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L’assurance qualité en Otorhinolaryngologie-Chirurgie Cervico-Faciale : l’agrément et la
certification
Dana Hartl, Département de Cancérologie Cervico-Faciale, Institut Gustave Roussy, Villejuif
Résumé
L’agrément ou l’accréditation des stages de formation en 3ème cycle des études médicales et la
certification des médecins spécialistes par un contrôle de connaissances ont pour objectif
l’identification des normes en termes de formation et de niveau requis pour la pratique de la
spécialité en ce qui concerne les soins. L’établissement de ces normes et leur implémentation
répondent à un besoin de contrôle de qualité pour l’optimisation des soins et de la qualité des
pratiques professionnelles. L’agrément sous-entend la transparence des critères de sélection des
services hospitaliers formateurs. La certification sous-entend une ou des évaluations sommatives
permettant d’assurer un certain niveau de connaissances. En France, l’agrément est délivré par
l’Agence Régionale de Santé et l’autorisation d’exercer la spécialité par le Ministère de l’Education
Nationale. La structure d’agrément (accréditation) et la structure pour la certification des médecins
spécialistes aux Etats-Unis (par le « Board ») sont deux structures privées et indépendantes.
L’accréditation et la certification ne sont pas obligatoires aux USA, mais elles permettent une
assurance quant aux moyens de formation et au niveau de connaissances vérifié par 2 examens. Ces
structures ont été créées au niveau Européen mais ne sont pas reconnues par les autorités en
France. Il n’existe en France aucun contrôle de connaissances au 3ème cycle pouvant correspondre à la
certification américaine. Le présent travail a pour objectif la comparaison des systèmes de contrôle
de qualité et de niveau en 3ème cycle (accréditation et certification) en France, en Europe et aux USA
pour la spécialité d’Otorhinolaryngologie et de Chirurgie Cervico-Faciale afin de formuler des
suggestions pour l’amélioration de l’assurance qualité en France.
Mots clés : agrément, accréditation, évaluation, certification, contrôle de qualité
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Introduction
Le professionalisme d’un médecin peut être défini par une compétence dans 6 domaines : les soins,
les connaissances médicales, l’apprentissage par la pratique, la communication, le rôle socio-
professionnel et l’intégration dans le système global de soins1,2. L’évaluation du professionnalisme,
concept complexe, doit être multi-dimensionnelle, et nous sommes encore loin d’avoir les outils pour
évaluer efficacement tous ces domaines de compétence3. Il est néanmoins possible d’évaluer le
niveau de connaissances pour assurer un niveau de qualité en termes de soins médicaux.
L’accréditation (ou l’agrément) des programmes d’enseignement du 3ème cycle des études médicales
et la certification des médecins spécialistes par un contrôle de connaissances ont pour objectif
l’identification des normes en termes de formation et de niveau requis pour la pratique de la
spécialité dans le cadre des soins. L’établissement de ces normes et leur application répondent à un
besoin de contrôle de qualité pour l’optimisation des soins et de la qualité des pratiques
professionnelles.
Des normes d’accréditation existent aux Etats-Unis depuis le début du 20ème siècle, d’abord sous la
forme d’une obligation de moyens (nombre d’enseignants, structures d’accueil adéquates, etc) et
plus récemment sous la forme d’une obligation de résultats, mesurés par la qualité des soins
médicaux mais aussi par l’optimisation des pratiques médicales et de l’utilisation des ressources
économiques par les praticiens4. Le contrôle des compétences professionnelles et l’assurance de la
qualité des médecins sont devenus une priorité dans le système de santé aux Etats-Unis. « Society
expects accountability in medical education » 4. En France, il n’existe pas de structure nationale
d’accréditation, mais l’Agence Régionale de Santé (l’ARS) 5 délivre l’agrément des services pouvant
recevoir les internes en formation6. Dans le cadre de la spécialité d’Otorhinolaryngologie et de
Chirurgie Cervico-Faciale (ORL-CCF) aucune structure nationale de certification ou de contrôle de
connaissances en fin de cursus n’a été mise en place.
Cet exposé a pour but de comparer les systèmes de contrôle de qualité et de niveau en 3ème cycle
(accréditation/agrément et certification) en France, en Europe et aux USA pour la spécialité d’ORL-
CCF afin de suggérer des solutions pour l’amélioration du système médical français.
L’état actuel en France
En 2010, 2791 médecins spécialistes en ORL-CCF ont été recensés7. Entre 2010 et 2014 environ 400
nouveaux spécialistes seront formés8. L’agrément des services pouvant accueillir les internes est sous
l’autorité de l’ARS. L’organisation de la formation est sous l’autorité du Ministère de l’Education
nationale qui publie dans son bulletin officiel les maquettes des spécialités. Une commission de
validation dépendant du Ministère de l’Education Nationale siège au niveau des interrégions pour
valider le cursus de chaque étudiant en fin de 3ème cycle. Les critères de validation des stages ne sont
pas formellement écrits, et les décisions de validation sont laissées à l’appréciation de chaque chef
de service.
Agrément des services pouvant accueillir des internes
La commission de subdivision-formation agrément siège au sein de l’ARS de chaque région et délivre
un agrément aux services hospitaliers pouvant accueillir les internes5,6. Les membres de la
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commission sont fixés par arrêté de l’ARS. Les commissions sont formées de représentants de l’ARS,
des universités, des hôpitaux et des internes nommés pour 5 ans renouvelables, à l’exception des
internes dont le mandat est d’un an renouvelable. Les coordonnateurs interrégionaux des DES ont
une voix consultative. Les commissions procèdent à une inspection sur site et s’assurent de la qualité
de la structure en termes d’activité médicale et de pertinence dans la spécialité. L’agrément est
accordé pour 5 ans (avec certaines exceptions).
Formation théorique du DES
La maquette du DES d’ORL-CCF comporte actuellement et depuis le 1er novembre 2009 une
formation sur 5 ans9 (ANNEXE 1). Sur les 10 semestres, 7 doivent être effectués dans la spécialité,
dont un dans un service agréé par le collège pour les explorations fonctionnelles audio-
phonologiques. Ces stages doivent être effectués dans au moins 2 services ou départements
différents. Par ailleurs il n’y a aucune obligation de suivre un minimum de formation spécifique en
ORL pédiatrique ou en cancérologie dans la maquette officielle publiée par le Ministère de
l’Education Nationale.
Plusieurs collèges d’enseignement de spécialité ont pris l’initiative depuis plusieurs années de
travailler sur les objectifs d’enseignement théorique et pratique. L’organisation pratique de
l’enseignement pratique et théorique du Diplôme d’Etudes Spécialisées (DES) d’ORL-CCF et le respect
de la maquette est gérée par le Collège Français d’ORL-CCF et par les coordonnateurs interrégionaux
du DES (élus parmi les professeurs de médecine de l’interrégion pour un mandat de 4 ans
renouvelable) 10. Le Collège Français d’ORL-CCF a édité des objectifs théoriques de l’enseignement de
l’ORL-CCF et ont établi un livret (appelé le « log book ») des interventions chirurgicales
indispensables dans la discipline. Ces initiatives n’ont pas à ce jour été reconnus par le Ministère de
l’Education Nationale dans la maquette. La maquette actuelle est respectée mais elle ne livre que les
grands chapitres de l’enseignement théorique et est sans contrôle final des connaissances.
Les membres du collège sont des ORL en exercice, anciens Chefs de Clinique-Assistants ayant fait une
demande d’adhésion avec une lettre de soutien de la part de 2 membres actifs du Collège. Le bureau
et le conseil d’administration sont élus. Le conseil d’administration est composé de délégués
régionaux, des représentants de différentes structures (hôpitaux publics et privés à but non-lucratif,
hôpitaux militaires, centres de lutte contre le cancer, les praticiens hospitaliers, etc), des
responsables nationaux du collège en ce qui concerne l’enseignement (2ème et 3ème cycles), les
responsables régionaux du DES, des représentants régionaux des praticiens libéraux, le secrétaire
général de la Société Française d’ORL-CCF, le représentant du syndicat national des ORL, et le
président de la sous-section ORL au Conseil National des Universités.
A l’instigation du collège, une première formation théorique et pratique à été organisée pour tous les
internes en ORL pendant leur première année, sous forme de séminaires, suivie d’un examen
national écrit, un contrôle de connaissances portant sur les objectifs généraux en chirurgie. Les
questions de l’examen sont tirées au sort à partir d’une banque, établie par le Collège Français
d’ORL-CCF, et l’examen est organisé par les coordonnateurs interrégionaux du DES. Les objectifs de
cet enseignement ont été rédigés et sont clairement affichés par le Collège11. Cet examen est
obligatoire et administré à tous les internes à la fin de la première année d’internat. Cet examen est
le seul contrôle de connaissances qu’un interne en ORL-CCF aura à subir et à valider pendant les 5
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ans de l’internat. Cependant, la validation de cet examen n’est pas reconnue par le Ministère de
l’Education Nationale.
Le Collège Français d’ORL-CCF organise également une formation théorique nationale sous forme de
séminaires, à partir du 3ème semestre de l’internat en chirurgie plastique et reconstructive cervico-
faciale et en audiophonologie et phoniatrie. Ces cours sont « hautement recommandés » mais non
reconnus par le Ministère de l’Education Nationale. Enfin, chaque interrégion organise des cours du
DES selon les items de la maquette. Ces cours sont « fortement recommandés » mais il n’existe
aucune obligation de présence et aucune évaluation sommative. Ces cours n’étant pas
« obligatoires » n’ont été suivis récemment dans certains modules que par 3 à 4 internes en Ile de
France, par exemple, sur les 20 internes par promotion.
L’autorisation d’exercer la spécialité d’ORL en France
L’autorisation d’exercer la spécialité d’ORL-CCF repose sur la validation de la maquette du DES et la
réalisation d’un mémoire de DES. Le mémoire est un travail individuel généralement de recherche
clinique supervisé par un ORL, généralement hospitalier. Le travail est présenté par écrit et
oralement au jury universitaire choisi par le coordonnateur régional du DES. Le diplôme est
systématiquement octroyé à condition que l’interne ait validé les semestres d’internat. Il n’y a pas
d’évaluation sanctionnante en fin de cursus qui pourrait correspondre à une « certification à
l’américaine ».
Les critiques
L’agrément des services pouvant former les internes est sous l’autorité de l’ARS, dépendant du
Ministère de la Santé, alors que la validation de la maquette de la spécialité est sous l’autorité du
Ministère de l’Education Nationale. Bien que l’ARS implique les professeurs de médecine dans les
commissions de subdivision-formation agrément, les motivations et objectifs des deux ministères
pourraient ne pas être cohérents.
En ce qui concerne la formation en stage, il existe des disparités régionales : en Ile de France, les
internes séjournent généralement dans 10 hôpitaux différents, alors que dans les structures de
formation en province, les internes passent plus de temps dans un service ou département donné
(les 10 semestres pouvant être partagés entre seulement 2 services).
La formation pratique est assurée par les services hospitaliers spécialisés voire sur-spécialisés, alors
que la pratique courante de l’ORL en ville est en grande partie représentée par les consultations
externes. La formation pratique n’est soumise à aucune contrainte nationale ni locale en ce qui
concerne les moyens de formation ni les moyens d’évaluation. Les objectifs en termes d’actes de
chirurgie observés et/ou réalisés avec ou sans aide ne figurent dans aucun carnet (le « log book » du
collège existe mais n’est pas reconnu officiellement). Les compétences professionnelles ne sont
évaluées ni par une évaluation formative obligatoire ni par une évaluation sommative obligatoire. Les
stages d’interne sont toujours validés, sauf exception extrême.
Les cours de formation théorique sont sans obligation de présence sanctionnée ni contrôle formatif
ou sommatif en fin de formation. En pratique, on s’aperçoit que les internes étrangers que nous
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recevons dans les services font preuve d’un niveau de connaissance théorique qui dépasse celui des
internes français. Le niveau de compétence pratique n’est cependant pas comparable.
Le mémoire du DES est le plus souvent écrit à la hâte en fin de cursus. Il pourrait servir à mesurer les
capacités de l’interne à conduire une étude de recherche clinique, à écrire en français et à faire une
présentation orale, mais la méthodologie scientifique est rarement corrigée ou critiquée. Cet
exercice n’évalue pas les capacités de l’interne à soigner les patients avec des pathologies ORL-CCF. Il
n’y a pas de trame ou d’autre obligation en ce qui concerne ce travail.
Le Ministère de l’Education Nationale détient la décision de rendre obligatoire des contrôles de
connaissances pendant et en fin de cursus. Les objectifs théoriques et le « log book » des
interventions établis par le Collège pourraient servir de canevas pour la mise en place d’un contrôle
de qualité en fin de 3ème cycle. Ceci relève d’une décision politique.
L’accréditation et la certification au sein de l’Union Européenne
L’accréditation des services pouvant accueillir les internes (« residents »)
L’Union Européen des Médecins Spécialistes (UEMS) a été établie en 195812. Trente cinq pays y sont
représentés (membres de l’Union Européenne et « pays associés »). L’objectif de l’UEMS est « de
promouvoir la mobilité des médecins spécialistes européens tout en assurant la meilleure qualité de
soins médicaux pour les citoyens européens » selon l’idéal du traité de Rome qui soutient « le libre
échange de personnes, services, biens et capitaux ». Les différentes spécialités médicales sont
regroupées en 37 sections. La section « otorhinolaryngology and head and neck surgery » (ORL-HNS)
existe depuis 196213. Les spécialités de chaque pays sélectionnent (selon leurs propres règles) leurs
représentants à l’UEMS, ainsi qu’un délégué représentant les internes pour chaque spécialité
(nommés par le « Permanent Working Group of European Junior Doctors »).
L’UEMS a publié en 1993 un canevas d’objectifs de formation théorique et pratique pour les
médecins spécialistes, le « Charter on Specialist Training » 12, puis un canevas pour l’évaluation des
internes pendant leur formation et en fin de cursus le « UEMS policy statement on assessments
during specialist postgraduate medical training » 14. Il s’agit de recommandations générales pour une
évaluation à la fois des connaissances, mais aussi des compétences pratiques, à l’intention des
sections de l’UEMS responsables de l’évaluation de la formation et des Boards Européens des
spécialités responsables de l’évaluation en fin de cursus. Il est important de souligner que
l’implémentation reste sous l’autorité totale des instances locales de la spécialité dans chaque pays.
L’UEMS n’a pas prévu de faire des visites sur site dans chaque pays pour vérifier que ces
recommandations sont suivies, cependant : « the responsible national authority is recommended to
establish programs for this purpose as far as these have not been developed already ».
En pratique, la maquette de formation stipule une durée de 5 ans, mais l’UEMS n’a aucune autorité
réelle pour faire respecter cette recommandation. Par exemple, lorsque la société Espagnole d’ORL-
CCF a décidé de diminuer la durée de la formation des spécialistes en ORL-CCF à 2 ans, l’UEMS a
addressé une lettre de désapprobation en signalant que les ORL espagnols risquaient une diminution
de leur compétitivité (et de leur réputation) en Europe (ANNEXE 2). Malgré les aspirations nobles de
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l’UEMS, elle n’a pas d’autorité réelle et il existe à l’heure actuelle peu de mobilité des spécialistes
européens une fois leur formation terminée.
L’autorisation d’exercer la spécialité d’ORL-CCF
L’autorisation d’exercer en tant que spécialiste médical est soumis à l’autorité de chaque pays
membre. A l’heure actuelle, aucun pays n’exige d’avoir réussi l’examen de fin de cursus proposé par
l’UEMS, à savoir l’examen de certification organisé par chaque Board Européen de spécialité.
Le Board Européen d’Otorhinolaryngology and Head & Neck Surgery (EBEORL-HNS) a été crée en
octobre 200815. Les membres sont nommés ou élus dans chaque pays (3 délégués par pays) et
l’exécutif élu parmi les membres. Les membres français sont nommés par la commission de
pédagogie du DES du Collège Français d’ORL-CCF.
Le EBEORL-HNS a défini des objectifs d’enseignement, le « Scope of Knowledge », publiés sur le site
de l’organisation16 (ANNEXE 3). L’examen du Board Européen est composé de 2 examens survenant à
2 moments différents dans l’année, généralement lors d’un congrès de la spécialité dans une ville
d’Europe. Le premier examen, écrit (QCM et CCQCM soumis par les membres du Board), doit avoir
été validé avant de pouvoir passer l’examen oral. Chaque examen coûte 600 euros. Le contenu est
établi selon les recommandations de la section ORL-HNS de l’UEMS. Pour les médecins ayant reçu
l’autorisation d’exercer dans leur pays, l’examen confère le titre de « Fellow du Board Européen
d’ORL-HNS », et pour ceux qui n’ont pas cette autorisation, il s’agit du titre de « Diplômé du Board
Européen d’ORL-HNS ». Ces diplômes ne remplacent en aucun cas les diplômes attribués par les pays
membres.
Les critiques
L’UEMS a été structurée selon le modèle des instances d’accréditation et de certification américaines
(cf infra). Cependant, les législateurs des pays membres ont encore à reconnaître l’autorité de
l’UEMS et des Boards pour que les recommandations, canevas et examens soient reconnus.
L’accréditation et la certification aux Etats-Unis d’Amérique
L’accréditation des services pouvant accueillir les internes (« residents »)
Les programmes (service ou groupe de services réunis) pouvant accueillir les internes de spécialité
sont de 2 types : les programmes reconnus seulement par l’école de médecine ou l’université et les
programmes également agrées (ou accrédités) par l’Accreditation Council for Graduate Medical
Education (l’ACGME) 1. L’accréditation n’est pas obligatoire, mais sans l’accréditation de l’ACGME un
service accueillant les internes ne peut recevoir un financement spécifique pour l’enseignement par
l’état fédéral (lié au financement du Medicare et du Medicaid). Les stages de formation non-
accrédités peuvent être validants pour une licence d’exercice, selon les prérequis pour un état
américain donné, mais la grande majorité des états exigent au moins une année de formation en 3ème
cycle dans un service accrédité afin d’octroyer une licence d’exercice. Pour pouvoir s’inscrire pour
passer les examens de certification (examens du Board), les internes doivent avoir effectué leur
formation de 3ème cycle dans un programme accrédité.
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L’ACGME est formé des représentants nationaux nommés à partir des associations qui sont
« impliquées dans l’enseignement du 3ème cycle » dont le comité de liaison sponsorisé par l’American
Medical Association et par l’American Association of Medical Colleges, et la Commission
d’Accréditation des Organismes de Santé (« the Joint Commission of Accreditors of Healthcare
Organizations »). Un représentant du gouvernement fédéral et un représentant des internes siègent
également à l’ACGME. Il existe 26 comités, un par spécialité, qui se chargent de l’accrédiation des
programmes de formation de 3ème cycle. Chaque comité (« Residency Review Committee ») est
composé de 8 membres nommés par les organismes de la spécialité (représentants à l’AMA,
membres du Board, membres des académies ou associations professionnelles) et un représentant
des internes, en cours d’internat. Les membres du comité doivent provenir d’états et d’institutions
différents.
Les prérequis pour l’accréditation en termes de moyens en personnel enseignant et les objectifs
d’enseignement pratique et théorique sont publiés par l’ACGME. Les prérequis pour l’ORL (revus tous
les 4 ans) décrivent les obligations du directeur du programme et des enseignants et précisent le
nombre d’années (5), leur organisation et les limites en nombre d’heures de travail des internes par
semaine (80, en moyenne sur 4 semaines) et de jours par semaine (1 journée libre par semaine,
moyenné sur 4 semaines). Le programme d’enseignement de soins, de connaissances et
d’apprentissage au lit du patient sont détaillés. Une évaluation formative et sommative régulière est
recommandée, mais les modalités sont du domaine du directeur de chaque programme17. Cent cinq
programmes de formation ont été accrédités aux USA pour l’ORL pour l’année scolaire 2011-2012
avec 1471 postes d’’interne18.
Un suivi informatique en temps réel existe sur un site web sécurisé, où les modifications du
programme sont répertoriées par les directeurs des programmes d’enseignement. Chaque
programme doit subir une visite initiale d’accréditation et des visites répétées tous les 4 ans environ,
pour maintenir leur accréditation.
L’autorisation d’exercer la spécialité d’ORL-CCF
La licence (« License ») équivalent de l’inscription au Conseil de l’Ordre en France est attribuée selon
des critères variables selon les états. On exige un diplôme d’une université de médecine et 1 ou 2 ans
de formation de 3ème cycle dans la spécialité (« Graduate Medical Education »), le plus souvent dans
un programme de formation accrédité par l’ACGME19.
Les objectifs de la formation pratique et théorique figurent dans le « comprehensive core
curriculum », document édité par l’American Board of Otolaryngology (ANNEXE 4). Le Board d’ORL
existe depuis 1924. Il s’agit d’un organisme à but non lucratif et les membres ne reçoivent aucune
compensation financière (hormis un honorarium modeste pour le président et les présidents de
séance lors des examens). Les directeurs, officiers, conseillers et examinateurs sont nommés ou élus
par des organisations de sous-spécialité (par exemple, l’American Laryngological Association, la sous-
section ORL de l’AMA, etc.) à raison de 2 membres du Board par organisation. Le Board organise
régulièrement des sessions d’entraînement à l’examen écrit. Il s’agit d’une évaluation formative
servant à aider les internes à se préparer pour l’examen de certification.
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Pour s’inscrire à l’examen de certification, il est exigé : une liste des cours et un relevé de stages
provenant de leur école de médecine (1er et 2ème cycles ou « undergraduate medical education »), la
licence pour exercer la médecine (délivré par un des états des USA), la liste d’interventions
chirurgicales observées et/ou effectuées pendant l’internat d’ORL et signée par le directeur du
programme de formation accrédité du 3ème cycle, et un niveau moral et éthique élevé20. Ce dernier
est vérifié par un service privé, le federation credentials verification service (Federation of State
Medical Boards21 qui détient le relevé du cursus professionnel de plus de 175000 médecins aux USA,
consultable sur demande. Le Board est un examen en 2 parties, centralisé et administré
généralement lors d’un congrès d’ORL (les candidats bénéficient d’une réduction du prix d’hôtel). La
première partie écrite doit avoir été réussie avant de pouvoir passer l’épreuve orale 1 à 2 jours plus
tard, pour lequel le candidat dispose de 3 tentatives en cas d’échec initial. En 2011, la certification
par le Board en ORL-CCF coûte $3250.
La certification par le Board n’est pas obligatoire pour exercer en tant que spécialiste ORL, et le
nombre de médecins qui choisissent de ne pas passer ces examens est en d’augmentation
(possiblement du fait du coût des examens et les possibilités d’exercer dans les zones
démographiquement moins peuplé aux USA sans certification) 19. Cependant, un certain nombre de
centres médicaux privés et publics et des compagnies d’assurance exigent une certification pour
embaucher les spécialistes ou pour rembourser leurs soins.
Les critiques
Les instances qui assurent la gouvernance de l’accréditation et de la certification sont des agences
privées où sont représentés des membres de différentes agences (l’état fédéral, l’American Medical
Association, l’agence d’accréditation des assurances privées, etc). De plus, l’ACGME et le Board sont
indépendants, ayant parfois des objectifs différents voire contradictoires en termes d’objectifs de
formation et d’évaluation des spécialistes, notamment par le poids accordé par ces différentes
agences à l’efficience financière du système de santé19.
Les internes sont formés le plus souvent dans des structures d’hospitalisation « tertiaires »
universitaires sur-spécialisées, alors que la pratique courante de la majorité des ORL une fois
autonomes sera de l’ORL générale essentiellement dans des cabinets de ville ou en clinique privée19.
Aux Etats-Unis comme en France, les internes sont des employés de l’hôpital et remplissent souvent
des fonctions qui ne sont pas ou peu formatrices. La formation bénéficierait d’une redéfinition du
rôle de l’interne.
Comment mieux faire chez nous ?
Que les organismes d’agrément et d’autorisation d’exercice d’une spécialité médicale soient publics
en France et privés aux Etats-Unis reflète les différences structurelles de la formation universitaire et
du système de santé dans les deux pays. Au vu de ces comparaisons cependant, on voit un décalage
des niveaux de contrôle de qualité entre la France et les USA, et un manque total d’autorité au
niveau Européen (tableau en annexe). Ce n’est pas sous-entendre qu’il y aurait un décalage de
qualité entre les ORL français et américains, mais que la formation et le contrôle des connaissances
des ORL français n’est pas formalisée. Voici quelques suggestions pour l’amélioration de notre
système :
9
Formation pratique
Veiller à l’adéquation entre la formation pratique et la pratique professionnelle ultérieure. Introduire
les stages d’interne chez le praticien en ville ou dans les dispensaires. Limiter le nombre de stages
dans les services hospitaliers hyperspécialisés, du moins en début de cursus.
Redéfinir le rôle de l’interne dans les services hospitalo-universitaires. Alléger leurs responsabilités
administratives (remplissage de formulaires, codage, etc) et réorienter leurs activités quotidiennes
vers une formation professionnelle véritable. On pourrait se demander si dans ce cas, la durée totale
de formation pourrait-être réduite, par l’optimisation du temps de travail de l’interne à l’hôpital.
Motiver les universitaires en établissant une mesure de leur temps des efforts engagés dans
l’enseignement des internes en stage. Ces mesures pourraient être incorporées dans l’évaluation de
la productivité de l’université à l’échelle nationale, tout comme les publications scientifiques.
Etablir une formation personnalisée avec le choix d’un mentor et l’utilisation d’un carnet de bord ou
d’un portfolio qui suit l’interne pendant toute sa formation. Développer des évaluations formatives
régulières obligatoires dans les services par les présentations, des lectures obligatoires et des études
personnalisées de cas cliniques, par exemple19,22.
Formation théorique
Depuis 3 à 4 ans le Collège Fr ORL-CCF a fait d’énormes progrès par la rédaction des objectifs en
chirurgie générale, en chirurgie de plastique et reconstructive et en audio-phonologie et phoniatrie
et par la mise en place de cours nationaux de formation théorique. Il conviendrait de mieux définir
(écrire et publier) les objectifs de connaissances en ORL-CCF. L’avantage du système français est
d’avoir une seule agence qui gouverne la formation en 3ème cycle des ORL (le Collège) :
l’implémentation des objectifs de formation et d’évaluation semble moins complexe que dans le
système américain, par exemple. Cependant, la non-reconnaissance des objectifs du collège par le
Ministère de l’Education Nationale reste une entrave à la mise en place formelle d’une formation et
d’une évaluation obligatoires.
Surtout rendre obligatoire une évaluation sanctionnante des connaissances soit en plusieurs étapes
pendant l’internat, soit en fin de cursus, comme il est suggéré par certains aux Etats-Unis, que tous
les spécialistes soient obligatoirement certifiés par le Board de leur spécialité19. Lé défi serait de fixer
un niveau élevé pour l’examen et non pas un nivellement par le bas.
Reste le problème de l’évaluation des compétences dans d’autres domaines telle des mesures des
qualités humaines, et des capacités de communication, de travail en équipe et d’innovation. On
dispose de peu des mesures multidimensionnelles et encore moins de mesures qui soient validés2,23.
Il existe en outre peu d’outils validés pour l’évaluation du raisonnement clinique et non pas
simplement des connaissances théoriques24. La recherche dans le domaine de l’enseignement, de la
psychologie de l’enseignement et de la cognition reste indispensable pour avancer dans l’assurance
qualité en médecine.
10
Avant tout, toute modification de notre système actuel nécessitera une volonté de la part des
enseignants de la spécialité et une motivation de la part des internes, à accepter l’éventualité d’un
examen sanctionnant afin de fournir une assurance qualité en France en ORL-CCF.
Conclusion
Si l’on ne peut à l’heure actuelle évaluer tous les domaines du professionalisme en médecine,
l’accréditation et la certification des spécialistes ont au moins l’avantage d’identifier des normes de
formation et de niveau pour assurer un niveau de qualité dans les soins et dans les pratiques
professionnelles. En France, la spécialité d’ORL-CCF ne répond à l’heure actuelle à aucun contrôle des
connaissances ou de certification pour la spécialité. Le Board Européen d’Otorhinolaryngologie et de
Chirurgie de la Face et du Cou a été créé en 2008 dans un but d’établir des normes en termes de
connaissances indispensables pour l’exercice de la spécialité. Cependant, ce contrôle de
connaissances n’est ni reconnu ni obligatoire pour l’exercice de l’ORL en France.
Nous avons besoin d’un canevas de réformes pratiques, un « leadership » ayant une légitimité
reconnue et surtout une volonté sur le plan de la discipline elle-même mais également sur le plan
politique pour mettre en place les réformes pour établir des standards de qualité dans le but
d’améliorer les soins et les pratiques professionnelles, pour optimiser nos ressources en termes de
santé publique, pour rendre nos médecins compétitifs sur le marché Européen et international.
Références
1. www.agme.org
2. Leach D. Competence is a habit. J Am Med Assoc 2002;287:243-244.
3. Epstein RM, Hundert EM. Defining and assessing professional competence. J Am Med Assoc
2002;287:226-235.
4. Davis DJ, Ringsted C. Accreditation of undergraduate and graduate medical education : how
do the standards contribute to quality ? Adv Health Sci Education 2006;11:305-313.
5. www.ars.sante.fr
6. Journal Officiel de la République Française. Arrêté du 4 février 2011 relatif à l’agrément, à
l’organisation, au déroulement et à la validation des stages des étudiants en troisième cycle
d’études médiales. Publié le 9 février 2011. www.sante.gouv;FR/IMG/pdf/Rapport_2010-
2011_Tome_1
7. Observatoire National de la Démographie de Professionnels de Santé. Compte-rendu de
l’audition des Oto-rhino-laryngologistes du 6 mai 2010.
www.sante.gouv.fr/IMG/pdf/Compte-rendu_de_l_audition_des_Oto-rhino-
laryngologistes.pdf
8. Observatoire National de la Démographie des Professionnels de Santé. Les internes en
médecine. Effectifs et répartition 2010-2014. Rapport annuel de l’ONDPS, Tome I, 2010-
2011.
11
9. Arrêté du 22-09-2004 Journal Officiel du 06-10-2004. (www.orlfrance.com)
10. www.orlfrance.org/collège/DESDESC.html
11. www.orlfrance.org/collège/DESitems/obj_Gen_DES_ORL.pdf
12. www.uems.net
13. www.eaorl-hns.org
14. www.admin.uems.net/uploadedfiles/801.doc
15. www.ebeorl-hns.org
16. www.orlns.org/spizakznanja.pdf
17. American Board of Otolaryngology-Head and Neck Surgery Comprehensive Core Curriculum :
www.aboto.org/Curriculum%2010-19-07%20final.pdf
18. www.acgme.org/adspublic/reports/accredit_programs.asp
19. Cooke M, Irby DM, O’Brien BC. Educating physicians. A call for reform of medical school and
residency. Josey-Bass : San Francisco, 2010.
20. www.aboto.org/booklet of information
21. www.fsmb.org
22. Bull DA, Stringham JC, Karwande SV, Neumayer LA. Effect of a resident self-study and
presentation program on performance on the thoracic surgery in-training examination. Am J
Surg 2001;181:142-144.
23. Epstein RM. Assessment in medical education. N Engl J Med 2007;356:387-396.
24. Norman G. Building on experience—the development of clinical reasoning. N Engl J Med
2006;355:2251-2252.
12
Tableau. Résumé comparatif des systèmes d’accréditation et de certification en France, en Europe et
aux Etats-Unis pour l’ORL-CCF.
France Europe Etats-Unis
Accréditation
des services
accueillant les
internes
Agence responsable ARS UEMS ACCGME
Critères publiés Non explicités non oui
Objectifs d’enseignement
pratique et théorique
Oui (mais par
le Collège, non
reconnus par
l’ARS)
oui oui
Visites de contrôle sur site Oui par l’ARS non oui
Durée de l’enseignement 5 ans 5 ans 5 ans
La certification Agence responsable Université EBORL-HNS
(sous l’égide
de l’UEMS)
ABOto
(indépendant
de l’ACGME)
Objectifs
d’enseignement/connaissances
théoriques
Oui (par le
Collège, non
reconnus par
le Ministère
de l’Education
Nationale)
oui oui
Evaluations formatives
administrées par l’agence
non non oui
Evaluations sommatives
administrées par l’agence
non oui oui
Type d’évaluation Validation des
stages
Examen écrit +
oral
Examen écrit
+ oral
(patients
standardisés)
13
Annexes
Annexe 1. La maquette du Diplôme d’Etudes Spécialisées en Otorhinolaryngologie et Chirurgie Cervico-Faciale9
Mémoire D.HARTL\ANNEXE 1.doc.pdf
Annexe 2. Lettre de l’Union Européenne de Médecins Spécialistes du 15 février 2010 12
Mémoire D.HARTL\ANNEXE 2.pdf
Annexe 3. Maquette d’objectifs d’enseignement du Board Européen d’ORL-HNS 16
Mémoire D.HARTL\ANNEXE 3.pdf
Annexe 4. American Board of Otolaryngology-Head and Neck Surgery Comprehensive Core Curriculum 17
Mémoire D.HARTL\ANNEXE 4.doc.pdf
ANNEXE R’
DIPLÔME D’ ÉTUDES SPÉCIALISÉES D’ OTO-RHINO-LARYNGOLOGIE ET CHIRURGIE CERVICO-
FACIALE
Durée : cinq ans
Internes nommés à compter du 1er novembre 2009
I – ENSEIGNEMENTS (Trois cents heures environ)
A) Enseignements généraux : - Méthodologie de l’évaluation des pratiques de soins et de la recherche clinique et
épidémiologique en oto-rhino-laryngologie et chirurgie cervico-faciale ; - Organisation, gestion, éthique, droit et responsabilité médicale appliqués à
l’exercice de l’oto-rhino-laryngologie et de la chirurgie cervico-faciale. B) Enseignements spécifiques : - Principes généraux de chirurgie ; - Anatomie, embryologie, développement et physiologie de l’oreille, des cavités
rhino-sinusiennes et des voies aéro-digestives ; - Principes de génétique, d’immunologie et d’oncologie appliqués à l’oto-rhino-
laryngologie ; - Pharmacologie (métabolisme, posologie, action et toxicité) des médicaments
usuels en oto-rhino-laryngologie ; - Explorations fonctionnelles en oto-rhino-laryngologie ; - Pathologie de l’oreille ; - Pathologie rhino-sinusienne ; - Pathologie du larynx et des voies aéro-digestives ; - Audio-phonologie ; Phoniatrie - Cancers des voies aéro-digestives ; - Pathologie ORL du nourrisson et de l’enfant, y compris les malformations cervico-
faciales ; - Traumatologie cervico-faciale ; - Pathologie des aires ganglionnaires cervicales ; - Pathologie des loges salivaires et thyroïdiennes ; - Chirurgie plastique, esthétique et réparatrice cervico-faciale ; - Chirurgie des tumeurs cutanées cervico-faciales ; - Pathologie du rocher et de la base du crâne ; - Organisation et prise en charge des urgences en oto-rhino-laryngologie et
chirurgie cervico-faciale.
2
II – FORMATION PRATIQUE
A) sept semestres dans des services agréés pour le diplôme d’études spécialisées d’oto-rhino-laryngologie et chirurgie cervico-faciale, dont 5 au moins doivent être accomplis dans des services hospitalo-universitaires ou conventionnés. Ces semestres doivent être effectués dans au moins deux services ou départements différents. Un semestre doit être effectué dans une unité d’exploration fonctionnelle d’ORL agréée (audio-phonologie et phoniatrie, exploration fonctionnelle otoneurologique…)
B) Trois semestres dans des services agréés pour une autre spécialité, dont deux au
moins dans des services de la discipline spécialités chirurgicales. L’un de ces deux stages doit être effectué dans un service de chirurgie générale, viscérale, vasculaire, thoracique et cardiovasculaire ou orthopédique et traumatologie ; l’autre doit être effectué, soit dans le même type de service, soit dans un service de neurochirurgie, de chirurgie plastique, reconstructrice et esthétique, ou de chirurgie maxillo-faciale et stomatologie. Un semestre peut être accompli dans un service agréé pour un autre diplôme d’études spécialisées (cancérologie, pédiatrie, neurologie ou pneumologie…)
UNION EUROPÉENNE DES MÉDECINS SPÉCIALISTES
EUROPEAN UNION OF MEDICAL SPECIALISTS
ORL SECTION & BOARD
Prof. Karl Hörmann
President
E-mail: [email protected]
Mr David Proops, M.S., F.R.C.S.
Secretary General
E-mail: [email protected]
Dr. María de la Mota
Permanent Secretary Telephone: +34.649.994.298
E-mail: [email protected] Fax: +34.914.312.692
15
th February 2010
To whom it may concern: We have recently been made aware of the planned new arrangements for medical graduation in Spain and we wish to inform you that the UEMS ORL Section and Board regards them as unacceptable. The recommended training time is five (5) years in Europe and even this may be inadequate because of the European Working time Directive. So the proposed reduction to two (2) years specific ORL training in Spain would not allow the Curriculum requirements, as detailed in the UEMS ORL logbook, nor fulfill the requirements to sit the European Board examination in ORL. This would therefore handicap Spanish ORL Specialists and not be to the Spirit of harmonization as set out in the UEMS Charter. We would like to see this project disregarded and not continued for the future of the Spanish ORL specialists, otherwise they will find it very difficult to compete in Europe. Yours sincerely,
Mr. David Proops Professor Karl Hörmann
Secretary General President
European Board Examination in Otorhinolaryngology - Head and Neck Surgery
by the UEMS - ORL Section
Scope of knowledge / European syllabus in ORL Page 1 of 6
I. Basic Objectives 1 emergency medicine and resuscitation 2 infection control 3 antimicrobial therapy 4 transfusions medicine/blood grouping/cross-matching etc. 5 haemostasis 6 oncology 7 wound healing 8 general surgical techniques 9 basics in plastic and reconstructive surgery 10 transplantation medicine 11 soft tissue and bone traumatology 12 immunology 13 endocrinology 14 oral and parenteral nutrition 15 basic psychosomatic investigation/management 16 radiation protection 17 medical quality control 18 ethical principles/consent for operation 19 basic nutritional medicine 20 basic laboratory procedures 21 basic laboratory investigations,
a. indication, correct taking and handling of b. samples and interpretation of the results
22 normal blood values 23 bacteriology/mycology 24 principal detection of fungi (cell culture) 25 antimicrobial medication 26 analysis of tumour-markers 27 allergology laboratory investigations
II. Otology A. Diagnostic Procedures
a.) CLINICAL EXAMINATION 1 otoscopy 2 endoscopy 3 microscopy
b.) HEARING FUNCTION 1 hearing distance test 2 tuning fork tests 3 impedance audiometry 4 pure tone audiometry 5 speech audiometry 6 supraliminal audiometry 7 objective hearing test
a. evoked response audiometry (ERA,BERA) b. oto-acoustic emissions (OAE)
8 paediatric audiology a. screening methods b. objective methods c. subjective methods
c.) VESTIBULAR FUNCTION 1 spontaneous nystagmus 2 induced nystagmus
a. positional nystagmus b. caloric testing c. electronystagmography d. rotating chair test e. spinal reflexes (Unterberger, Romberg) f. posturography g. videonystagmography
d.) FACIAL NERVE FUNCTION 1 topodiagnostic testing
a. e.g. Schirmer´s test, gustatory tests, stapedial reflex 2 neurophysiological testing
a. nerve stimulation tests (e.g. MST, NMG (ENoG), TFR ...) b. electromyography
e.) INTERPRETATION OF RELEVANT IMAGING 1 conventional X-Ray, CT, MRI, Angiography
B. Non-surgical Management 1 pharmacological treatment and/or physical rehabilitation: 2 ear infection 3 sensorineural deafness 4 tinnitus 5 vertigo and disequilibrium 6 facial nerve paresis / paralysis 7 post-op care
C. Surgical Management 1 temporal bone dissections (lab.) 2 local and regional anaesthesia 3 management of oto-haematoma 4 removal of osteomas 5 otoplasty 6 meatoplasty
European Board Examination in Otorhinolaryngology - Head and Neck Surgery
by the UEMS - ORL Section
Scope of knowledge / European syllabus in ORL Page 2 of 6
7 foreign body removal 8 polyps of auditory meatus 9 myringotomy 10 ventilation tubes 11 myringoplasty 12 tympanotomy 13 antrotomy 14 mastoidectomy
a. simple b. modified c. radical
15 tympanoplasty (reconstruction of ossicles) 16 implantation of prosthesis
a. middle ear prosthesis b. bone anchored hearing aids c. cochlear implants
17 stapedectomy / stapedotomy 18 saccotomy 19 neurectomy (vestibular nerve section) 20 acoustic neurinoma surgery 21 facial nerve surgery
a. decompression b. grafting c. monitoring
22 glomus tumour surgery 23 petrosectomy 24 skull base surgery (otobasis) with reconstruction 25 correction of malformations
a. auricle b. fistulas c. outer ear canal d. middle ear
26 repair of injuries 27 auricle 28 outer ear canal 29 middle and inner ear including nerves, vessels and dura of the temporal bone compartment 30 surgery of tumours
a. auricle b. outer ear canal c. middle and inner ear including nerves, vessels and dura of the temporal bone compartment
III. Nose and paranasal sinuses A. Diagnostic Procedures
a.) CLINICAL EXAMINATION 1 assessment and ethnic variation 2 aesthetic proportions of the face 3 effects of aging process 4 anterior and posterior rhinoscopy 5 endoscopy 6 microscopy 7 photography
b.) TESTS OF FUNCTIONS 1 rhinomanometry 2 acoustic rhinometry 3 olfactory tests (subjective, objective) 4 ciliary function tests
c.) IMAGING 1 ultrasound scan (a- and b-mode) 2 X-ray conventional 3 interpretation of
a. CT-scan b. MR-imaging c. Isotope scan (szinti-scan) d. Angiography
d.) ALLERGY INVESTIGATIONS 1 epicutaneous allergen tests 2 intracutaneous allergen tests (Prick, Scratch) 3 nasal provocation tests 4 nasal cytology 5 eliminative tests 6 interpretation of serological tests (RAST, IgE)
B. Non-surgical Management 1 pharmacological therapy 2 specific immunotherapy (hyposensitization) 3 anaphylaxis reaction therapy
C. Surgical Management a.) Nose
1 local and regional anaesthesia 2 control of nasal epistaxis
a. nasal packing b. nasal cautery
3 foreign body removal 4 nasal polypectomy 5 turbinate surgery
European Board Examination in Otorhinolaryngology - Head and Neck Surgery
by the UEMS - ORL Section
Scope of knowledge / European syllabus in ORL Page 3 of 6
6 reposition of nasal fractures 7 incising abscesses 8 septal surgery 9 revision septoplasty 10 septum perforation repair 11 closed rhinoplasty 12 open rhinoplasty 13 revision rhinoplasty 14 complicated rhinoplasty 15 augmentation rhinoplasty 16 cleft patient rhinoplasty 17 reduction rhinoplasty 18 rhinophyma operation 19 correction of malformations (e.g. choanal atresia, fistulas, dermoids, etc.) 20 management of immediate post-operative complications
b.) Paranasal Sinuses 1 sinus endoscopy 2 antral lavage 3 endoscopic antrostomy 4 radical antrostomy (Caldwell-Luc) 5 frontal sinus trephination 6 external frontal sinus surgery 7 external ethmoidectomy 8 endonasal ethmoidectomy (endoscopic, microscopic) 9 fronto-ethmoidectomy (endoscopic) 10 sphenoid sinus surgery 11 revision paranasal sinuses operation 12 closure of oro-antral fistula 13 ligation of maxillary or ethmoidal artery 14 orbital decompression procedures 15 dacryo-cysto-rhinostomy 16 management of CSF leak 17 tumour surgery
a. maxillectomy (partial, total) b. lateral rhinotomy c. midfacial degloving d. combined approach to the anterior skull base e. orbitotomy f. exenteration of orbit g. surgery of the anterior skull base (incl. osteoplastic flap, dura plasty and related techniques)
18 repair of injuries (traumatology) a. soft tissue injuries b. nasal fractures c. septal haematoma d. paranasal sinus fractures e. fractures of orbit including blow out fracture f. fractures of zygoma g. optic nerve decompression h. reconstruction of the anterior skull base
IV. Larynx. Tracheobronchial tree
A. DIAGNOSTIC PROCEDURES a.) CLINICAL EXAMINATION (in adults and children)
1 Indirect mirror laryngoscopy 2 Flexible endoscopic examination of larynx, trachea, bronchi, with or without washings for cytology 3 stroboscopy 4 Direct laryngoscopy with or without swabs for microbiological assessment 5 microlaryngoscopy 6 Endolaryngeal, endotracheal and endobronchial biopsy
b.) INTERPRETATION OF RELEVANT IMAGING 1 ultrasound scan, plain X-Ray, CT, MRI, PET
c.) INVESTIGATIONS 1 Techniques in voice analysis 2 electromyography
B. Non-surgical Management 1 Care of the professional voice 2 Voice restoration following laryngectomy/ total laryngectomy (care of the valve prosthesis) 3 Medical management of laryngotracheal disease
C. Surgical Management 1 Topical, local and regional anaesthesia 2 removal of foreign bodies from larynx, trachea and bronchi 3 endotracheal intubation 4 Tracheotomy - tracheostomy (including percutaneous) 5 closure of tracheostome 6 Incision of crico-thyroid membrane 7 Endolaryngeal, endotracheal and bronchial laser surgery 8 surgery for unilateral cord palsy 9 surgery for bilateral cord palsy 10 Phonosurgery ( surgery for voice and speech)
a. Frame work surgery (thyroplasty)
European Board Examination in Otorhinolaryngology - Head and Neck Surgery
by the UEMS - ORL Section
Scope of knowledge / European syllabus in ORL Page 4 of 6
b. Vocal cord augmentation
c. Botulinus toxin injection
11 Management of blunt and open laryngo-tracheal injury a.) SURGERY FOR LARYNGEAL TRACHEAL AND BRONCHIAL NEOPLASMS
1 endolaryngeal surgery for early cancer 2 endolaryngeal laser surgery for tumours in upper aerodigestive tract 3 Laryngectomy
a. total b. partial
4 Laryngo-pharyngo-oeseophagectomy with flap reconstruction or viscus interposition 5 Techniques for insertion of valves for voice rehabilitation 6 Management of laryngo-tracheal stenosis 7 Tracheal and bronchial stenting 8 Repair of tracheo-oeseophageal fistula in adults
b.) LARYNGEAL TRACHEAL AND BRONCHIAL DISEASES IN CHILDREN 1 Assessment and management of acute airway obstruction in children
c.) SURGICAL MANAGEMENT OF CONGENITAL MALFORMATIONS 1 Supraglotic stenosis 2 Laryngeal web 3 Subglottic haemangioma 4 Vocal cord paralysis 5 Laryngeal cleft 6 Vascular compression
d.) SURGICAL MANAGEMENT OF ACQUIRED CONDITIONS IN CHILDREN 1 Laryngeal papilloma 2 Tracheal stenosis 3 Inhalational injury
V. Oral Cavity. Pharynx and Oesophagus A. DIAGNOSTIC PROCEDURES
a.) CLINICAL EXAMINATION 1 inspection and palpation of oral cavity and oropharynx 2 endoscopic assessment of oral cavity, pharynx and oesophagus, with flexible and rigid endoscopes, including
biopsies, preparation of swabs, washings, and related techniques. 3 gustometry 4 functional tests of swallowing disorders 5 principles of assessment and diagnosis of sleep apnoea 6 principles of speech assessment and rehabilitation
b.) INTERPRETATION OF RELEVANT IMAGING 1 ultrasound scan, conventional X-Ray, OPG, CT, MRI, esophagogram 2 diagnosis and interpretation of swallowing disorders including reflux
B. Non-surgical Management 1 pharmacological therapy 2 swallowing and aspiration rehabilitation 3 non surgical treatment of sleep apnoea and roncopathy
C. Surgical Management 1 local and regional anaesthesia 2 adenoidectomy 3 tonsillectomy 4 abscess tonsillectomy (hot tonsillectomy) 5 arrest of tonsillar haemorrhage 6 drainage of abscess
a. peri- and retrotonsillar b. para- and retro-pharyngeal c. base of tongue
7 correction of malformations a. lingual frenulum b. ranula c. cysts inclusion d. macroglossia
8 sialendoscopy 9 transoral removal of salivary calculi 10 transposition of salivary duct 11 lithotripsy 12 removal of foreign bodies 13 surgery of pharyngeal pouch (open or endoscopic) 14 endoscopic biopsy and tumour staging 15 pharyngostomy 16 closure of pharyngostoma 17 cricopharyngeal myotomy 18 surgery of injuries
a. simple injuries b. complex injuries
a.) TUMOUR SURGERY 1 laser surgery of oral cavity and pharynx 2 resection of the tongue
a. partial glossectomy b. hemi glossectomy c. total glossectomy
3 reconstruction of the tongue 4 microvascular anastomoses 5 resection, osteosynthesis and reconstruction of mandible
European Board Examination in Otorhinolaryngology - Head and Neck Surgery
by the UEMS - ORL Section
Scope of knowledge / European syllabus in ORL Page 5 of 6
6 pharyngotomy 7 pharyngectomy
a. partial b. total
8 surgery for tumours of the nasopharynx 9 surgery for tumours of the oropharynx and reconstruction 10 resection of the lips and plastic reconstruction
a. simple b. complex
11 surgery of roncopathy and obstructive sleep-apnoea disorders including radiofrequency, UPPP, LAUP VI. Head and Neck and aesthetics. A. Diagnostic Procedures and multidisciplinary approach
a.) CLINICAL EXAMINATION 1 investigation of the cranial nerves
a. clinical b. electrophysiological
2 functional tests of salivary glands 3 fine needle biopsy
b.) INTERPRETATION OF RELEVANT IMAGING 1 Conventional X-RAY. OPG 2 CT, MRI Scan 3 Ultrasound and PET 4 Treatment planning
B. Non-surgical Management 1 pharmacological therapy 2 conservative treatment of wounds 3 chemo-radiation-therapy 4 application of botulinum toxin
C. Surgical Management 1 Topical, local and regional anaesthesia 2 management of wounds
a. management of wounds breakdown b. management of scar tissue
3 management of open neck wounds 4 fistula care 5 removal of
a. branchial cysts b. surgery of benign tumours c. fistulae
6 incision and drainage of abscess 7 surgery of skin tumours
a. Benign skin tumours b. Malignant skin tumours c. Treatment of melanoma
8 correction of malformations a.) REPAIR OF INJURIES
1 management of soft tissue injuries of the lateral and middle part of the face 2 combined fractures of the lateral and middle part of the face 3 osteosynthesis
b.) SURGERY OF CRANIAL NERVES (N.V, Nn.VII-XII) 1 exploration, decompression or neurolysis 2 plastic reconstruction
c.) DISSECTION OF TUMOURS 1 removal of cervical lymph-nodes 2 neck dissection
a. selective neck dissection level I to III b. selective neck dissection level I to V c. modified radical neck dissection d. radical neck dissection e. extended neck dissection
3 soft tissue neoplasms 4 vascular tumours 5 neurogenic tumours
d.) SURGERY OF THE SALIVARY GLANDS 1 removal of the submandibular gland 2 removal of the sublingual gland 3 Removal of minor glands 4 Parotidectomy
a. partial parotidectomy b. suprafacial parotidectomy c. subtotal parotidectomy d. total parotidectomy e. radical parotidectomy
e.) SURGERY OF VESSELS 1 preparation and ligation of vessels 2 direct or indirect catheterization of the internal jugular vein 3 vascular grafting 4 microvascular anastomosis
f.) SURGERY OF THE THYROID GLAND 1 hemithyroidectomy 2 total thyroidectomy 3 Parathyroidectomy 4 Level VI neck dissection
European Board Examination in Otorhinolaryngology - Head and Neck Surgery
by the UEMS - ORL Section
Scope of knowledge / European syllabus in ORL Page 6 of 6
g.) PLASTIC AND RECONSTRUCTIVE SURGERY 1 limited regional sliding and rotation flaps 2 free skin grafts 3 extensive plastic reconstruction
a. myofascial flaps b. myocutaneous flaps c. microvascular flaps
4 facial rehabilitation a. dynamic muscle flaps b. static procedures c. face-lifting procedures d. blepharoplastia procedures e. chin procedures
5 bone replacement 6 cartilage replacement
h.) FACIAL PARALYSIS 1 grading 2 gold weight insertion 3 temporalis muscle transfer 4 suborbicularis occuli fat pad lift 5 tarsorrhaphy
i.) AESTHETICS 1 face and brow lifting including endoscopic 2 upper lid blepharoplasty 3 lower lid blepharoplasty 4 otoplasty 5 genioplasty 6 liposuction 7 facial resurfacing 8 botox 9 injectable and implantable materials for rhytids / lip augmentation 10 genioplasty / mentoplasty 11 hair loss
American Board of Otolaryngology
Otolaryngology—Head and Neck Surgery Comprehensive Core Curriculum
October 2007
© 2007 by the American Board of Otolaryngology, Inc.
2
Contents
Page
Introduction 3 General Otolaryngology 4 Rhinology 8 Allergy 18 Laryngology, Voice, Swallowing 30 Adult Sleep Medicine 36 Pediatric Otolaryngology 42 Otology/Audiology 53 Head and Neck Oncology 68 Plastic and Reconstructive Surgery 80 Clinical Research 93
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Introduction
The Otolaryngology—Head and Neck Surgery Comprehensive Core Curriculum outlined below is a compendium of topics, diseases and disorders that is included in the scope of knowledge for Otolaryngology—Head and Neck Surgery. The Curriculum outlines and provides an operational structure for the body of knowledge that is available in Otolaryngology—Head and Neck Surgery Residency training programs. This Curriculum is the foundation for the written and oral certification examinations developed by the American Board of Otolaryngology. This document was developed by the Education Council , a committee established by the American Board of Otolaryngology, which is composed of representatives from the American Board of Otolaryngology, the ACGME Otolaryngology-Residency Review Committee, Society of University Otolaryngologists-Head and Neck Surgeons, and the Association of Academic Departments of Otolaryngology-Head and Neck Surgery. Contributors:
Bruce J. Gantz, MD (Chair) Patrick E. Brookhouser, MD Richard A. Chole, MD, PhD Dean M. Toriumi, MD Paul R. Lambert, MD Michael G. Stewart, MD, MPH Bradley F. Marple, MD Robert H. Ossoff, MD James A. Hadley, MD Edward M. Weaver, MD, MPH Jay F. Piccirillo, MD, PhD Mark A. Richardson, MD Clough Shelton, MD Steven A. Telian, MD Lanny G. Close, MD Randal S. Weber, MD Wayne F. Larrabee, MD
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GENERAL OTOLARYNGOLOGY CURRICULUM I. Fundamental Knowledge A. General Head and Neck Anatomy
1. Unit Objective
a. At the completion of this unit, the resident understands the basic anatomy of the head and neck, including surface and internal anatomy
2. Learner Objective s
a. Upon completion of this unit , the resident:
i. Understands the anatomy of the head and neck, including interrelationships between neural structures, aerodigestive tract, ear, facial skeleton, skull, etc.
ii. Knows the surgical anatomy of the head and neck iii. Understands radiologic imaging of the head and neck
3. Contents
a. Ear b. Face c. Nose d Paranasal sinuses e. Facial skeleton f. Skull g. Teeth h. Neck i. Aerodigestive tract j. Cranial nerves k. Vascular anatomy l. Radiologic evaluation and anatomy
B. General Head and Neck Embryology
1. Unit Objective
a. At the completion of this unit, the resident understands the basic concepts and importance of embryology of the head and neck, including the ear and temporal bone, pharynx, endocrine structures, nerves and vasculature
2. Learner Objective s
a. Upon completion of this unit, the resident understands:
i. Embryology of all structures of the head and neck, including interrelationships between adjacent and related structures
ii. Surgical implications of embryology (i.e., location of parathyroid glands, tracts for congenital
fistulas and sinuses )
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3. Contents a. Found in subspecialty curricula (i.e., Otology, Pediatric Otolaryngology, Head and Neck,
Laryngology, etc.) C. Physiology in General Otolaryngology
1. Unit Objective
a. At the completion of this unit, the resident understands the physiology of olfaction and taste, and the aerodigestive tract (humidification, respiration, phonation, and swallowing)
2. Learner Objective s
a. Upon completion of this unit , the resident understands the functions of smell and taste, and the multiple related functions of the aerodigestive tract
3. Contents
a. Olfaction (found in Rhinology section) b. Taste c. Nasal physiology (found in Rhinology section) d. Respiration & phonation in the larynx (found in Laryngology section) e. Swallowing
i. Dysphagia ii. Aspiration iii. Odynophagia
f. Laryngopharyngeal reflux
D. Physical Examination in General Otolaryngology
1. Unit Objective
a. At the completion of this unit, the resident understands how to perform a physical examination of the head and neck, including internal and external structures
2. Learner Objective s
a. Upon completion of this unit , the resident understands:
i. Evaluation of anatomy of the head and neck ii. Techniques for physical examination
3. Contents
a. Inspection b. Palpation c. Otoscopy d. Tuning fork testing e. Rhinoscopy f. Indirect (mirror) laryngoscopy and pharyngoscopy g. Fiberoptic endoscopy h. Neurologic examination i. Dental occlusion j. Anatomic zones of the neck
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4. Clinical Skills
a. During the training period, the resident:
i. Recognizes the normal and abnormal anatomy of the head and neck ii. Utilizes instruments and techniques to perform a complete physical examination of the head
and neck
II. Diseases and Disorders in General Otolaryngology
Most diseases are found within subspecialty curricula (i.e., Otology, Rhinology, etc.) A. Unit Objective
1. At the completion of this unit, the resident can recognize, assess, diagnose, and manage diseases and
disorders within general otolaryngology
B. Learner Objective s
1. Upon completion of this unit, the resident:
a. Recognizes the signs, symptoms and physical findings of diseases and disorders within general otolaryngology
b. Uses appropriate diagnostic tests c. Performs a physical examination of the head and neck d. Understands medical and surgical management of diseases and disorders with general
otolaryngology
C. Contents 1. Ear disease (see Otology section) 2. Nasal disease (see Rhinology section) 3. Sinus disease (see Rhinology section) 4. Allergy (see Allergy section) 5. Oral cavity
a. Cheilitis b. Stomatitis
i. Bacterial ii. Fungal iii. Viral iv. Ulceration
c. Pharyngitis/tonsillitis d. Peritonsillar abscess e. Sialadenitis/sialolithiasis f. Neurologic
i. Palate weakness ii. Tongue weakness/paralysis iii. Dysarthria
6. Larynx and voice (see Laryngology section) 7. Swallowing (see Laryngology section)
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8. Head and neck mass a. Congenital (see Pediatric section) b. Neoplasm (see Head & Neck section) c. Inflammatory
i. Lymphadenitis ii. Nontuberculous mycobacteria iii. Scrofula iv. Sarcoid
d. Rare diseases (sinus histiocytosis with massive lymphadopathy, etc.) 9. Trauma
a. Soft tissue injury b. Soft tissue loss c. Facial fracture
i. Frontal sinus ii. Maxilla and midface iii. Orbital fractures iv. Mandible v. Surgical approaches vi. Closed reduction vs. open reduction
d. Penetrating trauma i. Airway management ii. Neck zones iii. Imaging and evaluation iv. Vascular injuries v. Surgical management
e. Larynx trauma i. Airway management ii. Endoscopic evaluation iii. Radiologic evaluation iv Repair
10. Sleep-disordered breathing (see Sleep Disorders section) a. Snoring b. Sleep apnea c. Other sleep disorders
11. Systemic diseases with head and neck manifestations a. Wegener’s granulomatosis b. Sarcoidosis c. Behçet’s disease d. Pemphigus e. Rheumatoid arthritis f. Other
12. Syndromes a. Osler-Weber-Rendu b. Basal cell nevoid syndrome c. Other
D. Clinical Skills
1. At the completion of this unit, the resident can:
a. Perform a comprehensive history and physical examination, order appropriate laboratory and
diagnostic testing, develop a differential diagnosis, and arrive at a diagnosis of diseases and disorders in general otolaryngology
b. Discuss the nonsurgical and surgical management of diseases and disorders in general otolaryngology
c. Integrate the embryology, genetics, anatomy and physiology in the understanding of diseases and disorders of general otolaryngology
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RHINOLOGY CURRICULUM I. Fundamental Knowledge
A. Anatomy and Physiology of the Nose and Paranasal Sinuses 1. Unit Objective
a. At the completion of this unit , the resident understands the anatomy of the nose and paranasal sinuses, along with pertinent neural structures of the anterior skull base, vascular supply, and adjacent anatomic areas
2. Learner Objective s
a. Upon completion of this unit , the resident:
i. Understands the bony and soft tissue anatomy of the nose and paranasal sinuses and their relationship to related vascular, neural, orbital, and intracranial structures of the anterior and lateral skull base
ii. Knows the surgical anatomy, neural, vascular, and osseous components of the nose and
paranasal sinuses iii. Understands the surgical relationship of the neural, vascular, and osseous components of the
nose and paranasal sinuses to the anterior and lateral skull base iv. Knows operative approaches to the nose and paranasal sinuses
3. Contents
a. Structural surface anatomy i. External nasal anatomy ii. Septum
a) Quadrangular cartilage b) Perpendicular plate of the ethmoid c) Vomer d) Sphenoid rostrum e) Maxillary crest
iii. Lateral nasal wall structures iv. Choana v. Olfactory cleft
b. Bony anatomy i. Maxillary bone
a) Anatomic subunits b) Relationship to pertinent anatomy
i) Infraorbital nerve ii) Orbit iii) Alveolus iv) Pterygomaxillary space
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ii. Ethmoid bone a) Anatomic subunits
i) Uncinate process ii) Ethmoidal bulla iii) Basal lamella iv) Lamina papyracea v) Cribriform
(a) Lateral lamella (b) Lamina cribrosa (c) Middle turbinate
vi) Perpendicular plate vii) Crista galli
b) Extramural ethmoid cells i) Agger nasi ii) Other
iii. Sphenoid bone a) Anatomic subunits
i) Rostrum ii) Greater wing iii) Lesser wing iv) Planum sphenoidale v) Clivus vi) Pterygoid plates
b) Intra-sphenoid surface topography c) Relationship to surrounding structures
i) Optic nerve ii) Carotid artery iii) Cavernous sinus iv) Other
iv. Palatine bone a) Anatomic subunits b) Relationship to surrounding structures
i) Pterygopalatine fissure ii) Foramina
c. Functional anatomy i. Nasal valve
d. Vascular relationships i. External carotid
a) Superior labial artery b) Internal maxillary artery
ii. Internal carotid a) Anterior ethmoidal artery b) Posterior ethmoidal artery
e. Neural relationships i. Olfactory nerve ii. Trigeminal nerve
a) Ophthalmic division i) Nasociliary nerve
(a) Anterior ethmoidal nerve (b) Posterior ethmoidal nerve
b) Maxillary division i) Infraorbital nerve ii) Nasopalatine nerve
iii. Parasympathetic innervation a) Sphenopalatine ganglion b) Vidian nerve
iv. Optic nerve
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f. Diagnostic skills i. Radiology
a) CT b) MR c) Cisternogram
ii. Endoscopy
4. Clinical Skills
a. During the training period, the resident:
i. Recognizes the normal and abnormal anatomy of the nose and the paranasal sinuses ii. Interprets tests to diagnose anatomic abnormalities of the nose and paranasal sinuses iii. Performs surgical procedures that utilize anatomic knowledge of the nose and paranasal
sinuses
B. Embryology of the Nose 1. Unit Objective
a. At the completion of this unit , the resident understands the embryology of the nose and paranasal sinuses
2. Learner Objective s
a. Upon completion of this unit, the resident:
i. Knows the normal embryological development of the nose and paranasal sinuses
ii. Understands how embryological development impacts the anatomy of the nose and paranasal sinuses
3. Content
a. Development of the nasal cavity and paranasal sinuses
i. Nasal development ii. Olfactory placode iii. Maxillary iv. Ethmoid
a) Ethmoturbinals b) Primary furrows – form recesses and meati
v. Sphenoid vi. Frontal
b. Patterns of pneumatization i. Ethmoid
a) Anterior ethmoid cells b) Posterior ethmoid cells c) Variant patterns of pneumatization
ii. Frontal iii. Maxillary iv Sphenoid
c. Cleft palate d. Encephalocele e. Dermoid
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4. Clinical Skills
a. During the training period, the resident:
i. Recognizes the normal embryologic development of the nose and paranasal sinuses and its impact on the fixed and variable anatomy of the paranasal sinuses
ii. Recognizes how variations in paranasal sinus pneumatization contribute to subtle variations in
surgical anatomy in a predictable fashion iii. Interprets imaging and endoscopic studies that demonstrate variations and disorders of the
embryologic development of the nose and paranasal sinuses iv. Performs surgical procedures that utilize the embryologic knowledge of the nose and
paranasal sinuses
C. Physiology of the Nose and Paranasal Sinuses
1. Unit Objective
a. At the completion of this unit , the resident understands the normal physiology of the nose 2. Learner Objective s
a. Upon completion of this unit, the resident understands:
i. How normal function of the nasal mucosa contributes to the homeostasis of the nose and paranasal sinus
ii. The role of nasal airflow in the function of the nose
3. Content
a. Mucosa and mucociliary function i. Mucosa
a) Respiratory epithelium b) Pseudostratified columnar epithelium c) Cilia structure
i) Ciliary ultrastructure ii. Vascular dynamics
a) Autonomic control b) Nasal cycle
iii. Glandular anatomy a) Goblet cells b) Seromucinous glands
iv. Mucus a) Composition
b) Motility c) Immune function
v. Mucociliary flow a) Function b) Flow pathways
b. Air flow i. Air flow characteristics ii. Nasal air processing
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4. Clinical Skills
a. During the tra ining period, the resident:
i. Uses knowledge of nasal physiology to interpret causes of nasal disease ii. Performs surgical procedures, understanding their potential impact upon nasal and paranasal
sinus physiology
D. Olfaction
1. Unit Objective
a. At the completion of this unit , the resident understands nasal contribution to olfaction 2. Learner Objective s
a. Upon completion of this unit, the resident understands:
i. The relationship between normal function of the nasal mucosa and olfactory function
ii. The role of nasal airflow contributes to olfaction
iii. Neural pathways of olfaction 3. Content
a. Neuroanatomy i. Olfactory neuroepithelium
a) Histology b) Diffusion of odorants
i) Role of mucus ii. Olfactory tract neuroanatomy
a) Peripheral b) Central
b. Dynamics of olfaction i. Odorants ii. Airflow dynamics at olfactory mucosa iii. Odorant diffusion iv. Olfactory transduction and coding v. Central processing
c. Olfactory testing i. Sensorineural tests ii. Imaging iii. Lab
4. Clinical Skills
a. During the training period, the resident demonstrates:
i. Ability to evaluate and treat causes of olfactory dysfunction ii. Understanding of the potential impact of various treatments upon olfactory function
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E. Nasal and Paranasal Sinus Immunology/Inflammation
1. Unit Objective s
a. At the completion of this unit , the resident understands the role of the immune system in maintaining nasal and paranasal sinus homeostasis
2. Learner Objective s
a. Upon completion of this unit, the resident:
i. Understands the role of the immune system in maintenance of nasal and paranasal sinus homeostasis
ii. Recognizes the role of inflammation in common diseases of the nose and paranasal sinuses
3. Content
a. Immunology i. General aspects ii. Triggers of the immune response iii. Components
a) Inflammatory cells b) Immunoglobulins c) Inflammatory mediators
b. Microbiology c. Endocrinology d. Neurology e. Diagnostic interpretation
4. Clinical Skills
a. During the training period, the resident demonstrates ability to:
i. Recognize the role inflammation plays in chronic and acute disorders of the nose and paranasal sinuses
ii. Evaluate for underlying causes of inflammation iii. Maximize medical evaluation as a component of the management of patients with non-
emergent inflammatory paranasal sinus disease iv. Appropriately select surgical candidates based upon knowledge of underlying inflammatory
disorders F. Physical Examination
1. Unit Objective s a. At the completion of this unit , the resident demonstrates the components of a thorough physical
examination as it relates to the nose and paranasal sinuses
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2. Learner Objective s a. Upon completion of this unit, the resident:
i. Understands the individual components of the physical examination as it relates to the nose and paranasal sinus
ii. Performs a comprehensive physical examination as it relates to the nose and paranasal sinuses
iii. Interprets physical findings accurately
3. Content
a. External nasal examination b. Evaluation of nasal valve function c. Anterior rhinoscopy d. Indirect nasopharyngoscopy e. Nasal endoscopy
i. Rigid ii. Flexible
f. Olfactory testing g. Nasopharyngeal culture h. Sinonasal aspirate/culture
i. Antral puncture ii. Endoscopic middle meatal culture
i. Evaluation for CSF fistula j. Interpretation of findings
4. Clinical Skills
a. During the training period, the resident:
i. Develops the ability to perform a comprehensive physical examination directed to the nose and paranasal sinuses
ii. Accurately interprets results of the physical examination iii. Uses information gathered during physical examination to develop diagnostic/treatment plans
for diseases of the nose and paranasal sinuses II. Diseases, Disorders, and Conditions
A. Unit Objective
1. At the completion of this unit, the resident can recognize, assess, diagnose, and manage diseases and disorders of the nose and paranasal sinuses, and anterior skull base
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B. Learner Objective s 1. Upon completion of this unit, the resident:
a. Recognizes the signs and symptoms of diseases and disorders of the nose, paranasal sinuses, and anterior skull base
b. Uses the appropriate diagnostic tests to assess diseases and disorders of the nose, paranasal
sinuses, and anterior skull base
c. Develops a diagnosis of diseases and disorders of the nose, paranasal sinuses, and anterior skull base
d. Understands the surgical and non-surgical management of diseases and disorders of the nose,
paranasal sinuses, and anterior skull base
C. Content
1. Olfactory Disorders a. Neurosensory olfactory disorders
i. Viral ii. Trauma iii. Neoplasm iv. Demyelinating or degenerative CNS disorder
b. Conductive disorders i. Inflammatory rhinosinusitis
2. Nose a. Congenital malformations b. Genetic disorders
i. HHT c. Trauma d. Foreign body e. Anatomic obstruction
i. Nasal valve collapse ii. Inferior turbinate hypertrophy iii. Septal deviation
f. Infections i. Vestibulitis ii. Rhinitis
g. Inflammation i. Allergic rhinitis ii. Non-allergic rhinitis
h. Epistaxis i. Neoplasms
3. Paranasal sinuses a. Congenital malformations b. Trauma/foreign body c. Developmental
i. Mucocele d. Inflammatory
i. Chronic inflammatory rhinosinusitis with polyposis ii. Chronic inflammatory rhinosinusitis without polyposis iii. Allergic fungal rhinosinusitis iv. Relationship between rhinosinusitis and asthma
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e. Infectious i. Acute rhinosinusitis ii. Chronic infectious rhinosinusitis iii. Invasive fungal iv. Infectious complications of CRS or ABRS
a) Orbital b) Intracranial c) Facial soft tissue
f. Granulomatous g. Cystic fibrosis h. Autoimmune i. Complications of paranasal sinus surgery
a) Intracranial b) CSF fistula c) Orbital d) Recurrence/persistence of disease e) Neoplasms
4. Skull base a. Congenital b. Developmental c. Trauma d. Neoplasm
5. Pathology of regions adjacent to the paranasal sinuses a. Orbital/Lacrimal
i. Dacryocystitis ii. Grave’s exophthalmia
b. Intracranial i. Pituitary adenoma, etc.
D. Clinical Skills
1. Upon the completion of this unit , the resident can:
a. Obtain a comprehensive history, perform a focused physical examination, order appropriate laboratory and diagnostic studies to develop a thorough differential diagnosis, and arrive at a definitive diagnosis of the above diseases of the nose, paranasal sinuses and adjacent structures
b. Discuss the nonsurgical as well as surgical management of the diseases and disorders of the nose,
paranasal sinuses and adjacent structures c. Discuss the procedures and strategies necessary to treat the diseases and disorders of the nose,
paranasal sinuses, skull base, and adjacent structures III. Surgical Concepts
A. Unit Objective
1. At the completion of this unit , the resident understands the treatment strategies and procedures for the surgical management of diseases of the nose, paranasal sinuses, skull base, and adjacent structures
B. Learner Objective s
1. Upon completion of this unit, the resident:
a. Understands the surgical strategies necessary to treat diseases and disorders of the nose, paranasal sinuses, skull base, and adjacent structures
b. Performs surgical procedures to treat diseases and disorders of the nose, paranasal sinuses, skull
base, and adjacent structures
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C. Content
1. General a. Basic principles
i. Local anesthesia ii. Principles of hemostasis
b. Open approaches to the paranasal sinuses and anterior skull base c. Laser principles d. Equipment/instruments e. Intra-operative image guidance f. Graft materials
2. Specific surgical procedures a. Endoscopic
i. Nasal endoscopy ii. Inferior turbinoplasty iii. Endoscopic septoplasty iv. Maxillary antrostomy v. Ethmoidectomy vi. Sphenoidotomy vii. Frontal sinusotomy
a) Draf I b) Draf II c) Draf III
viii. Trans-pterygoid approach to: a) Pterygomaxillary fissure b) Sphenoid sinus
ix. Repair of CSF fistula (access to encephalocele/meningocele) a) Ethmoid b) Sphenoid
x. Concha bullosa xi. Orbital decompression xii. Dacryocystorhinotomy xiii. Medial maxillectomy xiv. Hypophysectomy xv . Laser ablation of telangiectasia (HHT)
b. Non-endoscopic i. Septoplasty ii. Inferior turbinoplasty iii. Anterior antrostomy iv. External ethmoidectomy v. Frontal
a) Trephine b) Osteoplastic flap c) Obliteration d) Cranialization e) Ablation
vi. Transeptal sphenoid sinusotomy vii. Medial maxillectomy viii. Septal dermaplasty
D. Clinical Skills
1. At the completion of this unit , the resident:
a. Understands the surgical strategies and procedures to manage diseases and disorders of the nose, paranasal sinuses, skull base, and adjacent structures
b. Selects the most appropriate surgical procedures to treat diseases and disorders of the nose,
paranasal sinuses, skull base, and adjacent structures
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ALLERGY CURRICULUM I. Fundamental Knowledge
A. Immunology of Allergic Ear, Nose and Throat Disorders
1. Unit Objective s
a. At the completion of this unit, the resident understands the structure and function of the immune system with its related cellular and humoral functions as it relates to allergic respiratory disorders
2. Learner Objective s
a. Upon completion of this unit, the resident understands:
i. The complex structure and function of the immune system as it relates to cellular and humoral function along with the cells and related cytokines that are produced during the allergic reaction
ii. The structural anatomy of the respiratory tract and related functions of conjunctiva, middle
ear, tracheal and bronchial mu cosa and sinus and nasal mucosa
3. Contents
a. Definition of immunity, anaphylaxis, allergy, atopy b. Role of innate and adaptive immunity
i. Non-specific responses ii. Specific responses
a) Specificity b) Memory c) Self-limitation d) Self-recognition (non-reaction to self) e) Amplification f) Feedback control g) Recruitment of secondary defense mechanisms
c. Components of the immune system i. Cells of the immune system
a) Classes of lymphocytes including T cells, B cells, null cells i) TH-1 and TH-2 cells ii) Suppressor T-cells
b) Mononuclear phagocytes and macrophages i) Role of antigen-presenting cells
c) Mast cells and basophils d) Eosinophils e) Neutrophils and platelets
ii. Antibodies and antigens a) Immunoglobulins b) Antibodies c) Antibody response to antigen challenge
iii. Nonspecific mediators: cytokines and lymphokines a) Role of interferon, GM-CSF, TNF-alpha, TNF-beta, role of interleukins
iv. Complement a) Classic and alternate pathway activation in the complement cascade
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v. Hypersensitivity reactions: Gell and Coombs reactions a) Type I: immediate (anaphylactic) hypersensitivity reaction along with early and late
phase reactions b) Type II: antibody-dependent cytotoxicity c) Type III: immune complex-mediated hypersensitivity reactions d) Type IV: cell-mediated hypersensitivity e) Other hypersensitivity reactions
4. Clinical Skills
a. At the completion of this unit , the resident understands the clinical impact of immunologic disorders of the head and neck
B. Inhalant Allergic Disorders
1. Unit Objective s a. At the completion of this unit, the resident understands the nature of inhalant allergens and their
impact on the patient with allergic and respiratory disorders
2. Learner Objective s a. Upon completion of this unit, the resident understands:
i. Relevant inhalant allergens giving ris e to allergic disorders and the cross reactivity of these allergens
ii. Nature of food allergy, types of food allergens and different food allergy reactions iii. Categories of antibodies, their production stimulation and secretion
3. Contents (nature of allergic antigens)
a. Categories of inhalant allergens i. Pollens
a) Tree, grass, weed pollens b) Thommen’s postulates
ii. Fungi iii. Bacteria iv. House dust mite v. Animal danders
b. Nature of food allergens and food allergy i. Immunologic reactions to foods ii. Cyclic food allergy
a) Various stages of cyclic food sensitivity b) Masked sensitization and food addiction c) Diagnostic techniques for cyclic food allergy
i) Oral challenge test ii) Skin testing techniques
(a) Intradermal testing technique (b) In vitro food tests
iii. Fixed food allergy iv. Signs and symptoms of food allergy v. Theory of action of neutralization treatment of food sensitivity
c. Development of antibodies i. Immunoglobulins: development of five different classes of the immunoglobulins
distinguished by antigenic and structural characteristics ii. Production of immunoglobulins by transformation of B cells into plasma cells
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4. Clinical Skills a. At the completion of this unit , the resident understands the pathophysiology behind
immunotherapy treatment of inhalant allergy
C. Hypersensitivity Disorders
1. Unit Objective s
a. At the completion of this unit, the resident understands the development of different types of hypersensitivity reactions and their impact on the patient with allergic and respiratory disorders
2. Learner Objective s
a. Upon completion of this unit, the resident understands:
i. Different types of hypersensit ivity reactions that give rise to allergic disorders ii. The nature of mechanisms of control of hypersensitivity reactions
3. Contents
a. Gell and Coombs hypersensitivity reactions i. Type I: immediate hypersensitivity reaction ii. Type II: antibody-dependent cytotoxicity iii. Type III: immune complex-mediated hypersensitivity iv. Type IV: cell-mediated hypersensitivity
b. Additional hypersensitivity reactions 4. Clinical Skills
a. At the completion of this unit , the resident understands the pathophysiology behind hypersensitivity reactions
D. Diagnosis of Allergic Ear , Nose and Throat Disorders
1. Unit Objective s
a. At the completion of this unit, the resident understands the diagnostic methods to determine the presence of an allergic disorder in the ear, nose and throat patient
2. Learner Objective s
a. Upon completion of this unit, the resident:
i. Understands the relevant history, chief complaints and medical history that demonstrate a diagnosis of upper respiratory allergy
ii. Understands the physical examination characteristics of a patient with respiratory allergy
including the conjunctiva, middle ear, tracheal and bronchial mucosa and sinus and nasal mucosa
iii. Understands the rational diagnostic methodologies and physical examination of the patient
with allergic disorders iv. Can formulate a plan of management for a patient with ear, nose and throat allergic disorders
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3. Contents
a. History, pertinent medical history, review of systems b. Family history: awareness of the possibility of familial involvement of inhalant respiratory
allergies c. Specific physical examination and physical findings
i. General a) Observation
ii. Skin a) Urticaria, eczema
iii. Eyes a) Allergic shiners b) Acute allergic conjunctivitis c) Atopic keratoconjunctivitis
iv. Ears a) External ear: Id reaction b) Middle ear: recurrent serous otitis media and eustachian tube dysfunction
v. Nose a) Chronic nasal congestion b) Allergic hypertrophic inferior turbinates c) Nasal crease d) Nasal polyposis
vi. Oral cavity/oropharynx a) Chronic mouth breathing b) High arched palate c) Posterior oropharyngeal cobblestone formation
vii. Larynx a) Edema of larynx
viii. Chest and pulmonary tract a) Asthma and classic expiratory wheezes
4. Clinical Skills
a. At the completion of this unit, the resident can diagnose:
i. Allergic disorders from history ii. Allergic disorders from physical examination
E. Diagnostic Testing for Allergic Ear , Nose and Throat Disorders
1. Unit Objective s a. At the comp letion of this unit, the resident understands the methods of inhalant and in vitro testing
techniques for the proper diagnosis of allergic respiratory disorders 2. Learner Objective s
a. Upon completion of this unit, the resident:
i. Understands the different methods of skin testing and their results ii. Understands the methods of in vitro testing for respiratory and food allergens and the results iii. Can formulate a plan of management for a patient with ear nose and throat allergic disorders
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3. Contents
a. Skin testing techniques b. Role of scratch testing c. Skin prick testing
i. Single prick techniques a) Wheal and flare response b) Method of measurement
ii. Multiple prick testing technique a) Different types of multiple prick testing methods
d. Intradermal testing i. Placement of a known quantity of antigen into the dermis ii. Skin endpoint titration (SET) iii. Screening for allergies using skin testing
e. In vitro testing techniques f. RAST testing g. Enzymatic in vitro techniques h. Indications for in vitro testing i. Allergy screening using in vitro techniques j. Immunotherapy based on in vitro test results k. Combining in vitro and skin testing techniques l. Diagnostic techniques for food allergy
i. History of food allergy reactions of patient ii. In vitro testing iii. Skin testing techniques
4. Clinical Skills
a. At the completion of this unit , the resident can diagnose allergic disorders using different diagnostic tests
II. Diseases , Disorders and Conditions
A. Unit Objective s
1. At the completion of this unit, the resident understands the different conditions of upper respiratory tract disorders and how allergy may relate to the disease and to symptoms
B. Learner Objective s
1. Upon completion of this unit, the resident can:
a. Diagnose common allergy problems b. Formulate a plan of management for a patient with ear nose and throat allergic disorders
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C. Contents
1. Allergic Rhinitis
a. Unit Objective s
i. At the completion of this unit, the resident understands the nature and etiology of common allergic rhinitis , as well as the mechanisms of management
b. Learner Objective s
i. Upon completion of this unit, the resident:
a) Understands the development of allergic rhinitis and signs and symptoms of the problem b) Understands the nasal anatomy and physiology and its relation to allergic disease c) Can formulate a plan of management for a patient with symptoms of allergic rhinitis d) Understands the differential d iagnosis of allergic rhinitis and other types of rhinitis
c. Conte nts
i. Seasonal intermittent rhinitis ii. Springtime allergy and related pollens iii. Fall allergy and related pollens iv. Perennial persistent rhinitis
a) Relative allergens causing the perennial symptoms v. Persistent rhinitis vi. Rhinitis medicamentosa vii. Rhinitis of pregnancy viii. Vasomotor rhinitis
d. Clinical Skills
i. At the completion of this unit , the resident can diagnose and treat common rhinologic problems related to allergy and inflammation
2. Allergic Ocular Disease and Conjunctivitis
a. Unit Objective s
i. At the completion of this unit, the resident understands the manifestations of ocular disorders and inhalant allergies
b. Learner Objective s
i. Upon completion of this unit, the resident:
a) Understands the signs and symptoms of allerg ic ocular disease b) Can formulate a plan of management of a patient with allergic ocular disorders c) Pathophysiology of the allergic reaction in the eye d) Classification of ocular allergy
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c. Contents
i. Seasonal/perennial allergic conjunctivitis ii. Vernal keratoconjunctivitis iii. Atopic keratoconjunctivitis iv. Giant papillary conjunctivitis v. Drug-induced allergic conjunctivitis vi. Therapy for allergic ocular disease
a) Topical antihistamines b) Topical mast cell stabilizers c) Nonsteroidal anti-inflammatory medications d) Corticosteroid therapy
d. Clinical Skills
i. At the completion of this unit , the resident can diagnose and treat common ophthalmologic disorders related to allergy and inflammation
3. Allergic Disease and Middle Ear Dysfunction
a. Unit Objective s
i. At the completion of this unit, the resident understands the different manifestations of middle ear disease as it relates to inhalant allergy
b. Learner Objective s
i. Upon completion of this unit, the resident:
a) Understands the role of IgE reactions and development of middle ear problems in the allergic patient
b) Can formulate a plan of management for a patient with ear, nose and throat allergic
disorders c. Contents
i. Mucous membrane and the middle ear ii. Manifestations of serous otitis media iii. Eustachian tube dysfunction
d. Clinical Skills
i. At the completion of this unit , the resident can diagnose and treat common middle ear
disorders related to allergy and inflammation 4. Allergic Disease and Inner Ear Dysfunction
a. Unit Objective s
i. At the completion of this unit, the resident understands the different manifestations of inner ear disorders and how they relate to symptoms of patients
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b. Learner Objective s
i. Upon completion of this unit, the resident:
a) Understands the rationale of the development of signs and symptoms of inner ear dysfunction with allergic symptoms
b) Can formulate a plan of management for a patient with inner ear allergic disorders
c. Contents
i. Ménière’s syndrome and indications for allergy testing ii. Vertigo induced from hypersensitivity
d. Clinical Skills
i. At the completion of this unit , the resident can diagnose and treat common inner ear disorders related to allergy and inflammation
5. Allergic Disorders and Rhinosinusitis
a. Unit Objective s
i. At the completion of this unit, the resident understands the mechanism of the development of rhinosinusitis in the patient with allergic symptomatology
b. Learner Objective s
i. Upon completion of this unit, the resident:
a) Understands the relationship of allergies to subsequent development of inflammatory and possible bacterial rhinosinusitis
b) Can formulate a plan of management for a patient with rhinosinusitis
c. Contents
i. Pathophysiology of paranasal sinus disorders ii. Acute rhinosinusitis iii. Recurrent acute rhinosinusitis iv. Chronic rhinosinusitis v. Allergic fungal rhinosinusitis (AFRS)
a) Diagnostic criteria of allergic fungal rhinosinusitis b) Pathophysiology of allergic fungal rhinosinusitis c) Role of fungal antigens in evaluation d) Testing for fungal allergy e) Therapy for AFRS f) Immunotherapy in the patient with AFRS
d. Clinical Skills
i. At the completion of this unit , the resident understands the association between allergy and rhinosinusitis and can treat accordingly
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6. Allergic Disease and Laryngeal Dysfunction
a. Unit Objective s
i. At the completion of this unit, the resident understands the different conditions of laryngeal and pharyngeal disorders and how they relate to symptoms of patients with allergy
b. Learner Objective s
i. Upon completion of this unit, the resident:
a) Understands the anatomy and physiology of the larynx and pharynx and the signs and symptoms of allergic laryngeal disorders
b) Can formulate a plan of management for a patient with laryngeal and pharyngeal allergic disorders
c. Contents
i. Laryngopharyngeal anatomy ii. Acute laryngopharyngitis: anaphylaxis iii. Allergic angioedema and laryngitis iv. Angioedema and urticaria of the larynx v. Role of ACE inhibitors vi. Oral allergy syndrome vii. LPR and GERD
d. Clinical Skills
i. At the completion of this unit , the resident understands the association between allergy and laryngeal dysfunction and can treat accordingly
7. Allergic Disease and Asthma
a. Unit Objective s
i. At the completion of this unit, the resident understands the different symptoms of asthma in allergic patients
b. Learner Objective s
i. Upon completion of this unit, the resident:
a) Understands the mechanisms of asthma and pathophysiology of this problem b) Can formulate a plan of management for a patient with asthma and understands the
pertinent medications to control symptoms c. Content
i. Asthma diagnosis ii. Auscultation iii. Pulmonary function testing
a) Role of flow-volume loop b) Peak flow measurements
iv. Pathophysiology of asthma v. Asthma severity vi. Pharmacotherapy of asthma
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d. Clinical skills
i. At the completion of this unit, the resident understands the association between allergy and asthma
8. Latex Hypersensitivity
a. Unit Objective s
i. At the completion of this unit, the resident understands the nature of latex hypersensitivity
b. Learner Objective s
i. Upon completion of this unit, the resident:
a) Understands the role of latex reactions and cross-reactivity b) Can formulate a plan of management for a patient with latex hypersensitivity
c. Content
i. Latex hypersensitivity ii. Cross reactions and latex hypersensitivity iii. Mechanism of management of the patient with latex hypersensitivity
d. Clinical Skills
i. At the completion of this unit , the resident understands and can treat latex hypersensitivity reactions
9. Allergic Manifestations of Chemical Sensitivity
a. Unit Objective s
i. At the completion of this unit, the resident understands the different manifestations of chemical sensitivity
b. Learner Objective s
i. Upon completion of this unit, the resident:
a) Understands the symptoms of possible chemical sensitivity in the allergic patient b) Can formulate a plan of management for a patient with e-chemical sensitivity and other
allergic disorders
c. Content
i. Nature of chemical sensitivity ii. Mechanisms of chemical injury
a) Acute poisoning b) Chronic poisoning
iii. Total allergic load iv. Chemical hypersensitivity tests v. Treatment of chemical sensitivity
d. Clinical Skills
i. At the completion of this unit , the resident understands and can treat chemical sensitivity disorders
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10. Non-Allergic Rhinitis
a. Unit Objective s
i. At the completion of this unit, the resident understands the signs and symptoms of a patient with rhinitis not due to any allergic sensitivities
b. Learner Objective s
i. Upon completion of this unit, the resident:
a) Understands the manifestations of symptoms of non-allergic rhinitis b) Can formulate a plan of management for a patient with symptoms of non-allergic
disorders
c. Content
i. Vasomotor rhinitis ii. Management of symptoms of non-allergic rhinitis
d. Clinical Skills
i. At the completion of this unit , the resident understands and can treat non-allergic rhinitis III. Habilitation/Rehabilitation
A. Unit Objective s
1. At the completion of this unit, the resident understands the methods to improve a patient’s symptoms of allergic rhinitis with development of avoidance techniques, environmental controls, pharmacotherapy and potential immunotherapy
B. Learner Objective s
1. Upon completion of this unit, the resident:
a. Understands the rationale for the use of environmental controls
b. Can utilize appropriate pharmacotherapy to help control symptoms of inhalant allergy
c. Can formulate a plan of management using appropriate allergen immunotherapy
d. Understands the potential reactions that may occur in the patient undergoing immunotherapy
treatment
C. Content 1. Environmental controls and avoidance techniques
a. Prevention of allergy b. Specific environmental controls
i. Pollen controls ii. Mold controls iii. Dust mite control iv. Epidermal avoidance v. Other allergens and their controls vi. Role of use of air filters and air conditioning
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2. Pharmacotherapy a. First and second generation antihistamines
i. Uses of classic antihistamines ii. Benefits of second generation antihistamines iii. Combination decongestant and antihistamine therapy
b. Decongestant therapy c. Mast cell stabilizers d. Corticosteroids
i. Topical a) Different topical medications b) Adverse reactions to topical intranasal steroids
ii. Systemic e. Anti-leukotrienes f. Mucolytic agents g. Monoclonal antibody therapy
3. Allergen immunotherapy a. Indications for immunotherapy b. Contraindications to immunotherapy c. Interpretation of allergy tests d. Mixing immunotherapy vials e. Immunotherapy escalation schedules f. Maintenance immunotherapy
i. Symptom-relieving dose of treatment ii. Maximally tolerated dose treatment iii. Optimal-dose treatment
g. Immunotherapy safety
D. Clinical Skills 1. At the completion of this unit , the resident understands and can:
a. Recommend environmental controls and avoidance techniques
b. Treat with pharmacotherapy
c. Treat allergic disorders with immunotherapy
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LARYNGOLOGY, VOICE AND SWALLOWING CURRICULUM I. Fundamental Knowledge
A. General Larynx Anatomy
1. Unit Objective
a. At the completion of this unit, the resident understands the basic anatomy of the larynx, including surface and internal anatomy
2. Learner Objective s
a. Upon completion of this unit , the resident:
i. Understands the anatomy of the larynx, including relationships between framework, muscles, and nerves
ii. Knows the surgical anatomy of the larynx
3. Contents
a. Cartilage i. Thyroid ii. Cricoid iii. Arytenoid, with emphasis on cricoarytenoid motion iv. Cuneiform and corniculate
b. Muscles, including actions c. Vascular supply and lymphatic drainage d. Nerves
i. Sensory ii. Motor
e. Mucosa, including layered histology i. Epithelium ii. Basement membrane iii. Superficial, middle and deep layers of lamina propria
a) Vocal ligament f. Membranes
i. Thyrohyoid ii. Cricothyroid iii. Conus elasticus iv. Quadrangular membrane
4. Clinical skills
a. At the completion of this unit , the resident understands the anatomy of the larynx
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B. General Larynx Embryology
1. Unit Objective
a. At the completion of this unit, the resident understands the basic concepts and importance of embryology of the larynx
2. Learner Objective s
a. Upon completion of this unit , the resident understands:
i. Embryology of the larynx, including interrelationships ii. Surgical implications of embryology
3. Contents
a. Embryologic fusion planes b. Branchial arches, pouches, etc.
4. Clinical Skills
a. At the completion of this unit , the resident understands embryology and its relationship to anatomy of the larynx
C. Laryngeal and Pharyngeal Physiology
1. Unit Objective
a. At the completion of this unit, the resident understands the physiology of respiration, phonation and swallowing
2. Learner Objective s
a. Upon completion of this unit, the resident understands the functions of the larynx and pharynx
3. Contents
a. Respiration b. Phonation
i. Cover-body theory of phonation, including meaning and significance of “mucosal wave” ii. Mechanism of pitch control iii. Anatomic and physiologic correlates of voice quality
c. Swallowing d. Airway protection
4. Clinical skills
a. At the completion of this unit , the resident understands the:
i. Physiology of different functions of the larynx ii. Impact of laryngeal dysfunction on different aspects of normal physiology
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D. Physical Examination in Laryngology
1. Unit Objective
a. At the completion of this unit, the resident understands how to perform a physical examination of the larynx
2. Learner Objective s
a. Upon completion of this unit , the resident understands the:
i. Evaluation of the anatomy of the head and neck ii. Techniques for physical examination
3. Contents
a. Inspection b. Palpation c. Indirect (mirror) examination d. Fiberoptic examination
i. Flexible ii. Hopkins rod
e. Stroboscopy f. Direct (operative) laryngoscopy g. Other evaluations
i. Voice analysis (jitter, shimmer, etc.) ii. EMG iii. Perceptual analysis
4. Clinical skills
a. At the completion of this unit , the resident can perform:
i. A comprehensive physical examination and evaluation of the larynx and laryngeal function
ii. Appropriate evaluation of the larynx II. Diseases, Disorders, and Conditions in Laryngology
A. Unit Objective
1. At the completion of this unit, the resident can recognize, assess, diagnose and manage diseases and disorders within laryngology
B. Learner Objective s
1. Upon completion of this unit, the resident:
a. Recognizes the signs, symptoms, and physical findings of diseases and disorders in laryngology b. Uses appropriate diagnostic tests c. Performs physical examinations d. Understands medical and surgical management of diseases and disorders within general
otolaryngology
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C. Contents 1. Infectious
a. Laryngitis i. Bacterial ii. Viral iii. Fungal
b. Pharyngitis i. Bacterial ii. Viral iii. Fungal
2. Inflammatory/traumatic a. Laryngitis b. Laryngopharyngeal reflux c. Hemorrhage d. Polyp e. Cyst f. Nodule g. Granuloma h. Reinke’s edema i. Scar
3. Neoplasm a. Benign
i. Papilloma ii. Other
b. Malignant i. Squamous cell carcinoma ii. Other
4. Structural a. Sulcus vocalis b. Voice changes of aging c. Saccular cyst d. Laryngocele
i. Internal ii. External iii. Mixed
5. Neurologic a. Vocal fold paralysis or paresis
i. Unilateral ii. Bilateral
b. Sensory deficit c. Spasmodic dysphonia
6. Syndromes and diseases with laryngeal involvement a. Sarcoid b. Amyloid c. Wegener’s d. Tuberculosis e. Other granulomatous disease
D. Clinical skills 1. At the completion of this unit , the resident can:
a. Develop a thorough differential diagnosis and arrive at a definitive diagnosis of the above diseases and disorders of the larynx
b. Discuss the different etiologies, manifestations, and patterns of laryngeal diseases and disorders
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III. Therapeutic and Surgical Concepts
A. Unit Objective
1. At the completion of this unit, the resident understands the treatment strategies and procedures for the medical, surgical and behavioral management of diseases of the larynx and pharynx
B. Learner Objective s
1. Upon completion of this unit, the resident:
a. Understands medical, surgical and behavioral strategies necessary to treat diseases and disorders of the larynx and pharynx
b. Can perform surgical strategies to treat diseases and disorders of the larynx and pharynx
C. Contents
1. Behavioral management a. Voice rest b. Voice therapy
2. Medical management a. Steroids b. Reflux medication c. Botulinum toxin d. Other
3. Surgical management a. External surgical approaches
i. Laryngofissure ii. Laryngeal framework surgery
a) Thyroplasty types 1 to 4 b) Arytenoid repositioning surgery
iii. ORIF of larynx b. Internal/endoscopic approaches
i. Fiberoptic flexible laryngoscopy a) Therapeutic
i) Injection ii) Foreign body removal iii) Other
ii. Direct laryngoscopy a) Suspension surgical laryngoscopy b) Micro-suspension surgical laryngoscopy
iii. Vocal fold surgery a) Injection b) Injection augmentation c) Botox d) Incisional biopsy e) Excisional biopsy f) Stripping g) Marsupialization h) Mucosal microflap
iv. Laser surgery a) CO2 b) Angiolytic lasers
v. Microdebrider surgery
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D. Clinical Skills
1. At the completion of this unit , the resident:
a. Understands and can perform endoscopic and open surgical procedures on the larynx b. Can select the most appropriate surgical procedure in order to treat diseases and disorders of the
larynx
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ADULT SLEEP MEDICINE CURRICULUM I. Fundamental Knowledge
A. Sleep Physiology
1. Unit Objective
a. At the completion of this unit, the resident understands the physiology of sleep, including sleep stages, and sleep disorders
2. Learner Objective s
a. Upon completion of this unit, the resident understands:
i. Sleep physiology ii. Sleep disorders iii. Sleep evaluation techniques
3. Contents
a. Sleep stages b. Sleep latency c. Neural centers d. Neural connections e. Electroencephalogram changes f. Circadian features related to sleep g. Sleep disorders
i. Sleep stage dysfunction ii. Sleep timing disorders: delayed sleep phase, advanced sleep phase, shift work/jet lag iii. Inadequate sleep/sleep deprivation iv. Restless limb syndrome/periodic limb movement disorder/bruxism v. Insomnia vi. Narcolepsy vii. Sleep disordered breathing
a) Central sleep apnea b) Obstructive sleep apnea/snoring/upper airway resistance syndrome
i) Sites of obstruction ii) Severity staging iii) Associated comorbidity
(a) Medical: hypertension, etc. (b) Sequelae: sleepiness, performance
4. Clinical skills
a. At the completion of this unit, the resident understands:
i. Normal and abnormal sleep physiology ii. Anatomic mechanisms of obstructive apnea iii. Evaluation of normal and abnormal sleep iv. Medical and functional consequences of sleep apnea
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B. Physical Examination in Sleep Disordered Breathing
1. Unit Objective
a. At the completion of this unit, the resident understands the examination of the patient with a sleep disorder
2. Learner Objective s
a. Upon completion of this unit, the resident can perform an appropriate physical examination of a patient with a sleep disorder
3. Contents
a. Nasal anatomy b. Soft palate c. Oropharynx and retrolingual airway d. Tonsil and adenoid tissue e. Tongue
i. Oral ii. Tongue base
f. Craniofacial (mandible, maxilla) g. Neck soft tissue h. Hyoid position i. Laryngeal anatomy j. Body habitus k. Body mass index
4. Clinical skill
a. At the completion of this unit, the resident can perform a comprehensive physical examination of the patient with a sleep disorder
C. Diagnostic Evaluation in Sleep Disorders (including apnea)
1. Unit Objective
a. At the completion of this unit, the resident understands the diagnostic evaluation of the patient with a sleep disorder
2. Learner Objective s
a. Upon completion of this unit, the resident can perform an appropriate diagnostic evaluation of the patient with a sleep disorder
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3. Content
a. Sleep study (polysomnography, ambulatory cardiorespiratory studies, actigraphy) i. Data measured (apnea index, etc.)
a) Normal ranges ii. Sleep architecture iii. Ventilation/respiration parameters iv. Oxygenation parameters v. Position, sleep stage
b. History: symptoms, comorbidities c. Physical examination d. Fiberoptic examination
i. Sedated ii. Awake
e. Occlusion f. Cephalometric evaluation g. Multiplanar radiologic evaluation
i. CT ii. MRI
4. Clinical skills
a. At the completion of this unit, the resident:
i. Understands indications for further evaluation of sleep dysfunction ii. Can interpret an overnight polysomnogram iii. Can use diagnostic tools for anatomic evaluation
II. Diseases and Disorders
A. Unit Objective
1. At the completion of this unit, the resident understands sleep diseases and disorders B. Learner Objective
1. Upon completion of this unit , the resident:
a. Knows the differential diagnosis of sleep disorders b. Can diagnose sleep disorders including sleep-disordered breathing
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C. Content
1. Sleep stage dysfunction 2. Sleep timing disorders: delayed sleep phase, advanced sleep phase, shift work/jet lag 3. Inadequate sleep/sleep deprivation 4. Restless limb syndrome/periodic limb movement disorder/bruxism 5. Insomnia 6. Narcolepsy 7. Sleep disordered breathing
a. Central sleep apnea b. Obstructive sleep apnea/snoring/upper airway resistance syndrome
i. Sites of obstruction ii. Severity staging iii. Associated comorbidity
a) Medical: hypertension, etc. b) Sequelae: sleepiness, performance
D. Clinical Skills
1. At the completion of this unit , the resident understands the differential diagnosis of sleep disorders III. Surgical Concepts
A. Unit Objective
1. At the completion of this unit, the resident understands the surgical treatment of some sleep disorders
B. Learner Objective
1. Upon completion of this unit , the resident:
a. Can perform surgical correction of anatomic deformities causing sleep apnea b. Understands the role of surgery, realistic goals of surgery, and staging of surgical procedures c. Understands indications for surgical intervention and expected outcomes d. Understands risks and complications of surgery
C. Content
1. Roles of surgery a. Adjunctive (i.e., facilitate CPAP) b. Salvage treatment for failure of nonsurgical treatment c. Primary treatment
2. Surgery staging a. Primary level of obstruction b. Multi-level strategies c. Global airway strategies
3. Nasal surgery a. Septum b. Turbinate
i. Partial resection ii. Tissue reduction (radiofrequency, cold ablation, etc.)
c. Nasal valve 4. Tonsillectomy 5. Adenoidectomy
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6. Palate surgery a. Uvulopalatopharyngoplasty
i. Multiple modifications b. Tissue reduction (radiofrequency, etc.) c. Stiffening procedures
7. Tongue surgery a. Volume reduction b. Tongue suspension
i. Suture ii. Genioglossus advancement
8. Mandible with or without tongue and maxilla a. Genioglossus advancement b. Sagittal split osteotomy with advancement
i. Maxillo-mandibular advancement 9. Neck
a. Lipectomy b. Hyoid suspension
10. Tracheotomy 11. Role of bariatric surgery 12. Outcomes of surgical interventions
a. Facilitation of nonsurgical therapies b. Polysomnography outcomes c. Clinical outcomes: symptoms, quality of life, function, medical risk, mortality risk d. Risks and complications of procedures
D. Clinical skills
1. At the completion of this unit, the resident understands: a. And can perform surgical procedures for obstructive sleep apnea
b. Staging and combination of multiple level surgeries c. Success and complication rates of different surgical techniques
IV. Non-surgical Treatments
A. Unit Objective
1. At the completion of this unit, the resident understands the nonsurgical treatment of some sleep disorders
B. Learner Objective
1. Upon completion of this unit, the resident understands:
a. Nonsurgical treatment b. Indications for surgical and nonsurgical intervention
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C. Content
1. Treatment of related disorders a. Obesity: weight loss b. Rhinitis: medication, allergy testing/treatment c. GERD: medication, lifestyle changes
2. Sleep positioning 3. Avoiding or changing medications 4. Sleep hygiene 5. Dental appliances, including tongue appliances 6. Positive airway pressure devices (CPAP, BiPAP, AutoPap) 7. Address related sleep disorders
D. Clinical skill
1. At the completion of this unit, the resident understand the nonsurgical treatment of sleep apnea, including success and compliance rates
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PEDIATRIC OTOLARYNGOLOGY CURRICULUM I. Fundamental Knowledge
A. Embryology and Anatomy
1. Unit Objective
a. At the completion of this unit , the resident understands:
i. Basic embryology of the head and neck and abnormalities of development including genetic, environmental, and spontaneous mutations
ii. Relative differences between adult and pediatric anatomy
2. Learner Objective s
a. Upon completion of this unit, the resident:
i. Understands the significance of differences between adult and pediatric anatomy as it relates to the temporal bone, nasal cavity and sinuses, pharynx and esophagus, larynx and trachea, cranial nerves, boney and soft tissues of the head and neck, including the salivary glands and endocrine structures
ii. Understands the normal and abnormal embryologic derivations of these structures
iii. Knows the various conditions and circumstances that lead to abnormal embryologic
development as well as normal variances in anatomy
iv. Knows the operative corrections/approaches for these disorders
3. Content
a. External ear/auric le b. Facial bones/cranium c. Nose/paranasal sinuses d. Larynx and trachea/pharynx and esophagus e. Lips teeth tongue and pharynx f. Salivary glands and endocrine structures 4. Clinical Skills
a. At the completion of this unit, the resident:
i. Can perform an accurate physical examination using advanced techniques and equipment, including fiberoptics, video, otomicroscopy etc. and utilizes and synthesizes laboratory and imaging data for evaluation and planning
ii. Can educate and train parents and other family members of the significance, etiology, impact,
origin of the abnormalities and the options for correction, including the timing and staging of surgery
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B. Child Developme nt and Parent/Child Interaction
1. Unit Objective
a. At the completion of this unit , the resident:
i. Has comprehension of the normal and abnormal development of children’s language, gross and fine motor skills, growth, psychology, etc.
ii. Understands pharmacology and fluid management and growth charts as they relate to children iii. Comprehends normal and abnormal parenting skills and can advocate for children iv. Can identify potential child abuse v. Can achieve informed consent
2. Learner Objective a. Upon completion of this unit, the resident:
i. Understands the normal and abnormal physiology and psychologic aspects of child
development
ii. Accurately assesses good, poor and harmful parenting skills and can advocate for children in need
3. Contents
a. Normal growth and development b. Pharmacology/dosing, special metabolic profiles of children versus adults c. Fluid management
d. Parenting skills, cultural norms e. Psychiatric stages of identity for children f. Children’s rights, ethics, informed consent g. Team approaches to children’s care 4. Clinical Skills
a. At the completion of this unit, the resident can:
i. Interview parents and children for history
ii. Apply appropriate developmental testing: motor, sensory, psychologic
iii. Appropriately prescribe drugs, fluids etc., based on weight/height or meter squared area
iv. Achieve informed consent and experimental study entry
v. Participate in interdisciplinary team care delivery for complex conditions
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C. Ears: Otology, Hearing and Hearing Loss
1. Unit Objective
a. At the completion of this unit, the resident understands:
i. Etiology of sensorineural and conductive hearing loss as well as the evaluation and management of those conditions
ii. Infectious and inflammatory diseases of the ear, their significance, etiology and treatment
iii. Balance disorders in childhood
iv. Causation and staging of microtia and aural atresia
2. Learner Objective
a. Upon completion of this unit, the resident:
i. Understands congenital, acquired and genetic aspects of sensorineural and conductive hearing loss
ii. Interprets and recognizes appropriate audiologic testing for infants and children including
OAEs, A BRs, VRAs, play audiometry, etc.
iii. Interprets and obtains appropriate imaging for the ear
iv. Comprehends basic microbiology and immunology as it relates to otitis, understands pathways of disease spread, complications and treatment
v. Understands the basic physiology of hearing and balance including mechanotransduction,
psycho-acoustics and central
3. Conte nts
a. Hearing and balance physiology b. Diagnostic testing c. Audiology c. Imaging d. Genetics e. Laboratory f. Acute and chronic otitis media, eustachian tube function (normal and abnormal), otitis externa,
cholesteatoma, aural dysplasia and atresia, pediatric disorders of the facial nerve and temporal bone
g. Congenital and acquired hearing loss (genetic and non-genetic)
4. Clinical skills a. At the completion of this unit, the resident can:
i. Obtain a history and physical assessment of the ears, use of the otoscope, otomicroscope
ii. Evaluate balance
iii. Interpret testing, including imaging and genetics
iv. Manage complications in children
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D. Nose and Paranasal Sinuses
1. Unit Objective
a. At the completion of this unit, the resident understands:
i. Specific aspects of developmental nasal disorders
ii. Infectious and inflammatory disorders of the nose and paranasal sinuses
iii. Basics of olfaction 2. Learner Objective s
a. Upon completion of this unit, the resident:
i. Understands allergy and its expression in the pediatric nasal cavity
ii. Understands microbiology and immunology of pediatric rhinologic infection including
pathways of spread and complications
iii. Understands anatomy and physiology of the nose and differences between children and adults
iv. Correctly interprets testing data, imaging, cultures and smears
v. Understands basics of olfaction, airflow dynamics and turbinate function 3. Contents
a. Nose (septum, external skeleton) b. Lateral superior and inferior nasal cavity c. Paranasal sinuses and relationships to optic, intracranial, and pterygomaxillary spaces,
nasopharynx, especially differences between pediatric and adult d. Vascular supply, neurogenic control, anatomy and physiology e. Imaging: CT, MRI f. Microanatomy of respiratory epithelium, olfactory neurons g. Microbiology of infection, pathways of spread of complications, treatment
4. Clinical skills
a. At the completion of this unit, the resident can:
i. Obtain a history and perform a physical examination of the pediatric patient including
fiberoptic visualization of the nasal cavity
ii. Interpret imaging of pediatric patients
iii. Surgically correct septal deformity, treat infectious complications, congenital abnormalities, epistaxis
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E. Pharynx and Esophagus
1. Unit Objective
a. At the completion of this unit, the resident understands:
i. Dynamic anatomy and contributions to speech, airway maintenance, and swallowing and feeding
ii. Infectious and inflammatory disorders, and complications in pediatrics, including
gastroesophageal reflux
iii. Effects of sleep disordered breathing in children
iv. Congenital and acquired disorders of the esophagus
2. Learner Objective
a. Upon completion of this unit, the resident understands:
i. Elements of proper speech production and speech pathology
ii. Evaluation and treatment of various sleep disorders in pediatric patients
iii. Microbiology, infections and complications related to tonsils adenoids and dentition in children
iv. Surgical indications and techniques
3. Content
a. Oropharynx/pharynx and esophagus anatomy, development and function b. Tonsils and adenoids c. Microbiology of the oral cavity d. Tongue, palate and other structures contributing to speech swallowing and airway maintenance e. Atresia, caustic ingestion, stenosis, reflux, trauma, foreign body, neurovascular supply and its
development f. Imaging and other diagnostic testing (CT, MRI, polysomnography)
4. Clinical skills
a. At the completion of this unit, the resident can:
i. Take a history and perform a physical examination of the pediatric patient including fiberoptic and video exams of swallowing and speech
ii. Interpret imaging, PSN, VPI evaluation, video swallow
iii. Surgically and nonsurgically manage sleep disordered breathing, speech disorders, infections
and inflammatory disorders, complications related to tonsil, adenoid and oral infections
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F. Larynx, Trachea and Bronchi
1. Unit Objective a. At the completion of this unit, the resident understands:
i. Functional aspects of the larynx and trachea as it relates to air exchange, speech production
and airway protection and maintenance in the pediatric patient
ii. Traumatic, infectious and inflammatory disorders that affect the larynx and trachea and their effects on the pediatric airway
iii. Congenital abnormalities that can result in stridor in the infant and their natural history
2. Learner Objective s
a. Upon completion of this unit, the resident:
i. Knows the embryologic derivation of laryngeal functional development, neurovascular anatomy, and central control pathways
ii. Uses multiple strategies for management of airway distress
3. Content
a. Embryologic development of larynx and trachea b. Physics of air passage through the larynx and trachea c. Normal voice production d. Neurovascular physiology of the larynx e. Laryngeal closure and protection (laryngospasm) f. Vocal fold mobility impairment g. Origins of infectious and inflammatory disorders of the pediatric la rynx and trachea h. Papilloma, laryngotracheobronchitis , epiglottitis, bacterial tracheitis i. Aspiration protection strategies j. Imaging and other evaluation techniques including EMG, video endoscopy, FEESST
4. Clinical skills
a. At the completion of this unit, the resident can:
i. Take a h istory and perform physical examinations, including fiberoptic flexible examinations
ii. Order and obtain appropriate additional information
iii. Interpret testing, exams and prior assessments
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II. Diseases , Disorders and Conditions
A. Unit Objective
1. At the completion of this unit , the resident can:
a. Recognize, assess, diagnose, and manage diseases and disorders of the pediatric patient’s ear, nose, sinus, pharynx, esophagus, larynx, trachea, face, salivary glands, endocrine glands
b. Note deviations from normal psychologic and physiologic development and help correct these
problems
B. Learner Objective 1. Upon completion of this unit, the resident can:
a. Recognize signs and symptoms of pediatric otolaryngologic disorders
b. Use appropriate tests and evaluation methods for pediatric otolaryngologic disorders
c. Develop a diagnosis for pediatric otolaryngologic disorders
d. Understand the surgical and nonsurgical management of pediatric otolaryngologic disorders
C. Content 1. External ear
a. Congenital malformations b. Trauma (hematomas, foreign bodies) c. Infections/inflammatory disorders
2. Middle ear and mastoid a. Congenital malformations b. Trauma c. Infection
i. Acute a) Suppurative and nonsuppurative
ii. Chronic a) Suppurative and nonsuppurative
d. Cholesteatoma i. Congenital ii. Acquired
e. Mastoiditis i. Coalescent-acute ii. Chronic
f. Complications i. Tympanic membrane perforations ii. Ossicular erosion, discontinuity iii. Abscesses iv. Meningitis
g. Neoplasm h. Inner ear
i. Neurosensory loss a) Genetic b) Acquired c) Congenital (Mondini, vestibular aqueduct, etc.)
ii. Vertigo a) Migraine b) Inflammatory
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i. Nose/paranasal sinus i. Congenital disorders
a) Dermoid cyst b) Glioma c) Encephalocele d) Choanal atresia/stenosis e) Hemangioma f) Pyriform aperture stenosis g) Cystic fibrosis h) Nasolacrimal duct cyst
ii. Infections a) Acute b) Chronic
i) Bacterial ii) Fungal
iii. Allergy and inflammation iv. Complications
a) Abscess i) Orbital ii) Epidural iii) Intracranial
b) Meningitis v. Neoplasms
a) Benign i) Antro-choanal polyp ii) Angiofibroma, etc
b) Malignant i) Esthesioneuroblastoma ii) Hemangioendothelioma, etc
j. Pharynx/esophagus i. Congenital
a) Atresia, stenosis b) Beckwith syndrome c) Cleft palate
ii. Infection/inflammation/allergy a) Tonsillitis
i) Acute and chronic b) Adenoiditis c) Reflux esophagitis d) Eosinophilic esophagitis e) Angioedema f) Stomatitis g) Glossitis
iii. Complications a) Peritonsillar abscess b) Retropharyngeal abscess c) Parapharyngeal abscess
iv. Neoplasms a) Benign
i) Lymphangioma ii) Dermoid, etc.
b) Malignant v. Hypertrophy/obstruction tonsils and/or adenoids
a) Sleep disorders b) Facial growth
vi. Speech disorders a) Hyponasality b) Hypernasality (VPI) c) Delayed speech acquisition
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k. Larynx/Trachea i. Congenital
a) Subglottic stenosis b) Saccular cyst, laryngocele c) Laryngeal cleft d) Laryngomalacia e) Hemangioma f) Tracheal stenosis g) Extrinsic compression of the trachea
i) Innominate, subclavian, aortic, pulmonary artery, cardiac h) Bronchial stenosis, malacia i) Tracheomalacia
ii. Infections/Inflammation a) Croup b) Epiglottitis c) Bacterial tracheitis
iii. Trauma a) Laryngeal fracture b) Laryngeal hematoma c) Laryngotracheal separation
iv. Foreign body a) Larynx b) Trachea
v. Neurologic a) Vocal cord paralysis
i) Unilateral ii) Bilateral
vi. Neoplasms a) Benign
i) Papillomas ii) Granular cell myoblastoma, etc.
b) Malignant vii. Dysmorphology
a) Craniosynostoses i) Crouzon’s
ii) Sathre Chotzen iii) Apert’s iv) Pfeiffer’s
b) Mandibulofacial dysostosis c) Robin sequence d) Stickler’s syndrome e) Velo-cardio facial (VCF) syndrome f) Cleft lip g) Craniofacial microsomia h) CHARGE association
viii. Head and Neck a) Embryologic
i) Thyroglossal cyst/lingual thyroid ii) Thymic cysts iii) Branchial cysts, clefts fistulae iv) Lympho-venous malformation/cystic hygroma v) Vascular lesions
(a) Hemangioma (b) Arterio-venous malformations (c) Venous malformations
vi) Tumors (a) Rhabdomyosarcoma (b) Lymphomas (c) Langerhans cell histiocytoses, etc.
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vii) Infections (a) Abscess (b) Immune deficiency (c) Adenopathy (d) Viral (Kawasaki)
D. Clinical skills
1. At the completion of this unit, the resident can:
a. Complete a comprehensive history and physical exam, order appropriate laboratory and diagnostic
studies to develop a differential diagnosis , and arrive at a definitive diagnosis of the above noted pediatric otolaryngologic disorders
b. Discuss surgical and nonsurgical management of pediatric otolaryngologic disorders
c. Discuss the strategies and procedures necessary to treat pediatric otolaryngologic disorders
III. Surgical Concepts
A. Unit Objective s
1. At the completion of this unit , the resident understands treatment strategies and procedures for surgical management of pediatric otolaryngologic disorders
B. Learner Objective s
1. Upon completion of this unit, the resident:
a. Understands surgical strategies needed to treat pediatric otolaryngologic disorders b. Can perform surgical procedures used to treat pediatric otolaryngologic disorders
C. Content
1. Specific surgical procedures a. Otologic
i. Tympanocentesis ii. Tympanostomy iii. Tympanoplasty iv. Mastoidectomy v. Cochlear implantation vi. BAHA and implantable hearing aids
b. Nose and Sinus i. Polypectomy ii. Endoscopic procedures of the lateral sinus wall iii. Drainage of peri-orbital abscess
c. Pharynx i. Tonsillectomy
a) Partial vs. total b) Cold instruments c) Powered instruments, etc.
ii. Adenoidectomy iii. Incision and drainage of abscess iv. Pharyngoplasty v. Esophagoscopy
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d. Larynx/trachea i. Endoscopic
a) Diagnostic b) Therapeutic (i.e., foreign body removal) c) Stent placement
ii. Tracheostomy a) Infant b) Pediatric
iii. Suspension microlaryngoscopy a) Epiglottoplasty b) Removal of papilloma
(i) Laser (ii) Shaver
iv. Open surgical procedures a) Cartilage graft b) Excision, reanastomosis
v. Intubation and airway management e. Head and Neck
i. Removal of branchial cysts and fistulae ii. Thyroglossal cyst excision (Sistrunk) iii. Lymph node biopsy iv. Sclerotherapy, intralesional injection v. Neck abscess, incision and drainage
IV. Habilitation/Rehabilitation
A. Hearing assistive devices
1. Non implantable hearing aids 2. Implantable
a. Cochlear implants b. Bone anchored hearing aids
B. Speech rehabilitation
1. Surgical 2. Prosthetic 3. Other therapy
C. Swallowing rehabilitation
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OTOLOGY/AUDIOLOGY CURRICULUM I. Fundamental Knowledge
A. Temporal Bone and Skull Base Anatomy
1. Unit Objective
a. At the completion of this unit , the resident understands the anatomy of the temporal bone, cranial nerves, vascular and neural structures of the lateral skull base, the peripheral and central anatomy of the cochlea and vestibular systems
2. Learner Objective s
a. Upon completion of this unit , the resident:
i. Understands the bony and soft tissue anatomy of the temporal bone and its relationship to related vascular, neural, muscular, and bony structures of the lateral skull base
ii. Knows the surgical anatomy, neural, vascular, and skeletal comp onents of the temporal bone
and lateral skull base iii. Knows the operative approaches to the temporal bone and lateral skull base iv. Knows the microscopic anatomy of the auditory and vestibular systems
3. Contents
a. Auricle b. External ear c. Tympanic membrane d. Ossicles e. Tympanum f. Eustachian tube g. Attic h. Mastoid i. Petrous apex j. Jugular foramen k. Cochlear and central auditory pathways
i. Osseous labyrinth, membranous labyrinth ii. Reissner’s membrane, spiral ligament, stria vascularis, basilar membrane, Böttcher’s cells,
Claudius’ cells, tectorial membrane, osseous spiral lamina iii. Organ of Corti (Hansen’s cells , Dieters’ cells, pillar cells, stereocilia, outer hair cells, inner
hair cells) iv. Neural anatomy of cochlea, and central auditory pathways
l. Vestibular end organs and neural pathways i. Vestibule, semicircular canals, saccule, utricle ii. Crista ampullaris, macula sacculi, macula utriculi, kinocilium, stereocilia, type I hair cells,
type II hair cells iii. Vascular supply iv. Peripheral and central neural anatomy (VOR, vestibulospinal tract, vestibulocerebellar tract)
m. Cranial Nerves i. III, IV, V, VI, VII, VIII, IX, X, XI, XII
n. Associated vascular, neural, and muscular structures of the lateral skull base o. Diagnostic imaging: CT scanning, MRI imaging, plain film
i. X-rays
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4. Clinical Skills
a. During the training period, the resident:
i. Recognizes the normal and abnormal anatomy of the temporal bone, lateral skull base, and auditory and vestibular systems
ii. Interprets tests to diagnose anatomical abnormalities of the temporal bone, lateral skull base,
and auditory and vestibular systems iii. Performs surgical procedures that utilize anatomical knowledge of the temporal bone, lateral
skull base, auditory and vestibular systems
B. Embryology of the Ear
1. Unit Objective
a. At the completion of this unit , the resident understands the embryology of the temporal bone, inner ear, and lateral skull base
2. Learner Objective s
a. Upon completion of this unit, the resident understands:
i. Normal embryological development and common embryological development disorders that affect the temporal bone, auditory and vestibular systems
ii. How embryological development disorders impact treatment of these disorders
3. Contents
a. Development of the external ear i. Aricular hillocks of His - 5th week gestation
a) 1-3: 1st pharyngeal arch b) 3-6: 2nd pharyngeal arch
ii. Microtia b. Complete membranous labyrinthine dysplasia (Siebenmann-Bing) c. Cochleosaccular dysplasia (Scheibe) d. Complete labyrinthine dysplasia (Michel) e. Incomplete partition (Mondini) f. Common cavity g. Semicircular canal dysplasia h. Enlargement of the vestibular and/or cochlear aqueducts i. Narrow internal auditory canal
4. Clinical Skills
a. During the training period, the resident:
i. Recognizes the normal and abnormal embryological development of the ear and how it influences management of disorders such atresia of the ear canal, and inner ear deformities related to hearing loss
ii. Interprets imaging studies and other diagnostic tests that demonstrate disorders of
embryological development of the ear and temporal bone iii. Performs surgical procedures that utilize the embryological knowledge of the temporal bone,
ear, and lateral skull base
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C. Physiology of the Eustachian Tube/Middle Ear/Mastoid
1. Unit Objective
a. At the completion of this unit , the resident understands:
i. The normal ventilation system of the eustachian tube, middle ear and mastoid ii. The pathophysiology of abnormal conditions of the same structures
2. Learner Objective s a. Upon completion of this unit, the resident understands:
i. How ventilation occurs in the middle ear and mastoid via the eustachian tube
ii. Consequences of poor ventilatory function
3. Contents
a. Anatomy and physiology of the eustachian tube/middle ear and mastoid b. Acute otitis media c. Chronic otitis media with effusion d. Idiopathic hemotympanum e. Chronic serous mastoiditis f. Cholesteatoma pathophysiology
4. Clinical Skills
a. During the training period, the resident:
i. Uses knowledge of physiology of eustachian tube ventilation to explain the causes of the above pathologic conditions
ii. Understands the rationale for the medical and surgical approaches for treatment of the above
pathophysiological conditions D. Physiology of the Auditory System
1. Unit Objective
a. At the completion of this unit , the resident understands the normal physiology of the auditory system
2. Learner Objective s
a. Upon completion of this unit, the resident understands:
i. How sound is amplified by the middle ear, transduction in the cochlea, and routes of transmission in the brainstem to the brain
ii. How pitch and intensity of sound is coded in the cochlea
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3. Contents
a. Definitions of sound b. Middle ear mechanics c. Cochlear mechanics d. Hair cell transduction e. Auditory nerve action potentials f. Efferent auditory system g. Pitch perception (temporal and place) h. Intensity
4. Clinical Skills
a. During the training period, the resident uses knowledge of:
i. Middle ear mechanics to interpret causes of conductive hearing loss
ii. Cochlear mechanics and physiology of auditory system to understand sensorineural hearing loss
E. Audiology
1. Unit Objective
a. At the completion of this unit , the resident has knowledge of the testing procedures used to evaluate hearing
2. Learner Objective s
a. Upon completion of this unit, the resident understands:
i. Common audiologic testing procedures
ii. Use of masking, methods of performing audiogram and speech testing
iii. Indications for performing auditory diagnostic tests
3. Contents
a. Audiogram b. Pure-tone air conduction c. Pure-tone bone conduction d. Speech testing e. Masking f. Acoustic impedance g. Otoacoustic emissions h. Electrocochleography i. Auditory brainstem response j. Steady state evoked potentials (ASSR) k. Play audiometry l. Visual response audiometry m. Intraoperative monitoring
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4. Clinical Skills
a. During the training period, the resident:
i. Performs routine audiometric testing such as air conduction and bone conduction audiogram, speech testing, acoustic impedance, otoacoustic emissions, auditory brainstem response and intraoperative auditory monitoring
ii. Interprets standard audiogram, ABR, acoustic impedance, and OAE, testing to diagnose
hearing loss
F. Physiology of the Vestibular System
1. Unit Objective
a. At the completion of this unit, the resident understands the physiology of the vestibular system sufficiently to make wise diagnoses, properly interpret vestibular testing in its clinical context, and plan appropriate medical, rehabilitative, or surgical treatment
2. Learner Objective s
a. Upon completion of this unit, the resident understands:
i. The peripheral and central vestibular system and its neural projections
ii. Sensory integration essential to human equilibrium, and its implications for vestibular diagnosis and treatment
iii. Vestibular compensation and its treatment implications
3. Contents
a. Semicircular canals b. Otolithic organs (Saccule, Utricle) c. Vestibuloocular reflex (VOR) d. Vestibulo-spinal reflex and output responses e. Nystagmus and Ewald’s laws f. Rationale for vestibular rehabilitation therapy g. Rationale for vestibular ablation procedures
4. Clinical Skills
a. During the training period, the resident can:
i. Take an organized medical history from a dizzy patient
ii. Determine appropriate testing and treatment
iii. Distinguish the surgical candidate from the non-surgical patient
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G. Vestibular Testing
1. Unit Objective
a. At the completion of this unit, the resident understands the clinical measures that may be used to assess a patient with balance disorders, including simple bedside testing and the testing modalities employed in a sophisticated modern vestibular testing facility
2. Learner Objective s
a. Upon completion of this unit, the resident understands:
i. Physical exam findings that indicate a unilateral peripheral vestibular lesion or a bilateral peripheral vestibulopathy
ii. Vestibular testing environment and basic principles for interpretation of test results, including
potential pitfalls and false positive results
3. Contents
a. Electro- or videonystagmography i Oculomotor testing: saccade latency, accuracy, velocity; smooth pursuit and optokinetic
testing ii. Spontaneous and positional nystagmus iii. Caloric irrigations
b. Rotary chair c. VEMP d. Posturography e. Bedside testing in vestibular disorders (See Physical Exam, below)
4. Clinical Skills
a. During the training period, the resident:
i. Performs a suitable bedside exam for the patient with balance disorders
ii. Can identify physiological and pathological nystagmus present in a computerized eye movement tracing, and interpret its significance
iii. Recognizes central abnormalities in oculomotor test results
iv. Performs calculations of unilateral weakness and directional preponderance from caloric
results
v. Properly interprets rotary chair and posturography response results
vi. Articulates a summary evaluation of vestibular abnormalities and how they relate to clinical diagnosis and treatment
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H. Facial Nerve Testing
1. Unit Objective s
a. At the completion of this unit , the resident understands the pathophysiology of nerve injury and the utility of facial nerve testing
2. Learner Objective s
a. Upon completion of this unit, the resident understands:
i. Sunderland classification of neural injury
ii. Use of nerve excitability testing, maximal stimulation testing, electroneuronography and electromyography
3. Contents
a. Pathophysiology of neural injury b. Clinical examples of neural injuries (Bells Palsy, facial nerve trauma)
i. Nerve excitability testing ii. Maximal stimulation testing iii. Electroneuronography iv. Electromyography
4. Clinical Skills
a. During the training period, the resident orders and interprets appropriate facial nerve testing for a given clinical lesion
I. Surgical Monitoring (Cranial Nerve, Auditory)
1. Unit Objective
a. At the completion of this unit , the resident understands the indications, techniques and pitfalls of
intraoperative cranial nerve monitoring 2. Learner Objective
a. Upon completion of this unit, the resident understands:
i. Techniques for facial nerve and intraoperative ABR testing
ii. Technique for lower cranial nerve monitoring (IX, X, XI, XII)
iii. Clinical indications for intraoperative monitoring
3. Contents
a. Physiologic basis of ABR and electromyography b. Intraoperative monitoring technique
4. Clinical Skills
a. During the training period, the resident:
i. Interprets the results of intraoperative monitoring
ii. Troubleshoots common sources of inaccurate cranial nerve monitoring
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J. Physical Examination
1. Unit Objective
a. At the completion of this unit , the resident can perform a complete examination of the auditory and vestibular systems and cranial nerves
2. Learner Objective s
a. Upon completion of this unit, the resident recognizes normal and abnormal anatomy of the ear, signs of auditory and vestibular diseases and disorders, and signs of lateral skull base diseases and disorders
3. Contents
a. Otoscopy b. Pneumatic otoscopy and fistula test c. Microscopic exam and debridement of the ear d. Tuning fork testing e. Cranial nerve exam f. Exam for nystagmus, including use of Frenzel glasses g. Halmagyi head thrust testi h. Fukuda stepping test i. Cerebellar testing (Romberg, finger-to-nose, tandem gait) j. Hallpike testing and particle repositioning maneuver for BPPV k. Sensorimotor neurological testing as indicated l. Oscillopsia test
4. Clinical Skills
a. During the training period, the resident:
i. Performs appropriate otoscopic exams with the binocular microscope and makes correct otoscopic diagnoses
ii. Cleans and debrides the ear canal or mastoid cavity safely and effectively
iii. Interprets tuning fork tests and correlates with the audiometric results
iv. Identifies unilateral and bilateral vestibular lesions and can indicate the level of compensation
on clinical grounds
v. Identifies non-vestibular contributions to balance dysfunction by use of the physical exam
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K. Otologic Imaging Studies
1. Unit Objective
a. At the completion of this unit, the resident can select the proper imaging study and interpret the results of that study for a given disease process
2. Learner Objective s
a. Upon completion of this unit, the resident recognizes normal and abnormal anatomy of the temporal bone, skull base, and cerebellopontine angle for the following:
i. Congenital abnormalities ii. Acquired pathology, intratemporal iii. Retrocochlear/CPA lesions iv. Vascular abnormalities v. Skull base osteomyelitis
3. Contents
a. Computerized tomography b. MRI c. Magnetic resonance angiogram/ venogram d. Angiography e. Nuclear medicine studies
4. Clinical Skills
a. At the completion of this unit, the resident can recognize:
i. Normal anatomy on the above imaging studies
ii. Pathologic lesions on the above studies
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L. Anesthesia for Otologic Surgery
1. Unit Objective
a. At the completion of this unit , the resident can provide local anesthesia with sedation for otologic procedures and be aware of special considerations for general anesthesia during otologic surgery
2. Learner Objective s
a. Upon completion of this unit, the resident:
i. Can perform a local field block of the ear canal and postauricular area for preparation of an otologic procedure
ii. Understands the options for providing sedation during a local anesthesia otologic procedure as
well as the management of complications of oversedation
iii. Understands the special considerations for general anesthesia and otologic surgery, such as the avoidance of neuromuscular blockade during cranial nerve monitoring, avoidance of nitrous oxide during middle ear procedures, use of hyperventilation and mannitol for intracranial procedures, and the use of hypotensive anesthesia for the control of blood loss
3. Contents
a. Local field b lock of external auditory canal b. Local field block of postauricular area c. Intravenous sedation d. General anesthesia
4. Clinical Skills
a. During the training period, the resident:
i. Performs otologic surgery under local anesthesia with sedation
ii. Interacts with anesthesia staff in order to perform otologic surgery under optima l general anesthesia conditions
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II. Diseases, Disorders, and Conditions
A. Unit Objective
1. At the completion of this unit , the resident can recognize, assess, diagnose and manage diseases and disorders of the external ear, middle ear, inner ear and lateral skull base
B. Learner Objective
1. Upon completion of this unit, the resident:
a. Recognizes the signs and symptoms of diseases and disorders of the external ear, middle ear, inner ear and lateral skull base
b. Uses the appropriate diagnostic tests to assess diseases and disorders of the external ear, middle
ear, inner ear and lateral skull base
c. Can develop a diagnosis of diseases and disorders of the external ear, middle ear, inner ear and lateral skull base
d. Understands the nonsurgical and surgical management diseases and disorders of the external ear,
middle ear, inner ear and lateral skull base
C. Content
1. External ear a. Congenital malformations b. Trauma/foreign bodies c. Infections-auricle/external canal d. Neoplasms -carcinoma/cholesteatoma/other
2. Middle Ear/eustachian tube/mastoid a. Congenital malformations b. Trauma/foreign bodies c. Infections
i. Otitis media a) Acute b) Effusion c) Chronic d) Chronic/cholesteatoma
ii. Mastoiditis iii. Petrositis iv. Complications of acute/chronic otitis media/mastoiditis
d. Tympanic membrane-trauma/perforation e. Ossicular disorders
i. Discontinuity ii. Otosclerosis
f. Neoplasms of middle ear (glomus tumor, carcinoma, other) 3. Inner Ear
a. Neurosensory hearing loss i. Hereditary (Usher syndrome, Waardenburg syndrome, etc.) ii. Trauma/noise/ototoxic iii. Autoimmune iv. Cogan’s syndrome v. Age-related vi. Sudden deafness vii. Neoplasms (acoustic neuroma, g lomus jugulare)
b. Tinnitus/hyperacusis c. Motion sickness d. Vestibular neuritis e. Labyrinthitis -serous/suppurative/circumscribed
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f. Benign paroxysmal positional vertigo g. Ménière’s disease h. Vertigo
i. Neurosyphilis ii. Migraine iii. Epilepsy
i. Superior canal dehiscence j. Bilateral vestibular hypofunction k. Cervical vertigo l. Labyrinthine fistula m. Pseudohypacusis
4. Facial nerve a. Facial paralysis
i. Idiopathic (Viral) ii. Herpes zoster iii. Traumatic iv. Iatrogenic v. Neuroma vi. Hemangioma vii. Neoplasm, other viii. Congenital
5. Lateral Skull Base a. Neuroma cranial nerves b. Acoustic neuroma c. Neurofibromatosis II d. Meningioma e. Clivus chordoma
D. Clinical Skills
1. At the completion of this unit , the resident can:
a. Perform a comprehensive history and focused physical examination, order appropriate laboratory and diagnostic studies to develop a thorough differential diagnosis, and arrive at a definitive diagnosis of the above diseases and disorders of the outer ear, middle ear, inner ear and lateral skull base
b. Discuss nonsurgical as well as surgical management of the diseases and disorders of the external
ear, middle ear, inner ear and lateral skull base c. Discuss the procedures and strategies necessary to treat the diseases and disorders of the external
ear, middle ear, inner ear and lateral skull base
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III. Surgical Concepts
A. Unit Objective
1. At the completion of this unit , the resident understands the treatment strategies and procedures for the surgical management of diseases and disorders of the external ear, middle ear, inner ear, and lateral skull base
B. Learner Objective s
1. Upon completion of this unit, the resident:
a. Understands the surgical strategies necessary to treat diseases and disorders of the outer ear, middle ear, inner ear, and lateral skull base
b. Can develop surgical strategies to treat diseases and disorders of the outer ear, middle ear, inner
ear, and lateral skull base in the temporal bone laboratory prior to performing the procedures
C. Content
1. Preoperative and Postoperative Care
a. Unit Objective
i. At the completion of this unit, the resident can: a) Assess a prospective surgical patient for fitness for undergoing anesthesia
b) Manage common postoperative otologic complications
b. Learner Objectives
i. Upon completion of this unit, the resident recognizes:
a) Preoperative abnormalities that may lead to intraoperative or postoperative complications
b) Postoperative complications and know their management c. Conte nts
i. Abnormalities of hemostasis ii. Sensitivities to anesthetic agents iii. Systemic illnesses (cardiac, respiratory, metabolic) iv. Need for special perioperative considerations (prophylactic antibiotics, management of
chronic anticoagulants) v. Management of postoperative complications:
a) Hematoma b) CSF leak c) Vascular complication d) Facial nerve paralysis e) Meningitis f) Intravascular volume depletion
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d. Clinical Skills
i. At the completion of this unit, the resident:
a) Can perform a preoperative history and physical and order appropriate laboratory studies to assess a patient’s fitness for anesthesia during an otologic surgical procedure
b) Recognizes the need for consultation with other specialists when indicated c) Recognizes and manages postoperative complications from otologic procedures
2. Specific Surgical Procedures
a. Content i. Canaloplasty ii. Middle ear exploration iii. Tympanoplasty iv. Meatoplasty v. Stapedectomy vi. Mastoidectomy vii. Tympanomastoidectomy viii. Endolymphatic sac surgery ix. Perilymph fistula repair x. Transtympanic drug therapy xi. Labyrinthectomy xii. Cochlear implantation xiii. Implantable hearing aids xiv. Congenital middle ear reconstruction xv . Facial nerve surgery xvi. Temporal bone fracture xvii. Laser surgery in the ear xv iii. CSF leak of temporal bone xix. Grafts (autografts, homografts, alloplasts) xx. Incisions, flaps xxi. Prosthetics
b. Clinical Skills
i. At the completion of this unit , the resident:
a) Has participated in and knows how to perform the surgical strategies and procedures to manage diseases and disorders of the outer ear, middle ear, inner ear, and lateral skull base
b) Can select the most appropriate surgical procedure in order to treat diseases and disorders
of the outer ear, middle ear, inner ear, and lateral skull base
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IV. Habilitation/Rehabilitation
A. Unit Objective
1. At the conclusion of this unit , the resident understands the utility of various prosthesis and therapies for the rehabilitation of hearing or balance deficits
B. Learner Objective s
1. Upon completion of this unit, the resident understands:
a. Available prosthetic options for the treatment of hearing loss b. The role of vestibular rehabilitation in the treatment of chronic balance disorders
C. Content
1. Hearing aids a. Behind the ear b. In the ear c. Completely in the canal d. Open mold e. CROS hearing aid
2. Assistive listening devices a. FM link b. Devices for telephone c. Devices for television d. Devices for alarm clock and fire alarm
3. Vestibular rehabilitation rationale and implications 4. Implantable hearing devices
a. Cochlear implant b. Acoustic + electric implants c. Implantable hearing aid d. Bone anchor hearing aid
D. Clinical Skills
1. At the completion of this unit , the resident:
a. Can recommend the most appropriate hearing aid, implantable hearing device, or assistive listening device for a hearing impaired individual
b. Has a general understanding of the fitting of these devices in clinical practice
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HEAD AND NECK CURRICULUM I. Fundamental Knowledge
A. Anatomy of the Head and Neck
1. Unit Objective
a. At the completion of this unit, the resident understands the anatomy of the upper aerodigestive tract including the nose, paranasal sinuses, ear and temporal bone, salivary glands, thyroid, parathyroids, lip, oral cavity, mandible, oropharynx, nasopharynx, hypopharynx, cervical esophagus, larynx, tracheobronchial tree and neck contents as each relates to neoplasms of the head and neck area
2. Learning Objectives
a. Upon completion of this unit , the resident:
i. Understands the anatomy of the upper aerodigestive tract ii. Knows the surgical anatomy, neurovascular and skeletal components of the upper
aerodigestive tract iii. Knows the operative approaches to neoplasms of the upper aerodigestive tract
3. Contents
a. Skin/surface anatomy b. Nose/paranasal sinuses c. Ear and temporal bone d. Salivary glands e. Thyroid f. Parathyroids g. Lip and oral cavity h. Mandible i. Oropharynx j. Nasopharynx k. Hypopharynx and cervical esophagus l. Larynx m. Neck n. Cranial Nerves
i. I-XII o. Osteology of the skull base p. Associated vascular, neural, muscular and lymphatic structures of the head and neck q. Diagnostic imaging: u ltrasound, PET, CT, MRI and plain film x-rays
4. Clinical Skills
a. During the training period, the resident:
1. Recognizes the normal and abnormal anatomy of the head and neck region 2. Interprets tests to diagnose anatomical abnormalit ies of the head and neck region 3. Performs surgical procedures that utilize anatomical knowledge of the head and neck region
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B. Embryology of the Head and Neck
1. Unit Objective
a. At the completion of this unit, the resident understands the embryology of the head and neck region
2. Learner Objective s
a. Upon completion of this unit, the resident:
i. Knows the normal embryological development and common embryological development disorders that affect the head and neck region
ii. Understands how embryological development disorders impact treatment of these dis orders
3. Contents (excluding cleft lip and palate – see Pediatrics under General)
a. Development of the branchial arch system b. Development of the thyroid and parathyroids
4. Clinical Skills
a. During the training period, the resident:
i. Recognizes the normal and abnormal embryological development of neck contents and how it influences management of disorders such as branchial cleft cysts, thyroglossal duct cysts, thyroid, parathyroid disorders, and cystic hygromas
ii. Interprets imaging studies, fine needle aspiration biopsies and other diagnostic tests that
demonstrate disorders of embryological development of the head and neck region iii. Performs surgical procedures that utilize the embryological knowledge of the head and neck
region
C. Physiology of the Head and Neck
1. Unit Objective
a. At the completion of this unit, the resident understands the normal physiology of the upper aerodigestive tract region as it relates to neoplasms of the head and neck
2. Learner Objective
a. Upon completion of this unit, the resident understands how the upper aerodigestive tract functions during communication, mastication, respiration, swallowing and digestion
3. Contents
a. Articulation b. Phonation c. Mastication/salivation d. Mechanics of swallowing
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4. Clinical Skills
a. During the training period, the resident: i. Uses knowledge of normal articulation and phonation to interpret causes of communication
disorders
ii. Uses knowledge of normal mastication, salivation and swallowing to interpret causes of swallowing disorders
D. Pathology of the Head and Neck: General Considerations
1. Unit Objective
a. At the completion of this unit, the resident has knowledge of biopsy techniques (1° tumors, unguided and guided FNAB of parotid, thyroid, cervical tumors, sentinel node biopsy) and an ability to interpret surgical pathology reports (tumor size, thickness, differentiation, pattern of invasion, margins of resection, etc.) in order to make clinical decisions in the treatment of head and neck tumors
2. Learner Objective s
a. Upon completion of this unit, the resident:
i. Understands biopsy techniques and indications for each of the following biopsies:
a) Fine needle aspiration b) Punch c) Incisional d) Excisional
ii. Understands the interpretation of pathology reports
iii. Knows the indications for frozen sections, immunohistochemistry, electron microscopy, flow
cytometry and cytogenetics in the evaluation of pathology specimens
3. Contents
a. Biopsy techniques b. Interpretation of pathology reports c. Indicators for special studies
4. Clinical Skills a. At the completion of this unit, the resident:
i. Performs routine biopsies including fine-needle aspirations
ii. Interprets pathology reports
iii. Knows indicators for special studies
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E. Histor y
1. Unit Objective
a. At the completion of this unit, the resident can obtain a clear understanding of the patients’ symptoms, pertinent co-morbid conditions, general state of health, previous treatments, nutritional status, tumor status, probable management and expected outcome
2. Learner Objective
a. Upon completion of this unit, the resident recognizes the importance of the history of present illness, medical history, social history and risk factors, family history, surgical history, current medications, significant family members support and other treating physicians
3. Contents
a. History of present illness b. Medical history c. Social history d. Risk factors e. Family h istory f. Surgical/radiation/chemotherapy history g. Medications h. Supportive resources/health care providers
4. Clinical Skills
a. At the completion of this unit, the resident:
i. Demonstrates ability to obtain a comprehensive history
ii. Understands indications for preoperative medical consultations for preoperative anesthes ia clearance
iii. Demonstrates appropriate correspondence with referring physicians
F. Physical Examination
1. Unit Objective
a. At the completion of this unit, the resident can perform a complete examination of the head and neck including the ears, nose, oral cavity, pharynx, larynx, neck, face and scalp, cranial nerves II through XII, a general evaluation of appropriate additional areas (i.e., Allen’s test for possible radial/ulnar forearm free flap)
. 2. Learner Objective
a. Upon completion of this unit, the resident recognizes normal and abnormal anatomy of the head and neck area
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3. Contents
a. General examination (weight, vital signs, Karnofsky status, etc.) b. Ears (otoscope, otologic microscope) c. Nose (including rigid and flexible endoscopy) d. Oral cavity/oropharynx (including bimanual palpation FOM, BOT) e. Pharynx/larynx (including endoscopy and mirror examinations), flexible fiberoptic laryngoscopy,
transnasal esophagoscopy f. Neck/thyroid gland g. Face and scalp h. CN II–XII i. Other
4. Clinical Skills
a. At the completion of this unit, the resident demonstrates:
i. Ability to perform a comprehensive physical examination
ii. Safe and appropriate use of the otoscope, indirect laryngoscopy mirror, flexible fiberoptic laryngoscope, otologic microscope, rigid nasal and laryngeal endoscope, video stroboscope
G. Diagnostic and Therapeutic Imaging
1. Unit Objective
a. At the completion of this unit , the resident can request the appropriate imaging modality based upon the differential diagnosis developed from the history and physical examination
2. Learner Objective s
a. Upon completion of this unit, the resident:
i. Understands current diagnostic and therapeutic imaging modalities and techniques available for the head and neck area
ii. Understands appropriate indications for each imaging modality and their limitations, as well
as their variations (i.e., IV contrast, fat-suppression, power Doppler)
iii. Can interpret imaging result reports and integrate that information into patient management
3. Contents
a. Plain x-rays/Panorex b. CT Scan with/without contrast c. Diagnostic ultrasound of the thyroid and neck d. MRI scan with/without contrast, T1 and T2 weighted images e. PET/CT f. Angiography/embolization
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4. Clinical Skills
a. During the training period, the resident:
i. Develops the ability to request appropriate imaging studies to assess the underlying pathology ii. Demonstrates the ability to identify and describe normal radiographic anatomy of the head
and neck iii. Demonstrates the skill to perform real time ultrasound of the thyroid and identify nodular
disease of the gland iv. Identifies and delineates pathologic lymphadenopathy
H. Staging of Head and Neck Cancer
1. Unit Objective
a. At the completion of this unit, the resident can:
i. Accurately stage malignancies of the head and neck using the AJCC TNM staging system ii. Understand the rationale for the AJCC staging system for malignant tumors of the head and
neck and the rules that govern staging assignment
2. Learner Objective s
a. Upon completion of this unit , the resident:
i. Understands the staging criteria for squamous cell carcinoma of the upper aerodigestive tract ii. Can acquire data from clinical and radiographic examinations to assign the appropriate stage
for a squamous cell carcinoma of the upper aerodigestive tract based on the staging rules iii. Can describe the impact of stage on prognosis and treatment options based on disease site and
stage
3. Contents
a. Staging criteria for SCC of the oral cavity, oropharynx, nasopharynx, larynx and hypopharynx b. Staging schema for metastatic SCC of the neck c. Staging criteria for differentiated thyroid cancer d. Staging criteria for malignant tumors of the major salivary glands
4. Clinical Skills
a. At the completion of this unit, the resident demonstrates the ability to collate physical examination with radiographic data to develop a TNM stage and overall stage assignment for patients with upper aerodigestive tract cancer
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I. Anesthesia for Head and Neck Procedures
1. Unit Objective
a. At the completion of this unit , the resident:
i. Understands the medical evaluation necessary to assess comorbidity for patients undergoing general anesthesia and the appropriate specialty or subspecialty evaluations necessary to assess perioperative risk and to optimize the patient’s medical condition prior to the proposed procedure
ii. Understands the various methods of airway management and indications for endotracheal
intubation, laryngeal mask anesthesia, emergency tracheostomy, cricothyrotomy iii. Understands the mode of action of commonly used local anesthetics for topical application
and local infiltration, mode of action, dose ranges, untoward effects, treatment of toxic reactions, and role of vasoconstrictors
iv. Can articulate regional anesthetics blocks commonly used in the head and neck
2. Learner Objective s
a. Upon completion of this unit , the resident can:
i. Describe the schema used for assessing anesthetic risk based on comorbidity
ii. Describe the methods for safe tracheal intubation based on the patient’s normal or abnormal anatomy and the options available
iii. Describe the commonly used local anesthetics, dose range for adults and children, common
side effects and their management
iv. Demonstrate regional blocks for the mental nerve, lingual and inferior alveolar nerves, greater palatine nerve, cervical plexus
3. Contents
a. Review the current risk assessment schema for general anesthesia including techniques of tracheal intubation: nasotracheal, endotracheal, tracheotomy, cricothyrotomy, laryngeal mask anesthesia
b. Pharmacology of commonly used local and topical anesthetics
4. Clinical Skills
a. At the completion of this unit , the resident understands:
i. Various methods of tracheal intubation, including fiberoptic and LMA
ii. Topical application of local anesthetics for various procedures
iii. Successful local anesthetic administration and regional nerve blocks
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J. Preoperative and Postoperative Care
1. Unit Objective
a. At the completion of this unit, the resident can describe:
i. Preoperative risk assessment strategies, appropriate consultation for management of comorbidity
ii. The role of prophylactic antibiotics and their indications and duration based on the type of
procedure iii. Fluid and electrolyte management in the perioperative period, strategies for acute pain
management, wound catheter management, glucose regulation in the diabetic patient, wound management both complicated and uncomplicated
2. Learner Objective s
a. Upon completion of this unit , the resident:
i. Understands strategies for assessing comorbidity in patients with hypertension, diabetes, coronary artery disease, cerebrovascular disease
ii. Can discuss the various types of wounds (clean, clean-contaminated and dirty) and the role for
antibiotics in each of these scenarios
iii. Understands the management of common fluid and electrolyte abnormalities, glucose regulation, blood pressure control, deep venous thrombosis prophylaxis, enteral feedings and perioperative analgesia
3. Contents
a. Review the assessment of medical co-morbidities, methods of optimization and appropriate medical consultative services
b. Anticoagulant therapy for DVT prophylaxis, insulin use to control postoperative hyperglycemia, antibiotic prophylaxis, fluid replacement, enteral feedings in patients who are tube fed
4. Clinical Skills
a. During the training period, the resident:
i. Conducts preoperative risk assessment, obtains appropriate medical consultations and writes
perioperative orders
ii. Obtains proper informed consent
iii. Understands ICU monitoring equipment and appropriate use
iv. Completes accurate and legible documentation in the medical record
v. Demonstrates appropriate inter-consultant communication
vi. Demonstrates useful communication with nursing and OR staff
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II. Diseases, Disorders, and Conditions
A. Unit Objective
1. At the completion of this unit, the resident can recognize, assess, diagnose and manage diseases and disorders of the head and neck
B. Learner Objective s
1. Upon completion of this unit , the resident:
a. Recognizes the signs and symptoms of diseases and disorders of the scalp and facial skin, nose and paranasal sinuses, ear and temporal bone, salivary glands, thyroid, parathyroids, lip and oral cavity, mandible, oropharynx, nasopharynx, hypopharynx and cervical esophagus, larynx, neck as well as unusual tumors of the head and neck area
b. Uses the appropriate diagnostic tests to assess diseases and disorders as listed above
c. Can develop a differential diagnosis of diseases and disorders as listed above
d. Understands the non-surgical and surgical management of diseases and disorders as listed above
C. Contents (anatomically based) 1. Scalp and facial skin 2. Nose/paranasal sinuses 3. Ear and temporal bone 4. Salivary glands 5. Thyroid 6. Parathyroids 7. Lip and oral cavity 8. Mandible 9. Oropharynx 10. Nasopharynx 11. Hypopharynx and cervical esophagus 12. Larynx 13. Neck mass 14. Unknown primary 15. Cervical metastasis/lymphoma 16. Unusual tumors of head and neck
a. Vascular b. Soft tissue sarcomas c. Bone tumors d. Pediatric
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III. Surgical Concepts
A. Unit Objective
1. At the completion of this unit, the resident understands treatment strategies and procedures for the surgical management of diseases and disorders of the head and neck region
. B. Learner Objective s
1. Upon completion of this unit , the resident:
a. Understands the surgical strategies necessary to treat diseases and disorders of the head and neck
region
b. Can perform surgical strategies to treat diseases and disorders of the head and neck region .
C. Contents (Specific Surgical Procedures)
1. Salivary glands a. Parotidectomy b. Submandibular gland excision c. Sublingual gland excision/Ranula marsupialization d. Salivary gland trauma management/ductal repair e. Sialolith resection
2. Nose and maxilla a. Rhinectomy/forehead flap reconstruction b. Lateral rhinotomy/midfacial degloving/alotomy c. Maxillectomy/medial maxillectomy d. Craniofacial resection e. Nasopharyngeal tumor resection
3. Lips a. Vermilionectomy b. Wedge excision/reconstruction c. Upper lip resection/reconstruction d. Lower lip resection/reconstruction
4. Oral Cavity a. Partial/total glossectomy (anterior 2/3’s) b. Partial/total glossectomy (base of tongue) c. Floor of mouth resection d. Marginal/partial/total mandibulectomy e. Mandibulotomy f. Mandible plating g. Dental extraction h. Resection hard/soft palate i. Intraoral reconstruction j. Mandibular reconstruction
5. Ear a. Auriculectomy/wedge resection/reconstruction b. Temporal bone resection
6. Neck a. Neck incisions b. Radical/modified radical neck dissection (including posterolateral and supraclavicular
dissection)/selective neck dissections c. Cervical/scalene node biopsy d. Transsternal mediastinal node dissection e. Drainage of deep neck abscess f. Management of penetratory neck injuries
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7. Larynx a. Endoscopic partial laryngectomy (supraglottic, glottic) b. Laryngofissure and cordectomy c. Vertical partial laryngectomy d. Supraglottic laryngectomy/supracricoid partial laryngectomy e. Total/near-total laryngectomy f. Pharyngolaryngectomy g. Tracheoesophageal shunt h. Recurrent laryngeal nerve surgery i. Laryngeal diversion j. Arytenoidectomy
8. Thyroid/Parathyroid a. Thyroid lobectomy/subtotal/total thyroidectomy (including paratracheal and/or superior
mediastinal lymph node dissection) b. Parathyroidectomy (with autotransplantation) c. Recurrent hyperparathyroidism/cancer of the parathyroid
9. Pharynx, trachea, parapharyngeal space a. Tracheotomy b. Tracheal reconstruction c. Cervical esophagectomy d. Zenker’s diverticulum surgery (open & endoscopic) e. Mediastinal exploration/dissection f. Cricopharyngeal myotomy/myectomy g. Revision stenotic tracheostoma h. Partial/total pharyngectomy i. Pharyngeal reconstruction
10. Endoscopy a. Direct laryngoscopy (fiberoptic and rigid) b. Nasopharyngoscopy c. True vocal fold injection/thyroplasty d. Laser/cold knife microlaryngeal surgery/arytenoidectomy e. Microdebrider endoscopy f. Esophagoscopy (diagnostic, foreign body removal, dilation) g. Bronchoscopy (diagnostic, foreign body removal, dilation, laser, fiberoptic)
11. Miscellaneous a. Incisional/excisional biopsy b. Needle biopsy (guided & unguided)/punch biopsy c. Endoscopic biopsy
D. Clinical Skills
1. At the completion of this unit, the resident:
a. Has participated in and knows how to perform in the surgical strategies and procedures to manage diseases and disorders of the head and neck region
b. Can select the most appropriate surgical procedure in order to treat diseases and disorders of the
head and neck region
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IV. Habilitation/Rehabilitation
A. Reconstruction
1. Principles 2. Local/regional flaps 3. Free tissue transfer 4. Prosthetic rehabilitation
B. Rehabilitation
1. Functional rehabilitation 2. Psychosocial rehabilitation 3. Speech pathology/therapy 4. Supportive care
C. Complications/Outcomes/Cost-effectiveness
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FACIAL PLASTIC AND RECONSTRUCTIVE SURGERY CURRICULUM I. Fundamental Knowledge
A. Facial Anatomy General and Systematic
1. Unit Objective
a. At the completion of this unit, the resident understands the general and systematic anatomy of the face and neck to include skeletal, skin, fascia, motor and sensory innervation, lymphatics and various patterns of vascular supply
2. Learner Objective s
a. Upon completion of this unit, the resident understands the bony and soft tissue anatomy of the face and neck and the relationships of hard tissue, soft tissue, vascular and neurological systems
3. Content
a. Facial Skeleton/hard tissue foundation b. Skin and soft tissue c. SMAS d. Facial musculature e. Facial nerve f. Facial sensory innervation g. Vascular patterns of the face h. Lymphatics of the face
4. Clinical Skills
a. At the completion of this unit , the resident uses the anatomy to:
i. Diagnose and define problems
ii. Perform cosmetic and reconstructive procedures of the face and neck
B. Functional Facial Anatomy by Region
1. Unit Objective
a. At the completion of this unit, the resident understands the detailed surgical anatomy of each region and the relevant function and physiology
2. Learner Objective s
a. Upon completion of this unit, the resident understands the functional anatomy of each regional area and the surgical applications
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3. Contents
a. Hair and scalp b. Forehead and brow c. Eyelids, Orbit, lacrimal system d. Nose
i. Nasal airflow to include rhinomanometry e. Ears f. Oral cavity
i. Dental alveolar ii. Lips iii. Pharynx iv. Physiology of speech deglutition
g. Neck/cervical
4. Clinical Skills
a. At the completion of this unit , the resident uses:
i. Anatomical and functional knowledge to diagnose specific clinical problems
ii. Detailed anatomy to perform surgical procedures to correct these problems
C. Embryology
1. Unit Objective
a. At the completion of this unit, the resident understands embryology of the face and neck
2. Learner Objective s
a. Upon completion of this unit , the resident understands:
i. Normal development
ii. Abnormal development in common clinical syndromes
3. Content
a. General embryology of facial development b. Detailed embryology of the ears, eyes, nose, and oral cavity to include lips
4. Clinical Skills
a. During the training period, the resident: i. Diagnoses and recognizes syndromes and abnormalities ii. Performs a functional anatomical reconstruction
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D. Wound Healing
1. Unit Objective
a. At the completion of this unit, the resident understands the basic physiology of normal wound healing
2. Learner Objective s
a. Upon completion of this unit , the resident understands:
i. Normal wound healing, to include scar formation and wound mechanisms
ii. Special characteristics of nerve and bone repair
3. Contents
a. Phases and histology b. Collagen formation c. Biochemistry/cytokines d. Nerve repair e. Bone repair
4. Clinical Skills
a. During the training period, the resident:
i. Interprets abnormal wound healing ii. Initiates pharmacologic or other interventions
E. Physical Exam/Endoscopy
1. Unit Objective
a. At the completion of this unit, the resident can perform a complete clinical examination of the face and neck
2. Learner Objective s
a. Upon completion of this unit, the resident can:
i. Perform a general physical and aesthetic evaluation of the face and neck ii. Perform specific focused evaluations of each anatomical area
3. Contents
a. Face i. Proportions ii. Symmetry iii. Cranial nerve exam
b. Eyes i. Lid position ii. Levator excursion iii. Extraocular muscles iv. Schirmer’s Test v. Anterior vector
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c. Brow i. Position ii. Shape iii. Symmetry
d. Nose i. Visual examination ii. Palpation iii. Intranasal and endoscopic examination
e. Oral i. Occlusion ii. Velopharyngeal competence
f. Ear i. Cephalometrics measurements
4. Clinical Skills
a. During the training period, the resident uses these skil ls to diagnose diseases, disorders and conditions
F. Facial Analysis and Cephalometrics
1. Unit Objective
a. At the completion of this unit, the resident understands the normal facial proportions and basic methods to analyze them
2. Learner Objective s
a. Upon completion of this unit, the resident:
i. Understands basic facial proportions ii. Understands basic soft and hard tissue cephalometrics iii. Recognizes common abnormalities
3. Contents
a. Angles classification b. Facial proportions c. Frankfort horizontal d. Soft tissue cephalometrics e. Hard tissue cephalometrics
4. Clinical Skills
a. During the training period, the resident:
i. Diagnoses facial abnormalities and precisely plans reconstruction ii. Makes appropriate referrals
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G. Photography
1. Unit Objective
a. At the completion of this unit, the resident understands the essentials of medical photography relevant to facial plastic and reconstructive surgery
2. Learner Objective s
a. Upon completion of this unit, the resident understands:
i. The importance of quality and consistent photography ii. Standard facial views for specific procedures iii. Basic aspects of equipment and technology
3. Contents
a. Standard facial views b. Equipment c. Imaging – Computer
4. Clinical Skills
a. During the training period, the resident uses these skills to accurately document clinical cases
H. Imaging
1. Unit Objective
a. At the completion of this unit, the resident understands the effective utilization of available imaging techniques
2. Learner Objective s
a. Upon completion of this unit, the resident understands:
i. Basic characteristics of available imaging technologies ii. How to select the most appropriate imaging study iii. How to interpret imaging studies for relevant clinical information
3. Contents
a. Plain Radiograph/tomography b. Panorex c. CT scans d. MRI e. Ultrasound f. Arteriography g. Bone scan h. Lymphoscintigraphy
4. Clinical Skills
a. During the training period, the resident uses this knowledge to diagnose patients in a precise, thoughtful, and cost effective manner
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I. Psychological and Social Assessment
1. Unit Objective
a. At the completion of this unit, the resident understands normal psychological reaction to surgery and recognizes the signs and symptoms of abnormal psychology
2. Learner Objective s
a. Upon completion of this unit, the resident:
i. Understands the psychological significance of physical deformities and normal reactions to them
ii. Recognizes abnormal psychological behavior
iii. Understands the importance of integrating social issues into the treatment plan
3. Content
a. Normal psychology of the five life cycles b. Normal reactions to grief and loss c. Psychopathology – neurosis, psychosis, personality disorders d. Specific relevant disorders, such as body dysmorphic syndrome and narcissistic personality
4. Clinical Skills
a. During the training period, the resident uses knowledge to:
i. Identify patients who may need added support , either psychological or social ii. Recognize patients with significant psychological problems who are not candidates for
surgery iii. Refer patients appropriately for social support or psychological evaluation and treatment
J. Implants and Biomaterials
1. Unit Objective
a. At the completion of this unit, the resident understands the properties and utilization of commonly available implants and biomaterials
2. Learner Objective s
a. Upon completion of this unit, the resident:
i. Understands the advantages and disadvantages of autogenous, autologous and alloplastic materials
ii. Can describe and recommend utilization of each material
3. Content
a. Homograft (Alloderm) b. Xenograft (Surgises) c. Alloplastic (Silastic, Gortex)
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4. Clinical Skills
a. During the training period, the resident:
i. Recommends the optimal material for a given problem ii. Provides effective informed consent to the patient
K. Laser Principles
1. Unit Objective
a. At the completion of this unit, the resident understands basic laser physics and physiology, to include laser selection for specific lesions
2. Learner Objective s
a. Upon completion of this unit, the resident understands:
i. Basic laser principles and terminology ii. Principles of laser selection for specific clinical problems iii. Principles of laser safety
3. Content
a. Laser biophysics b. Laser tissue interaction to include chromophores c. Laser characteristics (CO2, KTP, Erbium, etc.)
4. Clinical Skills
a. During the training period, the resident:
i. Selects the appropriate laser for a specific clinical problem ii. Performs laser procedures safely
L. Evaluation and Management of Surgical Patient
1. Unit Objective
a. At the completion of this unit, the resident understands the general concepts relevant to management of the facial plastic surgery patient
2. Learner Objective s
a. Upon the completion of this unit, the resident understands information necessary to evaluate and safely manage a facial plastic surgery patient
3. Content
a. Pre- and postoperative evaluation and care b. Universal precautions c. Infection control d. Coagulation evaluation
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4. Clinical Skills
a. During the training period, the resident provides appropriate and safe preoperative evaluation and postoperative care
M. Anesthesia
1. Unit Objective
a. At the completion of this unit, the resident understands the basic types of anesthesia and their potential problems
2. Learner Objective s
a. Upon completion of this unit, the resident understands:
i. Preop evaluation for anesthesia ii. Anesthesia selection iii. Potential complications and treatment
3. Contents
a. Classification of patients b. Local anesthesia
i. Regional blocks c. General anesthesia
i. Laryngeal mask ii. Endotracheal
d. Complications i. Malignant hyperthermia ii. Fire iii. Drug toxicity
4. Clinical Skills
a. During the training period, the resident:
i. Recommends the most appropriate anesthesia for a specific patient’s needs
ii. Provides informed consent
iii. Prevents and treat complications
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N. Surgical Facilities
1. Unit Objective
a. At the completion of this unit, the resident understands the types of facilities and required standards
2. Learner Objective s
a. Upon completion of this unit, the resident understands the levels of surgical facilities and their appropriate utilization
3. Content
a. Facility levels i. Hospital ii. Certified surgical centers (ASC) iii. Office operating suites
b. Staff training including ACLS c. Operating and recovery room equipment d. Certification and formal agreements
4. Clinical Skills
a. During the training period, the resident use knowledge to select the most appropriate surgical facility for a given patient
II. Diseases, Disorders, and Conditions (from New Classification System)
A. Unit Objective
1. At the completion of this unit , the resident can recognize, assess, diagnose and manage diseases, disorders and conditions of the face and neck to include congenital, traumatic, neoplastic, and cosmetic
B. Learner Objective
1. Upon completion of this unit , the resident:
a. Recognizes the signs and symptoms of congenital, traumatic, neoplastic and cosmetic diseases, disorders, and conditions of the face and neck
b. Uses appropriate diagnostic tests to assess these diseases, disorders and conditions
c. Can develop a diagnosis of these dis eases, disorders and conditions
d. Understands the nonsurgical and surgical management of congenital, traumatic, neoplastic and
cosmetic diseases, disorders and conditions of the face and neck
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C. Content
1. Congenital a. Cleft lip and palate b. Microtia and auricular deformities c. Syndromes
2. Trauma – general and soft tissue injury a. Initial evaluations A, B, C’s b. Imaging techniques
i. CT Scans ii. Angiogram iii. MRI
3. Skeletal trauma and deformities a. Nasal, mandibular, frontal sinus, zygomatic, dental, maxillary (LeFort) fractures b. Developmental deformities (microgenia, malar hypoplasia)
4. Neoplasias and facial skin malignancies a. Benign and malignant lesions b. Histopathology c. Diagnostic techniques d. Treatment
i. Medical ii. Radiotherapy iii. Surgery iv. Moh’s
5. Vascular a. Milliken & Glowacki’s classification system b. Classification hemangioma versus malformation c. Vascular malformation – slow flow, fast flow d. Clinical conditions
i. Pediatric a) Strawberry hemangioma b) Pyogenic granuloma c) Port wine stain (vascular malformation) d) Angiofibroma e) Spider angioma f) Lymphatic malformation
ii. Adults a) Pyogenic granuloma b) Spider angioma c) Telangiectasias d) Venous lake e) Acne rosacea
f) Poikiloderma of Civatte g) Cherry angioma h) Kaposi’s sarcoma
6. Facial Nerve a. Facial Paralysis
i. Acute a) Traumatic b) Iatrogenic c) Infectious
ii. Long-term 7. Hair and scalp
a. Androgenic, traumatic, iatrogenic, alopecia b. Chronology and patterns of male pattern baldness – Norwood System
i. Medical treatment of alopecia
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8. Aging face a. Skin changes b. Regional changes
i. Brow ii. Lids iii. Nose iv. Mouth v. Neck
c. Skeletal changes d. Lipodystrophy
9. Nose a. Nasal obstruction
i. Turbinates ii. Septum iii. Internal and external valve
b. Nasal deformity i. Traumatic ii. Congenital cleft lip/nose iii. Cosmetic
10. Psychogenic a. Body dysmorphic syndrome b. Narcissistic personality
i. Neurosis, psychosis ii. Personality disorder to include
a) Body b) Narcissistic
III. Surgical Concepts
A. Unit Objective s
1. At the completion of this unit, the resident understands the treatment strategies and procedures for the surgical management of reconstructive and cosmetic diseases, disorders and conditions of the face and neck
B. Learner Objective s
1. Upon completion of this unit, the resident:
a. Understands the surgical strategies necessary to treat reconstructive and cosmetic diseases, and disorders and conditions of the face and neck
b. Can perform surgical strategies to treat reconstructive and cosmetic diseases, dis orders and
conditions of the face and neck in the cadaver lab prior to performing them on the patients
C. Content
1. General a. Atraumatic techniques, hemostasis, precise sutures b. Healing by secondary intention c. Grafts
i. STSG ii. FTSG iii. Composite grafts iv. Mucosal grafts v. Bones grafts – calvarial/iliac/rib vi Cartilage grafts – auricular/rib/septal
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d. Flaps i. Local flaps
a) Advancement b) Rotation c) Rhomberg d) Bilobed e) Transposition/note flap f) Z-plasty
ii. Regional flaps iii. Free flaps
a) Fasciocutaneous b) Myocutaneous c) Osteomyocutaneous
e. Tissue expansion 2. Specific surgical procedures
a. Cranial facial anomalies b. Cleft lip and palate c. Trauma
i. Soft tissue d. Trauma
i. Hard tissue e. Facial reconstruction
i. Scalp ii. Forehead iii. Periorbital iv. Nose v. Cheek vi. Ear vii. Lips and chin
f. Facial paralysis and reanimation i. Static ii. Dynamic
g. Rhinoplasty h. Genioplasty and mandibular procedures i. Facial implants j. Scar revision k. Otoplasty l. Browplasty m. Blepharoplasty n. Liposuction o. Rhytidectomy p. Facial resurfacing
i. Dermabrasion ii. Chemical peels iii. Laser
q. Laser procedures i. Vascular ii. Tattoos iii. Hair removal
r. Injectables i. Botox ii. Fillers
iii. Lipostructure
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D. Clinical Skills
1. At the completion of this unit , the resident:
a. Has participated in and understands how to plan surgical strategies and perform procedures to manage reconstructive and cosmetic diseases, disorders and conditions of the face and neck
b. Can select the most appropriate surgical procedure to reconstruct diseases, disorders and
conditions of the face and neck IV. Habilitation/Rehabilitation
A. Speech therapy B. Osteo integrated implants C. Prosthetic devices
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CLINICAL RESEARCH CURRICULUM I. Medical Biostatistics
A. Unit Objective
1. At the completion of this unit, the resident understands the basics of medical statistics, including fundamentals of measurement, comparing two or more groups, interpretation of results from clinical trials, correlation, and regression
B. Learner Objective s
1. Upon completion of this unit, the resident understands:
a. Fundamentals of measurement b. Common statistical tests for the comparison of two or more groups c. Interpretation of results from clinical trials d. Concepts of correlation e. Concepts of regression and multivariable analysis
C. Contents
1. Fundamentals of measurement a. Four different types of variables
i. Dichotomous ii. Continuous iii. Nominal iv. Ordinal
b. Normal distribution of data c. Measures of central tendency (mean, median, and mode) and dispersion (range, standard
deviation) and the advantages and disadvantages of each d. Relationship between standard deviation and standard error e. Calculation of confidence intervals and their use in the interpretation of results from clinical trials f. Concept of unit-free data
2. Comparison of two groups a. Mean/median
i. Parametric (t-test) a) Paired b) Unpaired
ii. Non-parametric test (Mann-Whitney U-test) 3. Comparison of three or more groups
a. Mean/median i. Parametric (one-way ANOVA)
a) Adjustment for multiple comparisons i) Bonferroni ii) Others
ii. Non-parametric (Kruskal-Wallis test) 4. Comparison of proportions: ?2 test
a. Fisher Exact Probability Test b. Paired (McNemar’s ?2 test)
5. Measures of Agreement a. Percent agreement b. Kappa index
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6. Interpretation of results from clinical trials a. Confidence intervals b. When the experimental treatment reduces the probability of a bad outcome
i. Relative risk reduction ii. Absolute risk reduction iii. Number needed to treat
c. When the experimental treatment increases the probability of a good outcome i. Relative benefit increase ii. Absolute benefit increase iii. Number needed to treat
d. When the experimental treatment increases the probability of a bad outcome i. Relative risk increase ii. Absolute risk increase iii. Number needed to harm
7. Correlation – nondependent relationship a. Para metric Pearson’s b. Nonparametric Spearman’s Rho
8. Regression - Multivariable Analysis a. Linear regression b. Logistic regression c. Cox proportional hazard analysis
D. Clinical Skills
1. At the completion of this unit , the resident can apply data analysis to the review of pertinent data and literature, in the care of a patient
II. Critical Appraisal of the Medical Literature
A. Unit Objective
1. At the completion of this unit, the resident understands the methodological criteria used to assess the validity, importance, and applicability of the medical literature
B. Learner Objective s
1. Upon completion of this unit, the resident understands how to assess the validity, importance and applicability of:
a. Diagnostic articles b. Prognostic articles c. Harm/etiology articles d. Therapeutic articles e. Systematic reviews
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C. Contents
1. Reviewing the structure of an article a. Type of study; answering what type of question b. Abstract c. Research methods d. Inclusion, exclusion criteria e. Statistical analysis f. Reports reported g. Discussion in context with other studies
2. Diagnostic article a. Are the results of this diagnostic study valid?
i. Study design ii. Inclusion criteria iii. Potential bias iv. Which data are reported, and how
b. Are the valid results of this diagnostic study important? i. Statistical analysis ii. Clinical significance iii. Results in context of other studies iv. Other
c. Can you apply this valid, important evidence about a diagnostic test in caring for your patient? i. Generalizability ii. Translation to clinic practice
3. Prognostic article a. Are the results of this prognostic study valid? b. Are the valid results of this prognostic study important? c. Can you apply this valid, important evidence about prognosis in caring for your patient?
4. Harm/etiology article a. Are the results of this harm study valid? b. Are the valid results of this harm study important? c. Should these valid, potentially important results of a critical appraisal about a harmful treatment
change the treatment of your patient? 5. Therapeutic article
a. Are the results of this single preventive or therapeutic trial valid? b. Are the valid results of this randomized trial important? c. Can you apply this valid, important evidence about a treatment in caring for your patient?
6. Systematic Review a. Are the results of this systematic review valid? b. Are the valid results of this systematic review important? c. Can you apply this valid, important evidence about a treatment in caring for your patient?
7. Systematic review vs. meta-analysis a. Difference in review and meta-analysis b. Interpretation of meta-analysis
i. Homogeneity ii. Confidence intervals iii. Odds ratio, relative risk
D. Clinical Skills
1. At the completion of this unit , the resident can:
a. Review an article, and understand and report its findings, strengths and weaknesses
b. Apply the results of their literature appraisal to clinical care of a patient, in different scenarios
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III. Evidence-Based Medicine
A. Unit Objective
1. At the completion of this unit, the resident understands the concepts of evidence-based medicine, and can integrate the results of an evidence-based review with their own experience and the patient’s wishes, to provide evidence-based care
B. Learner Objective s
1. Upon completion of this unit, the resident understands:
a. The “three-legged stool” of evidence based medicine b. The five levels of evidence, applied to individual studies c. The four grades of evidence, and applying a grade based on individual study levels d. Assessment of the “number needed to treat”
C. Contents
a. Background and history of evidence-based medicine b. Three parts of evidence-based medicine (EBM)
i. Best available evidence from the literature ii. Physician’s clinical experience iii. Wishes of the patient and/or society
c. Formulating a focused clinical question i. Patient ii. Intervention iii. Comparison iv. Outcome
d. Obtaining the evidence i. Systematic, computerized searches ii. EBM databases (i.e., Cochrane, NHRQ) iii. Clinical research, human subjects only
e. Grading the evidence i. Individual studies are assigned a level
a) Based on study methodology b) Based on study quality
ii. Levels 1 through 5 iii. Review the results of individual studies, and assign an overall grade, based on the compilation of
evidence iv. Grades: A, B, C, D
f. Making an evidence-based recommendation i. Grade of evidence ii. Characteristics of patient and situation
g. Understanding analysis of evidence-based review i. Number need to treat/harm ii. Clinical vs. statistical significance
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D. Clinical Skills
1. At the completion of this unit , the resident can:
a. Formulate a question for an evidence-based review
b. Retrieve, evaluate, and grade the best evidence
c. Understand the recommendations from the best evidence
d. Incorporate the evidence into the care of an individual patient
