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1.
Drolet  BA, Frommelt  PC, Chamlin  SL,  et al.  Initiation and use of propranolol for infantile hemangioma: report of a consensus conference.  Pediatrics. 2013;131(1):128-140.PubMedGoogle ScholarCrossref
2.
International Society for the Study of Vascular Anomalies. Classification. http://issva.org/content.aspx?page_id=22&club_id=298433&module_id=152904. Accessed March 20, 2016.
3.
de Serres  LM, Sie  KC, Richardson  MA.  Lymphatic malformations of the head and neck: a proposal for staging.  Arch Otolaryngol Head Neck Surg. 1995;121(5):577-582.PubMedGoogle ScholarCrossref
4.
Cheng  J, Virbalas  J.  Vascular anomalies in otolaryngology–head and neck surgery resident education.  Otolaryngol Head Neck Surg. 2014;151(2):187-189.PubMedGoogle ScholarCrossref
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Original Investigation
July 2016

Education on, Exposure to, and Management of Vascular Anomalies During Otolaryngology Residency and Pediatric Otolaryngology Fellowship

Author Affiliations
  • 1Medical College of Wisconsin, Department of Otolaryngology, Children’s Hospital of Wisconsin, Milwaukee
  • 2Children’s Hospital of Pittsburgh of the University of Pittsburgh Medical Center, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania
  • 3Department of Otorhinolaryngology, Mayo Clinic, Rochester, Minnesota
  • 4Department of Otolaryngology, George Washington University, Washington, DC
  • 5Department of Otolaryngology, Eastern Virginia Medical School, Norfolk
  • 6Department of Otolaryngology, Dayton Children’s Hospital, Dayton, Ohio
  • 7Division of Otolaryngology–Head and Neck Surgery, Primary Children’s Hospital, University of Utah Health Sciences, Salt Lake City
  • 8Department of Otolaryngology, Washington University, St Louis, Missouri
  • 9Department of Otolaryngology, University of Arkansas, Fayetteville
  • 10Department of Otolaryngology, Harvard Medical School, Boston, Massachusetts
JAMA Otolaryngol Head Neck Surg. 2016;142(7):648-651. doi:10.1001/jamaoto.2016.0605
Abstract

Importance  The field of vascular anomalies presents diverse challenges in diagnosis and management. Although many lesions involve the head and neck, training in vascular anomalies is not universally included in otolaryngology residencies and pediatric otolaryngology (POTO) fellowships.

Objective  To explore the education in, exposure to, and comfort level of otolaryngology trainees with vascular anomalies.

Design, Setting, and Participants  A survey was distributed to 39 POTO fellows and 44 residents in postgraduate year 5 who matched into POTO fellowships from April 22 through June 16, 2014.

Main Outcomes and Measures  Survey responses from trainees on exposure to, education on, and comfort with vascular anomalies.

Results  Forty-four residents in postgraduate year 5 who applied to POTO fellowships and 39 POTO fellows were emailed the survey. Fourteen respondents were unable to be contacted owing to lack of a current email address. Thirty-six of 69 residents and fellows (18 fellows and 18 residents [52%]) responded to the survey. Twenty-seven trainees (75%) reported no participation in a vascular anomalies clinic during residency; 6 of these 27 individuals (22%) trained at institutions with a vascular anomalies clinic but did not participate in the clinic, and 28 of the 36 respondents (78%) reported that they had less than adequate or no exposure to vascular anomalies in residency. Among POTO fellows, 11 of 17 (65%) did not participate in a vascular anomalies clinic during fellowship, even though 8 of the 11 had a vascular anomalies clinic at their fellowship program. During fellowship training, 12 of 18 fellows (67%) reported that they had adequate exposure to vascular anomalies. Only 20 respondents (56%) felt comfortable distinguishing among diagnoses of vascular anomalies, and only 4 residents (22%) and 9 fellows (50%) felt comfortable treating patients with vascular anomalies. All fellows believed that training in vascular anomalies was important in fellowship, and 100% of respondents indicated that increased exposure to diagnosis and management of vascular anomalies would have been beneficial to their ability to care for patients.

Conclusions and Relevance  These data indicate that most otolaryngology trainees do not receive formal training in vascular anomalies in residency and that such training is valued among graduating trainees. Conversely, most POTO fellows felt their exposure was adequate and 50% of fellows felt comfortable treating vascular anomalies. However, 65% of POTO fellows had no participation in a vascular anomalies clinic, where many patients are managed by a multidisciplinary team. This finding may indicate that POTO fellows may have a false sense of confidence in managing patients with vascular anomalies and that residency and fellowship programs may consider changes in didactic and clinical programs.

Introduction

The field of vascular anomalies is one of constant change. In 2008, a case report on the treatment of infantile hemangioma with propranolol caused a major paradigm shift in the management of this vascular anomaly.1 In April 2014, the International Society for the Study of Vascular Anomalies proposed a new classification system that not only classified new vascular anomalies but included associated syndromes and genetic mutations.2 With ever-changing treatments and diagnostic challenges, multidisciplinary care is the criterion standard for managing and treating vascular anomalies with current medical, interventional, and surgical options.

The question arises: Are otolaryngology residents educated in these changes in the management and treatment of vascular anomalies? Furthermore, are pediatric otolaryngology (POTO) fellows trained to manage complicated vascular anomalies in this patient population? Otolaryngology trainees may assume that surgery is the definitive treatment for disease. However, in their staging of lymphatic malformations, de Serres et al3 demonstrated that the complication rate of surgical excision was 16% for the lowest stage of disease, and was 100% for the highest stage. Therefore, with lymphatic malformation and other vascular anomalies, surgery alone is not always the best option for treatment.

In May 2014, Cheng and Virbalas4 published results from an anonymous survey distributed to all otolaryngology residents and found that half of the respondents did not believe that they had enough clinical exposure to vascular anomalies and did not feel comfortable evaluating and managing patients with vascular anomalies. Also, 1 in 5 respondents in this study believed that their training did not provide a logical framework to evaluate vascular anomalies.

Because most vascular anomalies present during childhood, it is likely that initial evaluation of affected patients may be performed by a pediatric subspecialist. We, therefore, wished to compare the experience of resident trainees entering POTO fellowships with that of POTO fellows completing their training regarding their exposure to, training in, and comfort level in treating patients with vascular anomalies. To our knowledge, this is the first study aimed at providing a needs assessment for exposure to, and confidence in caring for patients with vascular anomalies among these subgroups.

Box Section Ref ID

Key Points

  • Question What formal training have residents and fellows in pediatric otolaryngology received in vascular anomalies?

  • Findings This survey of otolaryngology trainees indicated that most did not receive formal training about vascular anomalies during residency, but such training is valued among graduating trainees. Most pediatric otolaryngology fellows believed that their exposure to vascular anomalies was adequate and 50% of fellows felt comfortable treating patients with vascular anomalies; however, 65% of pediatric otolaryngology fellows did not participate in a vascular anomalies clinic.

  • Meaning More time and resources need to be allocated to improve the knowledge of and exposure to patients with vascular anomalies in and pediatric otolaryngology residency and fellowship training.

Methods

An anonymous online survey was developed by a subgroup of the Vascular Anomalies Task Force, an open organization of pediatric otolaryngologists interested in the research and advances in the management and treatment of children and adults with vascular anomalies. The survey was designed by members of that Task Force and underwent several rounds of changes based on expert feedback prior to consideration for national distribution. The final version of the survey was reviewed by the American Society of Pediatric Otolaryngology Research Committee as a prerequisite to distribution to the email list of current and future fellows.

The Medical College of Wisconsin Institutional Review Board approved this study as an exempt study. An anonymous online survey was sent to each resident in postgraduate year 5 entering a POTO fellowship and to POTO fellows nearing the end of their fellowship. This population was targeted because vascular anomalies are primarily seen in POTO clinics, so the assessment of the education about and exposure to vascular anomalies should be evaluated by these interested trainees. The survey asked participants if they had access to and had participated in a vascular anomalies clinic, if they had adequate exposure to patients with vascular anomalies, if they had quality didactic education in vascular anomalies, if they felt comfortable distinguishing and treating patients with vascular anomalies, and if they thought the increased exposure to vascular anomalies would have benefited them. Participants were not asked for consent but were given the option to not take the survey.

The survey was distributed via SurveyMonkey (SurveyMonkey Inc). To increase participation in the survey, a reminder email was sent 8 weeks after the original distribution. Data collection occurred in an anonymous fashion from April 22 through June 16, 2014, and was analyzed using an exact Wilcoxon rank sum test. P < .05 was considered significant.

Results

Forty-four residents in postgraduate year 5 who applied to POTO fellowships and 39 POTO fellows were emailed the survey. Fourteen respondents were unable to be contacted owing to lack of a current email address. Thirty-six of 69 residents and fellows (52%) responded to the survey. Eighteen respondents were fellows who provided information about both residency and fellowship; the remaining 18 were current residents.

Twenty respondents (56%) felt, at the very least, comfortable in distinguishing vascular tumors from vascular malformations. Furthermore, when asked their level of comfort in treating patients with vascular anomalies (prescribing propranolol hydrochloride or performing laser or open surgery for vascular anomalies), only 4 residents (22%) and 9 fellows (50%) felt comfortable in treating patients with vascular anomalies. All the respondents agreed that increased exposure to diagnosis and management of vascular anomalies would benefit their ability to care for patients with vascular anomalies.

Vascular Anomalies During Residency Training

Regarding their residency experience, 27 trainees (75%) reported no participation in a vascular anomalies clinic; 6 of these individuals (22%) trained at institutions with a vascular anomalies clinic but did not participate in the clinic. Most trainees (28 [78%]) believed that they had less than adequate or no exposure to vascular anomalies during residency. Many trainees (25 [69%]) also believed, however, that the didactic education regarding vascular anomalies was average or better. Twenty-seven trainees (75%) believed that residency training in the management and treatment of patients with vascular anomalies was important.

Vascular Anomalies During POTO Fellowships

Among the 18 fellows who responded to the survey, only 9 (50%) were comfortable treating patients with vascular anomalies, although 82% (14 of 17) believed that they had received average or superior didactic education in vascular anomalies during fellowship. Of these same individuals, 65% (11 of 17) did not participate in a vascular anomalies clinic, even though 8 of the 11 trained at institutions with such a clinic, and 6 fellows (33%) reported less than adequate or no exposure to surgical and clinical cases of vascular anomalies.

Discussion

In 2014, Cheng and Virbalas4 reported survey results showing that otolaryngology residents reported both a lack of exposure to and lack of confidence in caring for patients with vascular anomalies. Our study demonstrates that this educational gap continues even among otolaryngology residents bound for POTO careers and among POTO fellows. Our data suggest that most otolaryngology resident trainees do not receive formal training in vascular anomalies. This finding may be because many programs are at institutions that may not have a multidisciplinary vascular anomalies clinic. However, among the 27 respondents who indicated lack of clinical exposure to vascular anomalies during their residency training, 6 (22%) indicated that there was a vascular anomalies clinic at their institution. Even among fellows, one-third indicated less than adequate or no exposure to clinical or surgical cases of vascular anomalies. This lack of exposure suggests either a lack of otolaryngology participation in an existing vascular anomalies clinic, or missed opportunities to involve trainees in a multidisciplinary clinic despite an otolaryngology presence in the program.

In contrast to the lack of clinical exposure, 69% of residency-level respondents reported that the didactic education in vascular anomalies was average or better in their training programs. This finding may be a reflection of the addition of vascular anomalies in the core curriculum for residency education. However, given the dearth of clinical experience, it is also possible that trainees at the resident level are simply not aware of the detailed knowledge required to successfully treat patients with vascular anomalies. Since vascular malformations, unlike infantile hemangiomas, will affect patients well into adulthood, it is critical that general otolaryngologists, as well as pediatric subspecialists, be adequately trained in the diagnosis and management of these lesions.

Although the data among graduating POTO fellows were more encouraging than those among residents, there is still considerable room for improvement in their training in vascular anomalies as well. Nearly two-thirds had no clinical exposure to patients with vascular anomalies although the vast majority had a vascular anomalies clinic at their institution. Although many fellows felt comfortable with their didactic experience in vascular anomalies, half were still not comfortable treating such lesions near the completion of their training. As the majority of vascular anomalies present in the head and neck during childhood, directors of POTO fellowships should be certain that otolaryngology is included in their institutions’ vascular anomalies clinics, and that training in vascular anomalies is an integral part of their programs.

This study has several limitations. Mainly, the survey design relies on trainees recall of their clinical and didactic exposure to vascular anomalies and is subject to recall bias. The fellows who responded were asked to account for both their residency and fellow experience, which adds to their recall bias. In addition, while we did have a majority response rate, it was still relatively low at 52%, and thus has limitations regarding the implications of missing data and potential self-selection bias. However, as this survey is intended as a needs assessment for planning for future clinical rotation considerations and didactic curriculum development, this response rate is adequate.

Future surveys should attempt to decrease the nonresponse rate by ensuring delivery of email, contacting trainees via multiple modes of communication, and providing incentives for participation. To address the potential of recall bias, consideration could be given to similarly surveying residency and fellowship program directors. Furthermore, since many disciplines, such as plastic surgery, dermatology, and oncology, also treat and manage patients with vascular anomalies, future education gap surveys could be distributed to trainees in other disciplines as well.

Conclusions

This survey suggests that otolaryngology trainees may not receive formal training in vascular anomalies during residency or fellowship, and that such training is valued among graduating trainees. Attention should be given to increasing exposure to and formal didactic teaching in the management of patients with vascular anomalies during otolaryngology training and POTO fellowships. Multidisciplinary vascular anomalies clinics are a cornerstone to provide exposure to and education in the treatment and management of patients with vascular anomalies and are essential to POTO fellows.

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Article Information

Accepted for Publication: March 1, 2016.

Corresponding Author: Robert Chun, MD, Medical College of Wisconsin, Department of Otolaryngology, Children’s Hospital of Wisconsin, Children's Hospital Clinics Bldg, 9000 W Wisconsin Ave, Ste 540, Milwaukee, WI 53226 (rchun@mcw.edu).

Published Online: April 28, 2016. doi:10.1001/jamaoto.2016.0605.

Author Contributions: Dr Chun had full access to all the data in the study and takes responsibility for the integrity of the data and the accuracy of the data analysis.

Study concept and design: Chun, Jabbour, Grimmer, Perkins, Richter.

Acquisition, analysis, or interpretation of data: Chun, Jabbour, Balakrishnan, Bauman, Darrow, Elluru, Shin.

Drafting of the manuscript: Chun, Bauman, Darrow, Elluru.

Critical revision of the manuscript for important intellectual content: Chun, Jabbour, Balakrishnan, Darrow, Elluru, Grimmer, Perkins, Richter, Shin.

Statistical analysis: Chun, Jabbour.

Administrative, technical, or material support: Chun, Jabbour.

Study supervision: Chun, Bauman, Grimmer, Perkins, Richter.

Conflict of Interest Disclosures: None reported.

References
1.
Drolet  BA, Frommelt  PC, Chamlin  SL,  et al.  Initiation and use of propranolol for infantile hemangioma: report of a consensus conference.  Pediatrics. 2013;131(1):128-140.PubMedGoogle ScholarCrossref
2.
International Society for the Study of Vascular Anomalies. Classification. http://issva.org/content.aspx?page_id=22&club_id=298433&module_id=152904. Accessed March 20, 2016.
3.
de Serres  LM, Sie  KC, Richardson  MA.  Lymphatic malformations of the head and neck: a proposal for staging.  Arch Otolaryngol Head Neck Surg. 1995;121(5):577-582.PubMedGoogle ScholarCrossref
4.
Cheng  J, Virbalas  J.  Vascular anomalies in otolaryngology–head and neck surgery resident education.  Otolaryngol Head Neck Surg. 2014;151(2):187-189.PubMedGoogle ScholarCrossref
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