are invited to provide information about their fellowships to the ALA as outlined below. Information about these fellowship programs will be made available on the association’s website, www.alahns.org.

Laryngology is a subspecialty within Otolaryngology – Head and Neck Surgery encompassing a field of knowledge that deals with disorders of voice, airway and swallowing. The laryngologist has special expertise in the diagnostic and therapeutic approaches to problems in these areas and participates in the advancement of knowledge through clinical and/or basic science research. Laryngology is a recognized area within otolaryngology training programs and further postgraduate fellowship training is an option for those otolaryngologists wishing to further their education in the field.

Specialized postgraduate training in laryngology should allow exposure to the full range of laryngology, recognizing that each program will have different emphases and focus on certain areas more than others. Areas of emphases should include:

1.      Neurolaryngology

2.      Professional voice care

3.      Neoplastic and non-neoplastic diseases of the larynx

4.      Swallowing disorders

5.      Disorders of the upper airway

1.      Is responsible for development and implementation of laryngology fellowship training.

2.      Is responsible for periodic review of the fellowship program to ensure a high-level of training.

3.      Is responsible for periodic review of the fellow(s)’ academic and clinical performance.

1.      May include other otolaryngologists with focused interest in an overlapping area of laryngology.

2.      May include one or more post-graduate speech language pathologists with specific interests in voice disorders and/or swallowing disorders.

C. Other Faculty Responsibilities

1.      Participate in their own continuing education

2.      Participate in regional and national scientific societies

3.      Presentation and publication of scientific studies

4.      Active participation in scholarly activities that pertain to laryngology

5.      Active participation in regularly scheduled clinical discussions, rounds, and conferences to promote the spirit of inquiry and scholarship.

The program course of study should be comprehensive and should provide each fellow with opportunities for progressive management of patients in both the clinical and surgical environments.  Laryngology fellows should have completed a course of study in an ACGME-accredited residency in otolaryngology or the equivalent that has provided a knowledge base in the normal anatomy and physiology of voice and swallowing. More in-depth study of the pathology of voice and swallowing should be addressed in the fellowship curriculum. The program director is responsible for developing a structured curriculum with well-defined goals and objectives. Lines of responsibility must be clearly defined between the laryngology fellow and otolaryngology residents as related to areas of training, clinical responsibilities, and duration of training.

The academic component should provide supplemental education in the basic sciences related to laryngology including speech and rehabilitative sciences, genetics, (neuro)anatomy, (neuro)physiology, (histo)pathology, pharmacology and wound healing. The latter should include laser-tissue interactions with the various lasers used in laryngology. Fellows are expected to participate in periodic laryngology rounds that discuss comprehensive clinical issues, research issues and morbidity and mortality. The curriculum is designed so that upon completion, the fellow will have sufficient background and experience to establish an independent laryngology program at an academic institution.

Techniques in the diagnosis and management of patients with voice, airway and swallowing disorders should be taught to the laryngology fellow either through direct mentorship by the fellowship faculty or through other resources such as didactic learning or attendance at formal courses. Hands-on experience is expected.

Specific areas of training should include the following:

1.      In-office laryngoscopy: rigid transoral and flexible techniques

2.      Laryngeal videostroboscopy and other imaging techniques

3.      Transnasal esophagoscopy

4.      Laryngeal electromyography

5.      Functional endoscopic evaluations of swallowing

6.      Vocal function testing

7.      Correlation of histopathology specimens with the clinical presentations

8.      Imaging studies of the larynx, trachea and esophagus

B.      Interventional / Surgical Training – Indications and Techniques

1.      Phonosurgery for non-neoplastic vocal fold lesions of the lamina propria

2.      Injection laryngoplasty

3.      Medialization laryngoplasty via open approaches

4.      Botox® and surgical treatment for spasmodic dysphonia

5.      Surgical management for neoplastic laryngeal disease

6.      Laser technology for laryngeal and airway disease

7.      Surgical management (open and endoscopic approaches) for airway disorders

8.   Surgical management (open and endoscopic approaches) for swallowing disorders.

1.      Chronic laryngeal pathology

                    i.      Reflux-related

                    ii.      Allergy-related

                   iii.      Infectious and immune-related

2.      Behavioral voice disorders

3.      Neurological voice and speech disorders

4.      Swallowing disorders

D.     Exposure to associated allied professions should be available:

1.      Speech language pathology

                       i.      Voice specialists

                      ii.      Swallowing specialists

2.      Vocal pedagogy

3.      Pulmonary medicine

4.      Gastroenterology

5.      Neurology

1. A single entity should sponsor the laryngology fellowship program. Additional entities may participate in the training with agreement by with  the sponsoring entity.

2. The sponsoring entity should provide sufficient faculty, financial resources, clinical and research support and suitable academic work-space or office. Other educational resources such as a voice laboratory, a testing facility for phonatory and swallowing evaluations and other appropriate diagnostic, therapeutic, and research facilities to meet  the educational needs of a fellow are desirable.

B.     Library

1. Fellows should have access to a major medical library at or near the sponsoring entity.

2. Library services should include access to electronic retrieval services using medical databases. On-site or online journal access should also be available.

A.        Graduate medical education should take place in an environment of inquiry and scholarship in which laryngology fellows participate in the development of new knowledge, learn to evaluate research findings, and develop habits of inquiry as continuing professional responsibility. The faculty should establish and maintain an environment of inquiry and scholarship.

B.        The course of study should include research methodology, preferably not to exceed six months in a one-year program and one year in a two-year program in which there is protected time for pursuit of scholarly activities and research.

A.        The program director, with participation of the faculty, should:

1.         Evaluate each fellow at least semiannually using appropriate criteria and procedures reviewed with the fellow at the beginning of the fellowship period.  The evaluation must be confidential; and it should include observation, assessment, and substantiation of the fellow’s acquired body of knowledge, skills in examination, and patient communication, technical proficiency, professional attitudes and humanistic qualities demonstrated in the clinical setting, consultation skills, patient management, decision-making and critical analysis of clinical situations.

2.         Communicate each evaluation to the fellow in a timely manner and provide feedback on his or her performance, including appropriate counseling and necessary remedial  effort.

3.         Advance fellows to positions of higher responsibility based on evidence of satisfactory progressive scholarship and professional growth.

4.         Provide a final evaluation for each fellow graduating from the program that includes a review of fellow performance during the program. This evaluation should verify that the fellow has demonstrated sufficient professional ability to practice competently and independently. The final record should be part of the fellow’s permanent record maintained at  the institution.

5.         Maintain the record of surgical operative procedures performed by the fellow during the educational program. These records should be submitted to the program director and kept in a permanent file for review as requested.

B.      Faculty Evaluation

All faculty should be evaluated on a regular basis by the fellow(s). This evaluation should include teaching ability and commitment to the educational program, continuing medical education in laryngology, and scholarly contributions in laryngology.

C.     Program Evaluation

There should be evidence of periodic self-evaluation of the program in relation to the educational goals, the needs of the laryngology fellow(s), and the extent to which goals of the fellowship education have been met. Confidential written evaluations by the fellow(s) should be included in this process.

The ALA takes no responsibility in endorsing those fellowships that are listed on the website.  It is expected that fellowship directors who submit their programs for inclusion in the ALA website have voluntarily elected to adhere to the guidelines as described above.