Neurotology Fellowship Goals & Objectives

Goal

Fellows should be committed and able to provide compassionate, appropriate and effective medical care for their patients. Fellows are licensed otolaryngologists and should ensure that they follow these objectives and set an example for others working on their teams.

Objectives

• Be able to gather essential and accurate information about their patients and demonstrate an in-depth understanding of multiple electronic patient information systems
• Be able to demonstrate an ability to develop, communicate and implement patient care plans
• Be able to competently perform all medical and invasive procedures essential to the practice of neurotology that is expected for their level of training
• Be able to counsel and educate patients and their families
• Be able to work with health care professionals, including those from other disciplines, to provide patient-focused care
• Be able to use scientific evidence and methods to investigate and improve patient care

Goal

The neurotology fellow should demonstrate extensive medical knowledge of established and evolving biomedical, clinical and epidemiological sciences in the field of neurotology and be able to apply this knowledge to patient care.

Objectives

• Fellows should demonstrate commitment to a life of learning whereby they continuously acquire new knowledge and skills and integrate them into their daily clinical practice.
• Fellows should participate in active review and dissemination of current research and medical developments.
• Fellows should have command of core knowledge and a thorough understanding of the following specific knowledge areas:
  • Morphology, physiology, pharmacology, pathology, microbiology, biochemistry, genetics, allergy and immunology relevant to the temporal bone, lateral skull base and related structures
  • The communication sciences, including knowledge of audiology
  • Endocrinology and neurology as they relate to the temporal bone, lateral skull base and related structures
  • Neurophysiology, neuropathophysiology, diagnosis and therapy of advanced neurotologic disorders, including advanced audiologic and vestibular testing
  • Evaluation of cranial nerves and related structures
  • Interpretation of imaging techniques of the temporal bone and lateral skull base
  • Electrophysiologic monitoring of cranial nerves VII, VIII, X, XI and XII
  • Audiometric testing, including auditory brainstem responses and otoacoustic emissions
  • Vestibular testing, facial nerve testing, electrophysiologic monitoring strategies and neuroradiologic procedures used to evaluate the temporal bone, skull base and structures
  • Diagnostic expertise and ability to develop medical and surgical management strategies, including intracranial exposure and the postoperative care necessary to treat congenital, inflammatory, neoplastic, idiopathic, allergic, immunologic and traumatic diseases of the petrous apex, internal auditory canal, cerebellopontine angle, cranial nerves and lateral skull base, including the occipital bone, temporal bone and craniovertebral junction
  • Diagnostic evaluation and management of the surgical revision procedures for the treatment of chronic otitis media, disorders of the vestibular system, otosclerosis, profound hearing loss, facial nerve disorders and congenital, inflammatory, neoplastic, idiopathic and traumatic disorders of the extradural petrous bone and apex, occipital bone, sphenoid bone and related structures
  • Advanced surgical techniques to treat diseases and disorders of the auditory and vestibular systems and the extradural skull base, including the sphenoid bone and temporal bone
  • Reconstructive repair techniques for deficits affecting the auditory and vestibular systems and extradural skull base
  • The habilitation and rehabilitation techniques and procedures pertaining to vestibular disorders, hearing disorders (including, but not limited to, hearing aids, cochlear implants and assistive listening devices) and cranial nerve neuropathies, as well as speech rehabilitation for the hearing impaired
  • The diagnosis and medical and surgical management of congenital, traumatic, inflammatory, degenerative, neoplastic, allergic, immunologic and idiopathic diseases and other disease states of the temporal bone, occipital bone, sphenoid bone, craniovertebral junction and related structures
  • The current literature, especially pertaining to the areas listed above, and research methodology

Goal

Fellows must be able to investigate and evaluate their patient care practices, appraise and assimilate scientific evidence and improve their patient care practices.

Objectives

• Become well-versed in the academic literature in neurotology
• Perform practice-based improvement activities using a systematic methodology
• Demonstrate the ability to apply knowledge of study designs and statistical methods to the appraisal of clinical studies
• Identify strengths, deficiencies and limits in one's own knowledge and expertise, and implement an appropriate plan for self-improvement
• Incorporate performance feedback into daily practice
• Demonstrate effective time management skills
• Develop teaching and leadership skills
• Develop the habit of analyzing one's own practice for needed improvements

Goal

Fellows must be able to demonstrate interpersonal and communication skills that result in effective information exchange and collaboration with patients, patients' families and professional associates. Fellows are expected to lead by example and reinforce these attributes in their colleagues.

Objectives

• Be able to develop an ethical and therapeutic doctor-patient relationship with patients, regardless of ethnic and educational background
• Develop a sense of empathy regarding barriers that prevent patients from receiving optimal health care (e.g., lack of transportation, funds, insurance, family support, language skills, etc.)
• Work effectively as a member or leader of a health care team
• Be able to create complete and coherent clinic and consultation notes, whether written (legibly) or dictated
• Become well-versed in using translation services to communicate with non-English speaking patients

Goal

Fellows must demonstrate a commitment to carrying out professional responsibilities, adherence to ethical principles and sensitivity to a diverse patient population.

Objective

• Develop an understanding of and sensitivity to the impact of cultural, economic and ethnic factors on the doctor-patient relationship and the delivery of health care
• Learn to coordinate and optimize patient care through cooperation and respectful communication with all members of the health care team
• Develop an understanding of one's own abilities and limitations
• Consistently demonstrate courtesy when interacting with clinical and non-clinical staff members
• Understand the concept of confidentiality as it relates to patient care and communication
• Involve other providers (specialty or primary care) in the evaluation and care of patients when appropriate

Goal

Fellows must demonstrate an awareness of and responsiveness to the larger context and system of health care, as well as the ability to call effectively on other resources in the system to provide optimal health care.

Objective

• Learn to effectively deliver excellent neurotologic care in the following diverse health care settings:
  • A tertiary academic center (UC San Diego)
  • A health maintenance organization (Kaiser Permanente)
  • A private group practice (Scripps Green Hospital)
  • A government agency (Veterans Affairs San Diego Healthcare System)
• Incorporate considerations of cost awareness and risk-benefit analysis in the diagnosis and treatment of neurotologic conditions

The program is based on a system of graduated and increasing responsibilities in both the clinic and operating room. Fellows are expected to steadily increase their knowledge base and operative skills throughout their two years. The following timeline of the fellow's progression provides a general guideline that can be tailored to the individual fellow:

First Year

• Learn anatomy, physiology and pathology of the ear and lateral skull base
• Learn a complete neurotologic examination
• Learn neuroradiology of the lateral skull base, including CT, MRI and angiography
• Learn audiologic, vestibular and facial nerve testing
• Learn systematic evaluation of hearing loss, dizziness, tinnitus, otalgia and facial dysfunction
• Learn neurotologic manifestations of neurologic diseases
• Learn diagnosis and treatment of peripheral audio-vestibular disorders, lateral skull base lesions, CSF leak and facial palsy
• Perform all standard surgical approaches to the lateral skull base, including translabyrinthine, retrosigmoid, middle fossa and infratemporal fossa approaches in the treatment of acoustic neuromas, other schwannoma, meningioma and paraganglioma. By the end of the first year, fellows should be able to expose lateral skull base tumors in a safe and timely manner.
• Perform different approaches to petrous apex for treatment of cholesterol granuloma
• Decompress the facial nerve both lateral and medial to the geniculate ganglion
• Learn about intraoperative neurophysiological monitoring and image guidance
• Identify and develop research projects
• Write review papers and clinical research manuscripts
• Learn about academic publishing and reviewing manuscript submissions
• Develop skills as a surgical educator through lecturing otolaryngology residents and medical students and proctoring temporal bone labs

Second Year

• Assume more independence in workup of new patients, including ordering and interpreting diagnostic studies
• Develop more efficiency, precision and speed in all standard surgical approaches to the lateral skull base
• Gain more experience with dissection of tumors from nerves, vessels and the brainstem, while preserving the integrity of these critical structures. By the end of the second year, fellows should be able to independently expose lateral skull base tumors and remove the intracanalicular portion in a safe and timely manner.
• Gain more experience as a surgical educator both in didactic settings and in the operating room
• Complete research projects started in the first year
• Develop and expand research endeavors
• Present talks at courses and meetings
• Prepare for a faculty position as a neurotologist

Fellows meet with the program director on a regular basis to discuss their progression towards the objectives outlined above.

Throughout the two-year fellowship, fellows will alternate between rotations at UC San Diego Health System and Kaiser Permanente at three-month intervals. The full spectrum of neurotologic care is experienced and taught at each institution and the fellow should demonstrate progression in each of the areas of competency identified above throughout each rotation. Specific areas of emphasis related to each rotation are described below.

Kaiser Permanente Rotation

At the Kaiser Permanente San Diego Medical Center, the fellow acts as a member of the multidisciplinary skull base team providing tertiary medical and surgical care for patients from the entire Southern California region. The team is led by Roberto Cueva, MD, a neurotologist, and Bill Mastrodimos, MD, a neurosurgeon. During this rotation, the fellow will see a high volume of patients with skull base lesions, both in the clinic and in the operating room.

Skull Base Clinic The fellow will participate in a weekly multidisciplinary skull base clinic. Fellows are expected to learn how to:

• Obtain a complete patient history relevant to the diagnosis and treatment of skull base disorders
• Perform a complete exam of relevant systems, including a complete neurologic exam
• Critically evaluate and interpret imaging studies (MRI, CT and angiography), with a focus on the complex anatomy of the base of the skull
• Critically evaluate and interpret studies of cranial nerve function, such as audiograms and visual field tests
• Correctly diagnose lesions of the skull base, including vestibular schwannoma, meningioma, glomus tumor and hemangioma, and formulate appropriate treatment plans
• Effectively communicate with patients and their families in the clinic setting, including explaining the diagnosis, prognosis and treatment options for skull base lesions in language and terms that patients can understand
• Recognize and manage long-term complications of skull base disorders, including postoperative complications
• Order and interpret appropriate studies to monitor for progression or recurrence of skull base lesions

Skull Base Surgery The fellow will perform the majority of their skull base cases during the Kaiser Permanente rotation (usually two to three cases per week). At the completion of training, the fellow will demonstrate the ability to:

• Safely and efficiently expose tumors of the skull base through a variety of approaches (e.g., retrosigmoid, middle fossa, translabyrinthine, infratemporal fossa, etc.)
• Excise tumors from the internal auditory canal while preserving surrounding nerves and vessels
• Understand, interpret and successfully utilize intraoperative neurophysiological monitoring of cranial nerves, especially the 7 ^th and 8 ^th nerves
• Manage the postoperative care of skull base patients in the hospital, both in critical care and ward settings
• Recognize and treat acute postoperative surgical complications

Otologic Surgery With Dr. Cueva, the fellow will see referrals for complex otologic diseases, including ear canal atresia. This rotation will also include advanced neurotologic care for pediatric patients. Specific goals include:

• Evaluate ear canal atresia patients to assess candidacy for reconstructive surgery using patient history, physical exam, audiograms and temporal bone imaging
• Safely, efficiently and effectively perform reconstructive surgery for ear canal atresia

Expected Reading:

1. Otology & Neurotology (Fellows are encouraged to obtain a subscription to the journal, but articles are available online through the UC San Diego library)
2. Neurotology (Jackler and Brackmann): Chapters 19-24, 35, 36, 43-76, 82
3. Surgery of the Ear (Glasscock-Shambaugh)
4. Surgery of Cranial Base Tumors (Sekhar, Sekhar and Janeka)

UC San Diego Health System Rotation

During the UC San Diego rotation, fellows will be exposed to an academic neurotology practice under the guidance of Drs. Harris, Alexander and Nguyen. In addition to time at the UC San Diego Health System hospitals and clinics, the fellow will see patients and operate at the Veterans Affairs San Diego Healthcare System, Scripps Green Hospital and rarely, Rady Children's Hospital.

Clinical Neurotology Skills The full spectrum of neurotology patients is seen at UC San Diego Health System, Veterans Affairs San Diego Healthcare System, Scripps Green Hospital and Rady Children's Hospital. Fellows will be exposed to patients with skull base lesions and complex otologic conditions. In addition to the general goals outlined above, the fellow is also expected to learn to:

• Safely, efficiently and effectively perform surgery for hearing restoration, including cochlear implantation, stapedectomy, ossiculoplasty and implantation of osseointegrated hearing devices
• Evaluate and treat patients with vestibular disorders, including ordering and interpreting appropriate diagnostic tests and providing safe and effective medical and surgical treatment
• Continue to refine their skills in the evaluation and treatment of skull base disorders

Teaching The UC San Diego Health System rotation involves a greater emphasis on the development of teaching skills to prepare fellows to succeed as surgical educators. Fellows are expected to:

• Enhance otolaryngology resident learning by providing instruction in the clinic, operating room and during rounds - all under the supervision of the attending surgeon
• Prepare one-hour lectures for the monthly Friday morning neurotology conference. The conference is intended to provide education on neurotology topics for fellows, residents and medical students.
• Assist in the organization of the biannual temporal bone course given to teach residents temporal bone anatomy and drilling skills

Expected Reading:

1. Otology & Neurotology
2. Neurotology (Jackler and Brackmann): Chapters 1-18, 25-34, 37-42, 77-81, 83-85
3. Laryngoscope (relevant articles)
4. Otolaryngology - Head & Neck Surgery (relevant articles)
5. Pathology of the Ear (Schuknecht)

Conferences Throughout their training, fellows are expected to participate in the following:

• Neurotology seminars: Once or twice monthly (depending on the schedule of other lectures), the fellows will meet with a member of the neurotology faculty for a seminar in topics related to the subspecialty. Reading assignments will be made in advance.
• Monthly Friday morning neurotology conference
• Monthly M&M Conference (a quality assurance activity): Fellows are responsible for preparing any cases related to neurotology and skull base surgery alongside the appropriate resident team
• Biweekly Grand Rounds lectures and educational conferences
• Periodic Neurotology Research Journal Club: Fellows will select, critically review and present recent articles of interest related to neurotology
• Pertinent weekly resident teaching sessions
• Annual regional and national meetings: Fellows are encouraged to attend and present research at a variety of meetings including the American Neurotologic Society, the American Otologic Society and the Triological Society

Other Assignments