Residency versus Fellowship in Otolaryngology: What is Practiced and Referred after Graduation?

Two studies presented at recent Triological Society meetings, both of which surveyed former otolaryngology residents about current otolaryngology surgical training and postgraduate practice and referrals, shed light on the direction in which the specialty’s training may need to move.

What Is Taught and What Is Practiced?

A study conducted by a University of Cincinnati team that included Christopher R. Savage, MD, Robert W. Keith, PhD, and Myles L. Pensak, MD, aimed to determine the most common otologic and neurotologic procedures performed after completion of otolaryngology residency. Savage et al.1 distributed an Internet survey to 128 alumni trained within the past 25 years and received 70 responses (54.7%). The findings revealed that a majority of former graduates performed external ear incision and drainage (abscess/hematoma), excision of soft tissue external canal lesion, ventilation tube placement, tympanoplasty/ossiculoplasty, and mastoidectomy. Twenty-two performed stapedectomies/stapedotomies. A smaller number performed more complex procedures, including excision of glomus tumors, lateral temporal bone resection, and implantation or revision of bone-anchored hearing aids.

In contrast, mostly fellowship-trained neurotologists performed more advanced procedures, including labyrinthectomy, endolymphatic sac procedure, cochlear implant, facial nerve decompression, acoustic neuroma surgery, and vestibular nerve section.

The investigators concluded that despite demographics supporting increased interest in fellowship training and subspecialty practice, most otolaryngologists continue to perform basic otologic procedures taught during residency. Complex cases, revision cases, and neurotologic procedures, however, are more likely to be performed by fellowship-trained otolaryngologists.

Dr. Pensak, the H. B. Broidy Professor and Chair of Otolaryngology-Head and Neck Surgery and Professor of Neurosurgery at the University of Cincinnati Health Sciences Center, said that residency programs generally include standard cases-such as tympanoplasty, tympanomastoidectomy, and ossiculoplasty-in core training; however, the nature and faculty of each program will dictate program variations.

For instance, at the University of Cincinnati, training has historically included endolymphatic shunt surgery, cochlear implant, and labyrinthectomy. Dr. Pensak said he was a bit surprised to discover from his study’s survey data that those procedures are now primarily being performed by fellowship-trained physicians.

That being said, we have always enthusiastically endorsed that our residency program trains people to go into the community, and we felt and continue to feel that it is vitally important that these residents are broadly trained to deal with common ear disease problems of a surgical nature.

Implications for Treatment and Referrals

Michael J. Ruckenstein, MD, MSc, also reported findings at the Triological meeting.2 Dr. Ruckenstein, Professor and Residency Director in the Department of Otorhinolaryngology-Head and Neck Surgery at the University of Pennsylvania in Philadelphia, surveyed otolaryngologists in community practice regarding their treatment of otosclerosis and the performance of stapedectomy.