Otolaryngology Training Research Articles

Editorial introductions

Current Opinion in Otolaryngology & Head and Neck Surgery was launched in 1993. It is one of a successful series of review journals whose unique format is designed to provide a systematic and critical assessment of the literature as presented in the many primary journals. The fields of otolaryngology and head and neck surgery are divided into 11 sections that are reviewed once a year. Each section is assigned a Section Editor, a leading authority in the area, who identifies the most important topics at that time. Here we are pleased to introduce the Journal's Section Editors for this issue. SECTION EDITORS Jacqui E. AllenJacqui E. AllenJacqui E. Allen, MBChB, FRACS is a Consultant Otolaryngologist in the Department of Otolaryngology – Head and Neck Surgery at North Shore Hospital, Auckland, New Zealand and an Honorary Senior Lecturer in the Department of Surgery at the University of Auckland, New Zealand. Dr Allen's practice includes voice, laryngology with complex airway management, dysphagia and head and neck cancer. She earned her medical degree from the University of Auckland Medical School and completed ORL residency in New Zealand, followed by a fellowship at the University of California, Davis, USA, in the Voice and Swallowing Centre. She is a member of the New Zealand Society of Otolaryngologists Head and Neck Surgeons, the RACS Academy of Surgical Educators and a Fellow of the Royal Australasian College of Surgeons. Dr Allen's research interests include airway stenosis, cough and reflux, and novel dysphagia management. Her publications have appeared in journals such as Laryngoscope, Otolaryngology Head and Neck Surgery, Head and Neck and Dysphagia. Lisa BuckmillerLisa BuckmillerDr Lisa Buckmiller is a Pediatric Otolaryngologist at the Children's Hospital of San Antonio, Texas, USA. Dr Buckmiller completed her undergraduate training in molecular biology and biochemistry at the University of California, Santa Cruz, USA, and went on to do her medical training at the University of California, Irvine College of Medicine, USA, and her residency in otolaryngology at the University of California, Davis, USA in Sacramento. She then accomplished her fellowship training in pediatric otolaryngology at Arkansas Children's Hospital, USA, and continued on as faculty from 2002–2012. Dr Buckmiller directed two multidisciplinary teams, including the Cleft Lip and Palate Team as well as the Vascular Anomalies Team while on faculty at Arkansas Children's Hospital. In 2005, she was awarded the Benjamin and Milton Endowed Chair in Pediatric Facial Plastic and Reconstructive Surgery for her work to better the lives of children with facial deformities. She also is dedicated to serving overseas on medical missions several times a year and performs surgeries for both cleft lip and palate as well as hemangiomas and vascular malformations on these trips. She is board certified and is an active member of the: American Academy of Otolaryngology; International Society for the Study of Vascular Anomalies; American Cleft Palate Association; and the American Society of Pediatric Otolaryngology. Dr Buckmiller's research interests are in the areas of vascular anomalies as well as treatment of velopharyngeal insufficiency and primary rhinoplasty for cleft patients.

Survey of Otolaryngology Services in Central America: Need for a Comprehensive Intervention

In the developing world, there exists a scarcity of services and training in otolaryngology, audiology, and speech therapy, which is reflected by the gap between health care delivery in high-income countries and low-income countries. We surveyed, by questionnaire, the countries of Central America, except for Belize, because of the lack of otolaryngology services, on the following issues: availability of otolaryngology, audiology, and speech therapy services and equipment; otolaryngologist, audiologist, and speech therapist training; and availability of services in rural areas. Surveys were distributed via email and by hand at the 2011 Central American Congress of Otolaryngology, in San Salvador, El Salvador, to otolaryngologists, audiologists, and speech therapists. Not to our surprise, there is a shortfall in services and training in all three professions. The data collected and presented in this commentary will provide a basis by which change might take place.

Efficacy of Surgical Simulators for Otolaryngology Training

Program Description: Recently, there has been growing interest in developing and using simulation technologies for basic surgical skills training for residents. In addition, as our specialty continually evolves and we make efforts for quality and lifelong learning, simulation technologies may also be useful for keeping experienced surgeons up-to-date with their skills. We will present currently available surgical simulators for temporal bone dissection, endoscopic sinus surgery, airway endoscopy, and tonsillectomy. The presenters will provide descriptions and show videos demonstrating the function of these devices. In addition, each panelist will present data evaluating the efficacy of these simulators as being effective teaching instruments. Educational Objectives: 1) Differentiate the variety of simulation technology devices available for surgical skills training in otolaryngology–head neck surgery. 2) Recognize the advantages and limitations of using simulation technologies for acquiring and maintaining surgical skills. 3) Assess the validity of the studies presented to evaluate the efficacy of simulation devices as valuable learning tools.

Using Cumulative Summation to Draw Otolaryngology Trainees’ Learning Curves in Tonsillectomy

Objectives: Assess the applicability of cumulative summation (CUSUM) in 1) showing trainees progress, 2) achieving competency, and 3) highlighting concerns in tonsillectomy surgery. Methods: We followed 9 otolaryngology junior trainees in their first 6-12 months in the specialty between 2011-2013. Tonsillectomy is the most common operation that introduces trainees to operative otolaryngology. Two outcome measures were used: operative time and post-operative bleeding. These were then compared to experienced surgeons (>100 tonsillectomies). For time CUSUM, the mean and standard deviation of the experts’ performance was used as the factor to draw the curve applying the formula (Cn=0, Cn-1+Xn-k) on consecutive procedures. k=0.2 to allow for 20% incidence of overrunning. For bleeding CUSUM, any post-operative bleed was regarded a negative outcome and k=0.05 to allow for 5% incidence. Results: Trainees performed 14-35 tonsillectomies each (ongoing). The average time for experts over 150 procedures was 23min (SD:11). Trainees’ operative time was higher (38min, SD:16, P<0.01). Xn=0 if the time was within 1SD of the experts (34min) and 1 if higher. Trainees’ time CUSUM plateaued after a variable number of cases (20-30) while that of experts remained low. For bleeding CUSUM, Xn=1 if reported and 0 if not. Bleeding was rare and did not reflect the same pattern. Conclusions: CUSUM using time can be used to monitor performance and draw learning curves for tonsillectomy. Bleeding is a rare complication and hence needs larger numbers to show improvement. The flexibility of the CUSUM makes it adaptable to any outcome. It allows early detection of poor performance to instigate intervention.

Endoscopic Endonasal Approaches for Benign Tumors Involving the Skull Base

With continued refinements in endoscopic image quality, instrumentation, surgical navigation, skull base closure techniques, anatomical understanding, and advanced neurosurgical and otolaryngological training, the endonasal endoscopic approach has become a well-accepted and widely utilized technique for the resection of most benign midline ventral skull base tumors. While pituitary adenomas and Rathke’s cleft cysts constitute the most common lesions removed via this route, increasing experience has led to its broader utilization for more complex lesions, including craniopharyngiomas, midline meningiomas, and schwannomas. In this article, we review the recent literature published on this topic with an emphasis on the most interesting and important new results and discoveries for each type of benign skull base tumor.

Assessment of phonomicrosurgical training in otolaryngology residencies: A resident survey

The primary objective of this study is to assess the adequacy of clinical and laboratory-based phonomicrosurgical training in otolaryngology residency programs using a self-report survey. The study aims to establish whether there is a need and desire for focused surgical training in phonomicrosurgery. Self-report Internet-based questionnaire. An anonymous survey was sent to all current residents in otolaryngology training programs in the United States and Canada. For portions of the analysis, the residents were categorized into two groups--junior (R2 and R3) and senior (R4 and R5). One hundred ninety-one residents responded to the survey (USA: 166; Canada: 25), representing a 34.3% response rate. Approximately one-half of residents stated that their residency program includes a rotation during which the main emphasis is laryngology. Only 18.8% of residents were "very" satisfied with the phonomicrosurgery experience that their program offers and 21.6% of senior residents felt "very" comfortable performing a phonomicrosurgical removal of a vocal fold lesion. Whereas the vast majority of respondents found temporal bone laboratory training to be helpful, 82% had never performed laboratory training in phonomicrosurgery. The majority (87.4%) felt that their comfort level with phonomicrosurgery would increase if they had access to laboratory-based training. Our study suggests that there is a lack of emphasis on clinical and laboratory-based training in phonomicrosurgery and that there is a need and desire for focused surgical training in phonomicrosurgery.

The Financial Value of Fellowship Training in Otolaryngology

To evaluate the financial impact of pursuing a fellowship in otolaryngology. Retrospective financial analysis using American Academy of Otolaryngology-Head and Neck Surgery survey data. The American Academy of Otolaryngology-Head and Neck Surgery report, entitled Socioeconomic Study among Members April 2011, gives a financial profile of respondents who reported their primary area of specialization as either general otolaryngology or a specific area of subspecialization. Weighted averages were calculated from the reported data. The weighted averages were used to calculate a net present value (NPV) over a 30-year contiguous career. The NPV for general otolaryngology was $4.73 million. The NPV for the following subspecialties in relation to general otolaryngology were (in hundred thousands) as follows: otolaryngologic allergy (-$1153), sleep medicine (-$677), otology/neurotology (-$339), laryngology (-$288), head and neck (-$191), pediatric otolaryngology (-$176), facial plastic surgery (-$139), skull base surgery ($122), rhinology ($285), and allergy and immunology ($350). Ninety-four percent of general otolaryngology respondents were in private practice. Most subspecialists worked in an academic setting. Fellowship training in otolaryngology will affect career earnings of prospective fellows. The overall financial impact of fellowship training, calculating in the delay in receiving a full clinical salary, should be factored into the decision to pursue fellowship training.

Otolaryngology training programs: Resident and faculty perception of the mentorship experience

The purpose of this study is to compare faculty and trainees' perceptions of their mentorship experience in otolaryngology training programs in order to identify areas where improvements could yield more productive mentorship. Cross-sectional survey design. Residents and faculty from three otolaryngology-head and neck surgery programs were surveyed regarding their perceptions of their mentoring relationship. Trainees were asked about the characteristics of their mentorship experience. Separately, faculty were asked to describe their mentorship relationship, available resources to provide effective mentorship, and to identify areas in which formal training would improve their mentoring skills. Forty-eight trainees (72%) and sixty-one faculty members (73%) completed the survey. Ninety percent of residents meet with their mentors at least twice a year. Faculty and residents (> 80%) agreed that career planning was the most commonly addressed topic in mentorship sessions. However, faculty and residents differed in their perceptions of providing mentorship in other areas including clinical judgment (P = 0.003). The majority of faculty (56%) felt that formal mentorship training would improve their mentorship skills. While 95% of mentees agreed that their mentor is accessible, only 46% of faculty believed they have enough time to dedicate to mentoring (P < 0.001). Mentees are generally satisfied with the mentoring they receive, while most mentors are not satisfied with the time they have to provide mentorship. Further insights into differences in faculty and trainee perceptions may improve the mentorship experience.

Revision nasal surgery after septoplasty: trainees versus trainers

Otolaryngology trainees are expected to be able to successfully perform septoplasty early in their career. An important parameter to assess the success of an operation is to look at the revision surgery rate. This study aimed to investigate the revision nasal surgery rate after septoplasty based on the grade of the primary surgeon. Retrospective review of hospital records of all patients who underwent septoplasty with or without inferior turbinate reduction over 12 years (1998-2010) in a tertiary referral centre in North-East Scotland. Patients were identified from theatre log books and were excluded if they underwent any other simultaneous nasal procedure. Data were collected on demographics, type of primary and revision surgery, grade of surgeon and duration of hospital stay. 2,168 eligible patients (70 % male, 30 % female) with a mean age of 39 years were investigated. Surgeons were divided into four categories: junior trainee (Group A), senior trainee (Group B), staff grade (Group C) and consultant (Group D). There were 753, 644, 298 and 473 patients in Groups A, B, C and D, respectively. The revision rate in Group A was 4.4 % compared to 3.2 % for Group D and this difference was not statistically significant. For their operation, patients in Group A stayed for 1.54 nights compared to 1.47 nights in Group D, the difference being insignificant. Grade of the surgeon does not appear to strongly affect the need for revision nasal surgery and our patients do not appear to be disadvantaged if operated on by trainees.

USMLE step one, otolaryngology in-training examination scores, and the American Board of Otolaryngology examination performance

To determine if U. S. Medical Licensure Examination (USMLE) Step One scores have a positive correlation with performance on the annual Otolaryngology Training Examination (OTE) and subsequent performance on the American Board of Otolaryngology (ABOto) examination. A retrospective cohort study of 70 residents completing Otolaryngology residencies from 2005-2009. 103 otolaryngology training programs were contacted and USMLE Step 1 scores, OTE scores, and performance on the ABOto examination were collected for the graduating chief residents from 2005-2009 from a limited number of residency programs. The associations between the examinations were evaluated using Spearman\'s rank correlation coefficient and Pearson’s correlation. USMLE Step 1 scores and board performance were provided for 70 residents from 7 Otolaryngology residency programs. Positive correlations were found using Pearson’s and Spearman’s correlation to be significant for USMLE Step 1 scores compared with scores on the OTE-2, OTE-3, OTE-4, OTE-5 (p

Global health initiatives of US otolaryngology residency programs: 2011 global health initiatives survey results

The objectives of this work were to quantify the involvement of US otolaryngology residency programs in global health endeavors, identify goals and services provided, and determine the participation of residents and fellows. Cross-sectional survey of US otolaryngology faculty. A 10-point online questionnaire was distributed to 103 US otolaryngology residency program directors; all faculty involved in global health volunteerism were invited to participate. Twenty-nine global health initiatives were represented. Most of the 24 residency programs involved (66%) had organized global health offices at their institutions; only 4% actually cooperated with these offices. Most often, only one attending (55%) was involved at each institution. Residents/fellows participated 65% of the time. Abroad, US otolaryngologists worked with freestanding hospitals or clinics (24%), American nongovernmental organizations (17%), academic centers (14%), and remote locations (14%). Most (96%) provided specialty surgical services, but some provided primary care (28%) and general surgical services (14%); 72% trained foreign surgeons. Most respondents (79%) reported that the clinical work done abroad was substantial enough for Accreditation Council for Graduate Medical Education (ACGME) standards. Only one fifth of respondents knew the name of the nearest otolaryngology training institution. Humanitarian aid was the most prevalent goal (100%), followed by resident/fellow exchange (45%) and faculty exchange (21%). At least a quarter of US otolaryngology residency programs engage in global health volunteerism. Most do not utilize institutional global health resources and are unaware of otolaryngology training programs abroad. There may be a role for global health education within the ACGME competency of systems-based practice.

Objective Skills Assessment and Construct Validation of a Virtual Reality Temporal Bone Simulator

To evaluate construct validity of the Voxelman TempoSurg Virtual Reality (VR) temporal bone simulator by determining whether generated objective metrics can distinguish experienced otologic surgeons from intermediate and novice surgeons. Prospective assessment study. Two university-affiliated teaching hospitals. Sixty-five participants were recruited; 40 novice surgeons, 15 trainees in otolaryngology, and 10 experienced otolaryngology consultants with a specialist interest in otology were individually assessed on a standardized simulated temporal bone task. The task involved identification and delineation of the sigmoid sinus in a virtual left-sided temporal bone. Objective data were produced using a scoring matrix incorporated into the VOXEL MAN TempoSurg software. The simulator measured the total time taken to complete the task, the volume and efficiency of bone removal and error data for excessive force or injury to the facial nerve, dura, and sigmoid sinus. Experts and intermediates outperformed novices with respect to the total time taken to complete the task (expert versus novice: p < 0.001; intermediate versus novice: p < 0.001), total volume of bone removed (p < 0.001 and p = 0.03), efficiency of bone removal (p < 0.001 and p < 0.001), time spent with the drill tip obscured (p = 0.002 and p < 0.001), and number of injuries to the sigmoid sinus (p < 0.001 and p < 0.001). The intermediate group injured the sigmoid sinus on more occasions than the experts (p = 0.008) and were less efficient than experienced surgeons (p = 0.005). Simulator-generated objective metrics can be used to differentiate individuals of differing levels of experience using a standardized temporal bone task. VR simulation has potential as a training tool and may have a role in both formative and summative assessment.

Achieving flying colours in surgical safety: audit of World Health Organization ‘Surgical Safety Checklist’ compliance

The World Health Organization 'Surgical Safety Checklist' has been adopted by UK surgical units following National Patient Safety Agency guidance. Our aim was to assess compliance with our local version of this Checklist. Otolaryngology trainee doctors prospectively assessed compliance with the local Checklist over a six-week period. A staff educational intervention was implemented and the audit was repeated 12 months later. A total of 72 cases were assessed. The initial audit found that: 44 per cent of procedures were undocumented at 'Sign in'; 'Time out' was inappropriately interrupted in 39 per cent of cases; the procedure started before Checklist completion in 33 per cent of cases; and the 'Sign out' was not read out in 94 per cent of cases and was not fully documented in 42 per cent of cases. Following education, re-audit indicated that overall compliance had improved from 63.7 per cent (± 8.9 per cent standard error of the mean) to 90.4 per cent (± 2.7 per cent standard error of the mean). Our completed audit cycle demonstrated a significant improvement in Checklist compliance following educational intervention. We discuss barriers to compliance, as well as strategies for quality improvement, and we call for other surgeons to similarly publish their Checklist experience and assess its impact on surgical outcomes.

Surgical Skills of Applicants to Residency in Otolaryngology

Objective: 1) Measure baseline competence in the performance of a basic surgical task by 4th-year medical students applying to otolaryngology residency. 2) Determine whether information available in the standardized otolaryngology residency application correlates with competence in performance of the basic surgical task. Method: Applicants to residency in otolaryngology with the University of Tennessee Health Science Center in 2010 and 2011 constituted the study population. During the interview, the applicant was asked to close a simulated incision with sutures. A blinded observer recorded a 15-point Objective Surgical Assessment of Technical Skill score. Results: The OSATS score provided a measure of the suturing skills of individuals applying to residency training in otolaryngology. The OSATS score was incorporated into the calculation of an overall OSCE (Objective Structured Clinical Examination) score modified to focus on surgical skill performance and a professionalism measure. Initial data analysis produced a correlation value ( R value) between the OSCE score and data points gleaned from the standardized application (USMLE step I score, prior employment-related surgical experience, hobbies, musical background, athletic background, research experience that includes performance of surgical procedures). Conclusion: In contrast to other high-skill professions such as the airline industry, surgical educators have not universally developed a practice of testing prospective trainees for aptitudes that can be deemed critical to surgical competence. This study represents a methodology for assessment of a simple surgical skill to which all applicants to otolaryngology training should have been exposed. It also determines correlation with applicant data commonly used in selection, such as USMLE score.

Attainment of Surgical Competence in Otolaryngology Training

Objective: Determine postgraduate year (PGY) at which competence is achieved in key otolaryngologic procedures as reported by residents and program directors (PDs) and evaluate relationship between resident and PD perceptions. Method: Cross-sectional survey of residents and PDs in US otolaryngology residencies conducted in 2011 using surveymonkey.com , assessing attainment of competence by residents for 32 otolaryngologic procedures. PGYs at which competence is achieved per residents and PDs were determined using linear regression models, and associations were assessed with chi-square goodness-of-fit test. Results: A total of 277 residents (19.45%) and 39 PDs (37.86%) completed surveys. Compared with PD perceptions, residents felt they achieved subjective competence earlier than expected by PDs for 13 of 32 procedures, later than expected by PDs for 3 of 32, and at the same PGY for 16 of 32 (significance at P &lt; .05 level by pooled t test) . Degrees held, fellowship plans, and size of residency program did not significantly impact PGY at which residents felt competence was achieved for most procedures. Conclusion: We provide baseline data on PGY at which residents achieve competence in key otolaryngologic procedures. These results may guide efforts to establish appropriate milestones for resident training and assessment and better structure resident operative experiences.

Predictors of Performance in Endoscopic Rhinology Procedures

Objective: Investigate the best predictor of performance of otolaryngology trainees in a rhinology skills lab. Method: Cross-sectional study carried out in February 2012 where 15 trainees from the London otolaryngology training program (year 3-5) were asked to complete 9 operative tasks on a sheep head model and were assessed by 5 experts on task-specific and global performance using a previously validated tool. We tested 7 factors as predictors of performance including time (months) in surgical training, time in otolaryngology training and time in rhinology sub-speciality training, practical rhinology courses attended, total rhinology procedures, procedures as main operating surgeon, and precourse operative global scores from video recordings. Results: The task-specific and global scores correlated well (Pearson 0.66). Six out of the 7 factors did not show correlation with performance at the skills lab (time in surgery, time in otolaryngology, time in rhinology, number of courses, total procedures, and procedures performed, Pearson: 0.19, 0.12, 0.3, 0.11, 0.28, and 0.13, respectively). The only measure that correlated well is precourse performance scored blindly and independently using the same tool based on video recordings of trainees operative procedures (Pearson: 0.62) Conclusion: Predicting surgical performance is a multi-factorial complex process. The assessment process including the tool and assessors have been validated further by showing consistency in scoring the same trainee twice, before and during the course as well as good correlation between task-specific and global assessment. Previously acquired skills have the highest predictive value.

Validating the Sheep Model in Rhinology Skills Training

Objective: 1) Investigate face and content validity of the sheep model in operative rhinology skills training. 2) Investigate the applicability and transferability of skills acquired in otolaryngology training curriculum. Method: An evaluation study conducted in February 2012. Fifteen otolaryngology trainees (level: 3-5) and 5 experts completed 9 operative rhinology tasks on a pre-prepared sheep model and assessed face and content validity using a Likert scale across 20-item questionnaire. Participants also evaluated the model in teaching individual tasks and globally as training tool. Results: The model achieved face validity of 4.1 with no significant difference between expert and intermediate groups (4.0 and 4.3, Wilcoxon P = .14). Content validity score was 4.2, with experts scoring higher than the intermediate group (4.0 and 4.5, Wlicoxon P = .043). The highest scoring skills were improving hand-eye-coordination and operative skills (4.7 and 4.6), and the worst was anatomy teaching (3.4). The highest scoring tasks were foreign-body removal and cerebrospinal fluid leak repair (4.4 and 4.0), and the worst was middle-meatal-antrostomy and septoplasty (3.3 and 3.6). Two data points were missing (99.5% completion). All agreed on transferability, incorporation into curriculum, and recommending to colleagues (4.2, 4.5, and 4.4). Conclusion: The sheep model achieved face and content validity and is recommended by experts and trainees for teaching rhinology skills. Advantages include availability, realism, and applicability of acquired skills in rhinology procedures. The model achieved &gt;4/5 Likert scale in teaching endoscopic examination, foreign-body removal, cerebrospinal fluid leak repair, and sphenopalatine artery ligation.

Do Residency Applicant Measures Predict Future Performance?

Objective: To determine if residency applicant measures are predictive of resident performance. Method: A retrospective review of the residents graduating from 2006-2012 was performed. Residency applicant measures including board scores, medical school grades, and applicant rank were recorded. These were compared to measures of resident performance including otolaryngology training exam (OTE) scores and composite 360° evaluation scores obtained during the final year of residency. Results: Data was available on 20 residents. Residency applicant board scores were minimally predictive of resident OTE scores during the final year of residency ( r2 = 0.377). There was no significant correlation between board scores and performance on evaluations ( r2 = 0.10). Grade received during the surgical clerkship had an inverse correlation with performance on the OTE ( r2 = 0.13). The surgical clerkship grade also had no correlation with evaluation score ( r2 = 0.04). Most notably, applicant rank had minimal correlation with final resident performance as measured by composite evaluation score ( r2 = 0.06). Conclusion: Commonly used measures of applicant quality are minimally predictive of ultimate resident performance. Further studies are indicated to identify better predictors of resident performance.

Fat Is Exciting, but . . .

I must confess: I still have as much enthusiasm for plastic surgery as I did over 35 years ago, in 1976, when I was a first-year resident and had just completed my training in otolaryngology. You might ask how someone now in the twilight of his professional career has remained excited for so long. I think the answer lies in one word: innovation. Plastic surgery is the medical specialty that epitomizes innovation. My continuing enthusiasm stems from having been privileged to witness the initial description, subsequent evolution, and eventual institution of techniques and concepts that most of today’s graduating plastic surgery residents take for granted. Among those innovations were craniofacial surgery, tissue expansion, musculocutaneous flaps, free tissue transfer, and negative pressure wound therapy. And there were countless milestones in aesthetic surgery as well—liposuction, open rhinoplasty, soft tissue fillers, cosmetic applications for botulinum toxin, a deepening anatomic knowledge of facial planes and their clinical significance (eg, the superficial musculoaponeurotic system; SMAS), and so many more. Most of the above-named innovations are either uniquely cosmetic or reconstructive in nature. In contrast, recent scientific and clinical breakthroughs concerning fat encompass both reconstructive (“regenerative’) and cosmetic medicine. Although fat has been employed for many years in a variety of clinical settings, it is mainly within the past 5 years that reports of significant new research and unique applications have emerged. As exciting as the current clinical and research accomplishments related to fat transfer are, it is even more exciting to imagine what the future may hold. In a world where dwindling health care resources are a grim reality, adult …

Do South African universities provide the required training platforms for otolaryngology specialist training?

Concern exists about the quality of specialist training platforms at South African universities and teaching hospitals. We conducted an audit of the quality of training at South African otolaryngology (ENT) training institutions from the perspective of the registrars. Some institutions were deficient in terms of supervision, theatre time, access to teaching aids and research tools, and range of surgery, and do not provide the required training platforms for ENT specialist training. Five out of 8 institutions have produced <2 publications in peer-reviewed journals over the past 5 years. The HPCSA fails to adequately police the quality of training in South Africa. Training programme shortcomings must urgently be addressed to ensure proper education and training of otolaryngologists.