EDUCATION IN
LARYNGOLOGY: RISING TO OLD CHALLENGES
ROBERT T. SATALOFF, MD, DMA
As we approach the new millennium, it seems appropriate to ask whether
education in laryngology and voice has kept pace with the remarkable clinical
and technological advances of the last 2 decades. Throughout the history
of otolaryngology, considerable time and thought have been devoted to educational
issues. The founders of the American Laryngological Association (ALA) were
deeply concerned with training in laryngology. This was the subject of
Louis Elsberg's Presidential Address at the first meeting of the ALA on
June 10, 1879, in New York.(1) Elsberg had begun teaching
laryngology in 1861, and he established the first training clinic affiliated
with any institution, in 1863, at the University of the City of New York.
By 1879, when the ALA was formed, Elsberg reported that there were 25 laryngology
teachers in American medical schools. Elsberg's extraordinary address (57
published pages) provides a fascinating review of the history of laryngology,
and culminates with a section entitled "Laryngological Instruction." Elsberg
reviewed the mission of laryngology, and of the ALA in particular, as being
not only to develop greater knowledge and skills, but also to disseminate
them and raise the standard of care and education. Elsberg's address to
the second meeting of the ALA was delivered by Jacob SolisCohen, in Elsberg's
absence. (2) Elsberg dedicated this entire address to
specific training issues, including requirements for basic science, and
clinical knowledge that should be acquired before physicians in training
are permitted to care for patients. He was an advocate for both undergraduate
and graduate education in laryngology and even proposed instruction in
comparative laryngology to enhance the understanding of the human larynx
through the study of other species. In his Presidential Address before
the fourth meeting of the ALA, Frederick Knight emphasized the same concerns.
He observed, "It will be a great gain when every physician feels he
must own a laryngoscope. A more important point for us here arises, how
we can make him use it intelligently; how all men who graduate from our
medical schools shall be given a little available knowledge of laryngology
during their precious time of pupilage."(3)(P4) Knight
stressed the importance of both didactic education and laboratory and clinical
training. He also recognized the expense of medical training and called
for endowment of medical schools to support education, an uncommon notion
in his day. In addition, Knight offered specific recommendations for the
teaching of laryngology within the medical school curriculum, even courageously
calling for an extension of the duration of medical study. In Birmingham,
England, in 1890, John St Swithin Wilders addressed the section of laryngology
and rhinology of the British Medical Association in "On the Teaching
of Laryngology."(4) He, too, emphasized the importance
of educating all physicians in the fundamentals of laryngology and use
of the laryngo scope, and raised concerns about specialty hospitals, especially
those that were not used by medical students in their education. He stressed
the importance of laryngological education within general hospitals "which
profess to educate students" and even raised an extremely controversial
call "that no more special hospitals will be founded."(4)(P377)
Concerns about laryngology and its place in medical education were highlighted
again in Henry L. Swain's Presidential Address to the 23rd meeting of the
ALA, in which he called for specific time within the medical school curriculum
for courses in our field.(5) Since that time, training
issues have been addressed sporadically. For example, in 1906, Knight6
reviewed the state of training in laryngology, highlighting the proliferation
of instrumentation. Reflecting back on Elsberg's day, Knight noted that "the
meagre armamentarium offered in the olden time is in striking contrast
with the vast collection of apparatus now at our command. It is not certain
that the enormous multiplication of instruments in recent years brings
marked advantage."(6)(P840) It would be interesting
to hear his perspective if he were alive today amid technological developments
that make his own armamentarium look meager indeed.
Thomas J. Harris (7) addressed the complex issues of
postgraduate training in laryngology in an insightful paper read before
the ALA in 1913. Residency programs as we know them had not yet been developed.
Harris emphasized the importance of undergraduate preparation, trainee
selection, basic science education (particularly anatomy and pathology),
postgraduate courses, and supervised clinical experience. He also advocated
the establishment of a minimum postgraduate training time for qualification
in otolaryngology. Skillern, writing in JAMA in "Post-graduate Work
in Laryngology," echoed these concerns, noting that "prior to
1918, practically no undergraduate teaching on a systematic and comprehensive
scale had been successfully carried out in this country."(8)(P1145)
Skillern observed that "the aspiring young laryngologist became of
the opinion that once the submucous resection and the enucleation of the
tonsil were mastered, he forthwith had become a fullfledgedandcompetent
specialist."(8)(P1145) Atthattime, a 6-week course
was typical for specialty training in otolaryngology. He called for more
rigorous and longer training in otolaryngology, and instruction in subspecialty
areas such as laryngology and otology.
In the years following these early papers devoted to education in laryngology,
only a few authors have returned to this important subject. Milligan (9) argued
that there was insufficient time devoted to laryngology in the undergraduate
medical school curriculum in Britain. Dean (10) devoted
his 1925 ALA Presidential Address to the teaching of undergraduate laryngology,
and Layton(11) addressed undergraduate and postgraduate
education in 1940. In 1966, Alford (12) wrote an excellent
review of the evolution of undergraduate and graduate medical training
in the United States, the development of standards and quality control,
and the effects of the evolving medical educational milieu on residency
training in otolaryngology. Bailey (13) provided interesting
insights into the early years of the introduction of laryngology as a component
of otolaryngology training for medical students in the same issue of the
Laryngoscope in which Alford's article was published. Thirty-three years
later, the training of medical students in laryngology remains an important
and challenging issue, as does the education of the general public on the
importance of laryngological and related disorders; but they are beyond
the scope of this paper, which is devoted to postgraduate training in laryngology.
Currently, Medline lists more than 300 articles that address training in
otolaryngology. However, specific laryngology and voice training issues
are rarely mentioned in these publications, and when they are, they usually
focus on the teaching of indirect laryngoscopy to medical students. Considering
the historical importance of laryngology to the development of otolaryngology,
it is surprising how little has been written about teaching this challenging
subspecialty, especially in recent years.
In addition to concerns about curricular issues, laryngologists have been
interested in the many practical aspects of teaching clinical laryngology.
For example, before the advent of video-monitored laryngoscopy, a variety
of devices was conceived to allow trainees to see the larynx during examinations
performed by their mentors. Most involved the use of mirrors, such as Lukens'
demonstroscope (14) in 1929 and a device developed at
the Mayo Clinic around 1960 that attached a shortened laryngeal mirror
to a headlight with a reflecting mirror.(15) It is also
worth remembering that the laryngeal mirror itself was originally introduced
as a training device, albeit for singers, by singing teacher Manuel Garcia
in 1854.(16) A great many other clever devices have been
introduced before and since that time that have enhanced diagnosis, treatment,
and training in laryngology.(17) As early as 1936, Francis
LeJeune reported that "the motion picture film has been found of inestimable
value in teaching the younger student clinical pathology of the larynx."(18)(P492)
LeJeune's fascinating report indicates that he not only recognized the
educational value of motion pictures in teaching laryngoscopy and laryngeal
surgery, but also that he learned from his studies. His careful observations
of the larynx led him to advocate "carrying out sharp dissection with
the laryngeal knife for the removal of the growth. Such a procedure usually
ensures a smooth, straight cord when healed."(18)(P492)
Nevertheless, because of the cumbersome equipment, the delay necessary
to develop the film, and the time-consuming nature of motion picture laryngoscopy,
this technology was not utilized widely in laryngology clinics. However,
in the late 1950s and early 1960s, von Leden and Moore established a voice
clinic and used high-speed motion pictures extensively in clinical care
and laryngeal research. (19)(20)(21)(22) They
also described the importance of television as a teaching device in otolaryngology. (19) The
application of an operating microscope to direct laryngoscopy improved
not only surgical management but also training. Tardy (23) was
among the first to highlight the importance of combining the microscope
with a color television camera, in his 1972 article "Microscopic Laryngology:
Teaching Techniques." He advocated television display of laryngeal
surgery for the purpose of enhancing training by allowing everyone in the
operating room to see what the surgeon was doing. In addition to describing
the value of new technology (microscope-assisted laryngoscopy and color
television monitoring), Tardy showed photo documentation of magnified laryngeal
polyp resection using techniques considerably more delicate than the "stripping" technique
popular at the time. This insightful article specifically listed the teaching
value of televised microscopic laryngeal surgery and called for its use
in residency programs. Although today Tardy's observations seem obvious
it should be remembered that at the time, some respected otolaryngologists
and educational institutions still considered even the microscope (television
monitoring aside) superfluous even for mastoid surgery, let alone laryngoscopy;
and it was still believed by many that laryngoscopy could be performed
perfectly well while holding an unsuspended laryngoscope with one hand
and using instruments only in the other. Tardy's work was an important
early step toward improving both physician education and patient care.
Even so, it took a while to catch on. For example, at the University of
Michigan, the first camera for the otolaryngology department's microscope
was not purchased until 1978. Even then, it was ordered by Dr A. C. D.
Brown of the department of anesthesia so that the anesthesiologist could
see the surgical field during mastoid surgery, rather than by the otolaryngology
department to enhance otological and laryngological training. In retrospect,
such lengthy delay in acquiring television monitors from so venerable a
training program seems hard to fathom. Hence, it behooves each of us entrusted
with the training of young otolaryngologists to reflect upon whether we
are guilty of perpetrating similar unfathomable delays at our own institutions
today.
Since 1975 (in English in 1977), when Hirano (24) described
the layered structure of the vocal fold, laryngology has enjoyed unprecedented
growth. Great advances in our understanding of the anatomy and physiology
of phonation have been paralleled by technological developments for voice
quantification and outcomes assessment.(25) These advances
have resulted in dramatic improvement in the standard of care for all patients
with laryngological disorders, (26) and they have affected
clinical care remarkably quickly, due largely to exceptional interdisciplinary
collaboration. Stimulated by meetings such as the Voice Foundation's Annual
Symposium on Care of the Professional Voice, founded by Wilbur James Gould,
Hans von Leden, and others in 1972, laryngologists, speech-language pathologists,
basic science researchers, singing teachers, acting teachers, performers,
and others have worked together to advance knowledge and enhance patient
care. They have developed a common language, posed questions of practical
value in the clinic and studio, and developed an interdisciplinary paradigm
for answering important questions through valid, reliable research. Much
of this research has been reported at meetings of the ALA and of the American
Broncho-Esophagological Association (ABEA), the Voice Foundation symposia,
and dozens of other, similar meetings that have evolved over the last 2
decades. Because of the interdisciplinary nature of many of these meetings
and research efforts, and the collaborative, penetrating discussions that
occur among professionals of different disciplines at such meetings, even
the most esoteric scientific advances are promulgated quickly. Their practical
importance is probed at the time of their presentation, and new discoveries
are applied to patient care throughout the world within days after such
meetings end.
While the sheer amount of new information, equipment, diagnostic and therapeutic
approaches, and surgical advancements is exciting, it has also created
inconsistencies among training programs in the United States and throughout
the world. Advances have been integrated piecemeal into various educational
programs at different rates, and to different degrees. Now that laryngology
and voice is well established as a subspecialty, it seems timely to reflect
on what we have learned, what anyone finishing a residency in otolaryngology
or a fellowship in laryngology and voice should be expected to know, and
how we can best teach these essentials. The development and adoption of
training guidelines for laryngology and voice should be encouraged not
only to help program directors, but also to ensure reasonable consistency
in minimal basic knowledge among graduates from all programs, with the
end result being a consistently high level of care for laryngological patients.
However, the rapid and successful evolution of our field highlights the
need to consider more than just facts and skills as we develop training
priorities. We should also try to impart an enthusiasm for the kind of
interdisciplinary creativity that was responsible for our current evolution
as a field and try to encourage and inspire similar academic and clinical
creativity.
While laryngology (including voice, speech, swallowing, and related disorders)
constitutes only one segment of otolaryngology, it is particularly important,
for several reasons. First, laryngological problems are common. Estimates
of the incidence of voice disorders in school-age children range, for example,
from 6% to 23%. (27) Although there are no reliable,
valid data on the incidence of voice disorders in the adult population,
they are probably as prevalent as they are in children; and they may be
even more common in elderly adults, who are more likely to develop neurologic
disorders with related voice, speech, and swallowing abnormalities. Most
of our graduates will be called upon to care for patients with laryngological
disorders and to educate colleagues (including primary care physicians)
on the proper diagnosis and treatment of laryngeal problems. Second, the
standard of care and state-of-the-art for management of voice disorders
have changed dramatically and continuously throughout the 1980s and 1990s. (26)(28) The
diagnostic techniques, methods of documentation, and imperative for outcomes
assessment that are now standard were nonexistent just a few years ago.
Some surgical techniques that were routine in the 1970s are now considered
negligent; and newer surgical techniques that replaced them in the 1980s
are already obsolete. If we do not make a concerted effort to ensure that
our residents are fully aware of these developments and their practical
implications, then they may provide outdated treatment; and both they and
their patients will suffer the consequences.
Providing such training is especially difficult in laryngology, because
of the speed with which the field has developed. It is certainly not possible
for all otolaryngologists, or even all academic otolaryngologists, to keep
up with all developments in all fields within our specialty. There are
many programs in which laryngology is managed and taught by general otolaryngologists,
or by head and neck cancer surgeons without special training in the modern
clinical and research aspects of laryngology. However, even if every training
program in the United States had the desire and funds to hire an experienced
and/or fellowship-trained laryngologist, there are not enough to supply
all of the positions, yet. Therefore, at least until the number of laryngologists
has caught up with the number needed, we must be especially diligent about
defining expected areas of basic knowledge.
Details of a recommended curriculum are beyond the scope of this paper.
However, suggestions have been articulated, at least in preliminary form.
One such document was developed by the Speech, Voice and Swallowing Committee
of the American Academy of Otolaryngology, in a subcommittee chaired by
Dr Steven Zeitels (personal communication). However, to date, no proposal
has been accepted by the bodies that guide otolaryngology residency training.
The thoughts that follow constitute only a broad overview of my vision
of minimum residency requirements with regard to substantive knowledge
and clinical skill. They are offered not as definitive recommendations,
but rather, to encourage dialog and an eventual consensus. This paper concentrates
onvoicebecause voice is the most advanced and complex division of laryngology
at present, and in order to limit the length of this paper. A similar model
should be applied to training in the management of swallowing disorders
and selected speech and language disorders.
Basic Science. Comprehensive knowledge of relevant anatomy, physiology,
and pathology is required for insightful diagnosis and expert treatment
of laryngological patients. Every trainee should be familiar with the layered
microanatomy of the vocal fold, the characteristics of its basement membrane,
neuromuscular anatomy (including the latest concepts in fiber composition
and subspecialization within given muscles), laryngeal aging (from embryo
to death), and the nature and importance of supraglottic and infraglottic
components of the vocal tract. Neurolaryngology has emerged as a new field,
and is vitally important to the clinician. Just as neurotology has expanded
our scope of training in otology, so must neurolaryngology in laryngology.
Training should include elements of neuroanatomy and neurophysiology that
seemed irrelevant until recently. Every graduate of a residency should
also be familiar with the intricacies of voice physiology, including respiration,
infraglottic power-source functions, the details of sound production at
the level of the vocal folds, and the resonator functions of the supraglottic
vocal tract. Understanding each component of the anatomy and physiology
is not simply an academic exercise. Such knowledge allows the clinician
to perform a "systems analysis" on the voice, determine which
components are malfunctioning or misfunctioning, and establish diagnoses
and treatment paradigms rationally. (28) Moreover, just
as we expect our trainees to understand audiograms and how to interpret
them, every trainee should be familiar with instrumentation for objective
voice quantification and should be able to interpret data generated from
voice laboratories. They should also be familiar with instruments for outcomes
assessment in patients with voice disorders. (29)
Research. Research is an essential component of any postgraduate
training program. Ultimately, at its best, research is the means by which
we figure out how to improve the condition of patients whom we cannot help
now. Each resident should receive training in research methodology and
should have practical experience with basic and/or clinical research. Such
training is essential not only to teaching incisive interpretation of the
literature, but moreover, to developing the ability to formulate precise
questions relevant to the practice of laryngology, and to design rational
paths toward their answers. Good research training should help solidify
the dissatisfaction all physicians feel about our limitations, and it should
encourage a lifelong curiosity and an unwillingness to accept the limitations
of our knowledge. Research should become a vital tool of daily practice
through which we advance the boundaries of our specialty and enhance the
care of our patients.
Diagnosis and Medical Management. Residents should master the details
of the comprehensive, multisystem history required for patients with voice
disorders, with special techniques for physical examination, and be familiar
with the many other special considerations that must be taken into account
when caring for voice professionals. (30)(31)(32)(33) They
should be able to recognize not only obvious laryngological problems such
as benign and malignant vocal fold lesions, but also less obvious lesions
and related disorders. Graduates of our residencies should be able to differentiate
voice dysfunctions emanating from the infraglottic or supraglottic vocal
tract, as well as laryngeal manifestations of systemic disease (reflux,
thyroid disease, and many others). They should also gain experience in
performing and interpreting strobovideolaryngoscopy and be familiar with
the application of other diagnostic tests, including acoustic analysis,
airflow assessment, laryngeal electromyography, and others. In addition,
otolaryngology residents should receive specific training in the principles
and practice of voice therapy, and they should spend at least some time
observing therapy performed by an expert speech-language pathologist. Sufficient
knowledge should be imparted to allow any laryngologist to determine whether
a specific speech-language pathologist is providing his or her patient
with appropriate, safe, and beneficial therapy. Physicians who refer their
patients to speech-language pathologists cannot fulfill this basic obligation
unless they have a reasonable understanding of the indications for referral,
of the techniques utilized by modern voice therapists, and of the expected
duration and progress of therapy. Ideally, residents should also be given
an opportunity to work with a multidisciplinary voice team. It is also
essential, of course, for trainees to be familiar with medical treatment
of voice disorders, including the vocal consequences of various medications
prescribed by otolaryngologists and other physicians (iatrogenic dysphonias).
In addition, we must prepare our trainees for "special situations" for
example, complex problems such as laryngeal trauma, vocal fold scarring,
and arytenoid dislocations that often require special expertise and/or
rapid diagnosis and management. High-performance professional voice users
also pose special challenges, obligations, and risks with which any practicing
otolaryngologist should be familiar in order to avoid well-meaning but
potentially costly treatment errors.
Surgery. Otolaryngology boasts an excellent tradition of teaching
surgical skills. Prior to performing neck surgery on humans, residents
have been instructed on the anatomy and physiology of neck structures and
pathophysiology, and they have performed neck dissections on cadavers.
They have also generally observed or assisted in numerous similar surgical
procedures. The training tradition is even more consistent and rigorous
for surgery of the temporal bone. Temporal bone laboratory dissection with
professorial instruction and supervision is required in most programs before
residents are entrusted with surgical care of human ears. Unfortunately,
the same systematic approach to teaching of surgical skills is often not
applied to laryngeal surgery in most institutions. Laryngeal endoscopy,
microscopic voice surgery, and phonosurgery (including framework surgery)
are amenable to a similar thorough and systematic approach to training.
In addition to instruction in anatomy and physiology of phonation, examination
and quantification of voice function, outcomes assessment, alternatives
to surgery, and timing of surgery before operating, the resident should
have a thorough knowledge of surgical instrumentation (traditional and
laser). Practice under supervision in laryngeal dissection laboratories
(similar to temporal bone laboratories) and periods of observation in the
operating room should precede resident surgery on human larynges. Attention
to surgical technique and ergonomics is essential, because of the technical
difficulties involved in maintaining perfect control of the tips of long
laryngeal instruments. Indeed, laryngeal microsurgery may well be approached
conceptually as ear surgery with longer instruments. Resident surgery on
patients should be supervised closely and should follow a planned progression
from simple to complex cases; and it should be recognized that microdissection
of the vibratory margin of the vocal fold may be more challenging technically
than some seemingly "larger" cases such as laryngectomy. Results
from residents' surgery should be comparable to those achieved by professorial
faculty. Training should also include criteria for determining which cases
should not be performed by the inexperienced or occasional laryngeal surgeon,
and guidelines for referral to tertiary care laryngologists.
Special Considerations. In addition to providing training in facts
and skills, attention must be paid to the art of patient care. This is
extremely important in the management of all patients, and acutely important
when caring for high-performance voice professionals.
Residents in otolaryngology, and fellows in laryngology and voice, should
also be imbued with curiosity about the many questions that remain unanswered.
They should receive historical information about the development of our
field, and exposure to voice professionals in other disciplines such as
speech-language pathologists, singing teachers, and arts-medicine specialists
in other fields.
Fellowship programs in laryngology have proliferated recently in response
to clinical and academic demand, but they have actually existed for many
years. For example, Dr Hans von Leden and the late Dr Wilbur James Gould
have trained fellows since the 1950s and 1960s, among them such distinguished
individuals as Drs Minoru Hirano and Nobuhiko Isshiki. This author began
providing such training in 1981; and since that time, fellows have included
not only laryngologists, but also speech-language pathologists and singing
teachers. If our specialty is to provide enough practitioners to meet the
need for high-caliber laryngology and voice care teams, then we must participate
in advanced training for physicians and for professionals in other disciplines
who will constitute the interdisciplinary teams of the future.
While no formal guidelines for fellowship training have been accepted
or implemented to date, they may be anticipated in the near future. A draft
document has been developed by Dr Robert Ossoff, this author, and other
members of The Ad Hoc Committee on Laryngology Fellowship of the ALA. The
need for quality control and some standardization in minimum experience
in fellowship programs will hopefully lead to further action on this document
or a similar set of guidelines in the near future.
Interdisciplinary opportunities for creativity in medicine still offer
the potential for excitement, joy, and innovation in daily practice. (34) The
current advances in laryngology were inspired by interest in the problems
of professional voice users, particularly opera singers; but this trend
in laryngology was not isolated. Modern voice medicine is but one component
of a larger field of arts medicine that offers similar interdisciplinary
team care for pianists, string players, dancers, wind instrumentalists,
and others.(35) The arts-medicine aspects of laryngology
are exciting for at least 2 reasons that should be addressed in any training
program. First, performers and artists place critical demands on their
bodies, and they do not have the usual tolerance for incomplete cures.
An injured finger that returns to 98% normal function may be adequate even
for a microsurgeon, but it is not adequate for a premier pianist. That
extra 2% separates the famous artist from those who have not quite reached
the "top." Arts-medicine patients force us to redefine "normal" much
more narrowly, and they challenge our abilities to recognize, quantify,
and restore physiological perfection. Much of the fun and many of the ideas
that have helped advance laryngology and voice have come from close interactions
with such patients, as well as with speech-language pathologists, voice
scientists, singing teachers, acting teachers, and other colleagues, all
of whom provide insights useful in clinical practice. Second, arts medicine
provides physicians with an opportunity to work closely with professionals
and educators in the arts and humanities. The arts and medicine are inherently
similar in many ways. However, through our educational process, physicians
too often lose sight of the importance of the arts to our practices, and
there is a movement in medical education to correct this deficiency. Arts
medicine offers the clinician a chance to work and think with colleagues
in related fields, such as artists and performers, and to find new solutions
to complex problems. It also may afford us with the inspiration and opportunity
to study one of the arts. In our quest to master the science and art of
healing, we can learn much from our colleagues in the arts and humanities
that will help our insight, sensitivity, and ability to empathize. Such
interactions also help keep us from being trapped intellectually by existing
paradigms and allow us to approach questions with a broader vision, creating
new solutions to problems that seem insurmountable within the compartmentalized
framework of our traditional training, and even allow us to create new
fields of medicine.
Laryngologists of the future will be ideally positioned to thrive as sophisticated
diagnosticians, surgeons, and scientists; but they will also have exceptional
opportunities to remain "physicians" in the truest and broadest
sense. It is incumbent upon us to offer training environments that will
not merely provide skills, but will also kindle and nurture their curiosity,
creativity, and broader vision. In these days of economic and legal crises,
medicine has precious few reminders of the reasons why most of us were
inspired to become doctors. For the last 2 decades, modern laryngology
has been built on such enthusiasm, and practicing it has been a daily joy.
We must ensure that the next generation will not have to settle for anything
less. If we are successful, 20 years from now, our practice will look as
crude as Elsberg' s methods seem to us now; and we will have accomplished
our mission as educators and left behind training centers filled not only
with information, but also with inspiration and imagination.
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