Trends in Laryngology Fellowship Training: A Survey Study of Graduates and Directors

ABSTRACT

Objectives

To date, there has not been a comprehensive evaluation of laryngology fellowship training content or structure, and trainee and mentor perceptions of preparedness for practice remain unexplored.

Methods

An anonymous survey was emailed to known fellowship‐trained early‐career laryngologists (Graduates) and fellowship Directors. Survey questions explored demographics, fellowship structure, case types and load, autonomous practice, comfort in treating a variety of laryngological disorders, and current practice environment. Descriptive analysis, Chi‐square analysis, and Mann–Whitney U tests were performed.

Results

85 known fellowship Graduates and 32 fellowship Directors were contacted, and a 60% response rate or higher was obtained. When asked to report confidence in the independent practice of a variety of laryngologic disorders, Graduates expressed confidence across the vast majority. Directors expressed confidence with more consistent and higher levels of agreement than Graduates. Graduates report less exposure and less confidence in swallowing disorders and transcervical operations. Increased confidence scores are noted among Graduates with more frequent autonomous experiences. Most Graduates report a near even distribution of voice, upper airway, and swallowing disorders in their current practices with 51% seeing more swallowing disorders than in fellowship training.

Conclusion

Most recent Graduates of laryngology fellowship training programs feel adequately trained for their current practice. Graduates express less training and less comfort in caring for patients with swallowing disorders as compared to voice and breathing disorders, despite this being a large part of their practice. Autonomous clinics and ORs as well as additional training in swallowing disorders and transcervical operations could benefit future fellows.

A survey study of laryngology fellowship Graduates and Directors reveals overall high level of confidence in preparedness to practice in the care of most laryngologic disorders. Respondents reported less exposure to swallowing disorders in fellowship with resulting lower confidence to practice independently in this area, despite seeing a good proportion of swallowing disorders in post‐fellowship practice. Graduates with increased autonomous experiences reported higher confidence levels. More robust training in swallowing, transcervical operations, as well as frequent autonomous clinics and ORs could enhance future training.

1. Introduction

Laryngology is a subspecialty within otolaryngology that is dedicated to the diagnosis and treatment of disorders primarily affecting voice, airway, and swallowing functions. The scope of practice for laryngologists is continuously growing as clinical demands become more varied. New technologies in the assessment of these disorders, evolving rehabilitation strategies, and innovative surgical techniques also require constant incorporation and mastery. Thus, robust and contemporary laryngology fellowship training is required to ensure clinicians are adequately prepared for independent practice. At this time, what is known about the structure, breadth, and depth of individual laryngology fellowship training programs is limited, and there have not been studies that seek to compare the experience across programs.

The present study aims to evaluate current trends in laryngology fellowship training by comparing survey responses from fellowship‐trained, early‐career laryngologists (Graduates) and Directors of laryngology fellowship programs. By exploring the perspectives of both groups, we seek to illuminate the educational experience across programs and deduce if Graduates are being trained to effectively manage the scope and complexity of voice, airway, and swallowing disorders in their independent practices. Additionally, this study aims to evaluate the comprehensiveness and uniformity across fellowships to identify areas for educational improvement. Furthermore, any potential discrepancies among the perceptions of Graduates and Directors on the educational experience and consequent preparedness for independent practice are examined.

2. Materials and Methods

This study was approved by the University of Virginia Institutional Review Board for Social Sciences and Behavioral Research.

2.1. Study Design and Participants

This cross‐sectional survey study targeted 2 groups: (1) fellowship‐trained early‐career laryngologists (Graduates) who were up to 7 years post‐training, and (2) fellowship Directors. A list of known Graduates and Directors was compiled from publicly available institutional websites, professional society member directories, and personal contacts of the authors. A total of 85 Graduates and 32 Fellowship Directors were identified and contacted by email to complete the survey. Participants were contacted by email a total of three times spaced 6–8 weeks apart or until completion of the survey, whichever came first.

2.2. Survey Instrument

A structured, anonymous questionnaire was developed to address core areas of interest for fellowship Graduates: (1) demographic information (age, gender, years in practice), (2) fellowship structure (duration of training, faculty mentor composition), (3) case mix and surgical volume, (4) opportunity for autonomous practice, (5) perceived confidence in managing a variety of laryngological disorders, awake clinic procedures, and operations, (6) current practice environment, location, and composition of patient disorders. Graduate Survey can be found in supplemental files. Items included single‐choice, multiple‐choice, Likert‐style scale, and optional free‐text responses for open‐ended comments or clarifications. A similar structured, anonymous questionnaire was developed for fellowship Directors, adjusting the content slightly to probe the nature of their fellowship training program. Director Survey can be found in supplemental files. Content validity was assessed and refined through feedback from several fellowship‐trained laryngologists. Informed consent was implied by voluntary completion of the survey. No identifying information was solicited to ensure the confidentiality of participants' responses.

2.3. Data Analysis

Data from all fully completed surveys was used for the study. All submitted responses were de‐identified (if information was willingly provided) and aggregated into “Graduate” or “Director” data before analysis. Descriptive statistics were calculated for participant demographics, fellowship structure, and clinical practice patterns. Categorical variables were analyzed using Chi‐square tests. The Mann–Whitney U test was performed for comparison of Likert‐style scale responses among Graduates and Fellowship Directors. Autonomy variables—including running independent clinics and operating rooms, as well as performing awake clinic and operative procedures—were coded ordinally. Confidence scores were averaged across domains, and associations between autonomy and confidence were assessed using Spearman's rank correlation. Statistical significance was set at a p‐value of < 0.05 for all analyses.

3. Results

3.1. Demographics

Of the 85 known early‐career laryngology fellowship Graduates who were contacted, 51 (60%) responded to the survey. Twenty‐four different laryngology fellowship programs were represented. Twenty‐six (51%) of respondents identified as male, and 47 (92%) were between 30 and 39 years of age. All Graduates confirmed completion of a laryngology fellowship program less than 7 years prior.

Thirty‐two known Directors of laryngology fellowship programs were contacted, and 21 (66%) responded to the survey. Eighteen (86%) respondents identified as male, and a majority (67%) reported their age between 40 and 60 years.

Considering responses from both Graduates and Directors, 27 unique laryngology programs are represented.

3.2. Fellowship Structure

See Table 1 for Director and Graduate responses to different components of their fellowship training programs.

TABLE 1.

Director and Graduate responses for the structure of their fellowship training programs.

Fellowship component	Directors	Graduates	Confidence effect (Graduates)
Duration of training program
10+ years	62%	—	—
6–10 years	24%	—	—
0–5 years	14%	—	—
Number of fellows per year (range 1–2)
2	10%	—	—
1	90%	—	—
Number of Laryngology Faculty Mentors (range 1–7)
5+	19%	13%
2–4	76%	75%
1	5%	12%
Formal didactic curriculum present (yes)	48%	52%	U = 309.5, p = 0.009
Opportunity to collaborate with subspecialists (yes)	90%	78%	U = 291.0, p = 0.003
Opportunity to train learners (yes)	100%	86%	U = 284.0, p = 0.002
Opportunity to run an independent laryngology clinic			ρ = 0.448, p = 0.001
At least monthly	81%	75%
Never	0%	18%
Opportunity to run an independent laryngology OR			ρ = 0.572, p < 0.001
At least monthly	52%	63%
Never	14%	14%
In the last half of fellowship, fellow acting as:
Primary surgeon for awake clinic procedures			ρ = 0.655, p < 0.001
“Almost always” or “often”	67%	69%
“Rarely”	5%	4%
Primary surgeon for operative procedures			ρ = 0.678, p < 0.001
“Almost always” or “often”	95%	88%
“Rarely”	0%	0%

Note: Confidence effect is calculated for controllable variables including formal didactic curriculum, opportunity to collaborate with subspecialists, and train learners (Mann–Whitney U test) and for autonomy variables including running an independent clinic or OR and performing awake and operative procedures as the primary surgeon (Spearman's rank correlation). Italicized values denote statistically significant association. (p < 0.05)

Structured educational and collaborative experiences during fellowship were associated with increased confidence scores. Statistically significant overall confidence scores were reported for Graduates who had a formal didactic curriculum (U = 309.5, p = 0.009), opportunities to collaborate with subspecialists (U = 291.0, p = 0.003), and opportunities to train learners (U = 284.0, p = 0.002).

Greater fellowship autonomy was significantly linked to higher self‐reported confidence across diagnostic and procedural domains. Specifically, leading an independent laryngology correlated with increased overall diagnostic confidence (ρ = 0.448, p = 0.001). Increased frequency of serving as the primary surgeon for awake procedures correlated with higher procedural confidence (ρ = 0.572, p < 0.001). Likewise, increased frequency of serving as the primary surgeon in operations and running an independent operating room correlated with increased operative confidence (respectively, ρ = 0.655, p < 0.001 and ρ = 0.678, p < 0.001).

3.3. Fellowship Case Mix and Surgical Volume

Graduates were asked to estimate their exposure to a variety of procedures and surgeries during their fellowship. Without significant variability between respondents, the most commonly observed and/or performed procedures and operations were rigid transoral laryngoscopy, flexible laryngoscopy, laryngeal videostroboscopy, phonomicrosurgical treatment of recurrent respiratory papilloma, phonomicrosurgical treatment of benign vocal fold lesion (cyst, polyp, benign fibrous mass), laryngeal framework surgery for glottic insufficiency (type 1 thyroplasty or related procedures), Botulinum toxin injections for neurologic voice disorders, endoscopic treatment of subglottic or tracheal stenosis, and awake laser treatments. Without significant variability, respondents report no exposure to selective denervation/reinnervation for laryngeal dystonia, endoscopic mucosal reconstitution surgery (Maddern or similar), or pharyngeal reduction. See Table 2 for a detailed, ranked list of Graduates' exposure to procedures during their fellowship.

TABLE 2.

Frequency of Graduates' exposure to procedures and surgeries during their fellowship.

Procedures & surgeries	Median	IQR
Rigid transoral laryngoscopy	12	0
Flexible laryngoscopy	12	0
Laryngeal videostroboscopy	12	0
Phonomicrosurgical treatment of recurrent respiratory papilloma	12	0
Phonomicrosurgical treatment of benign vocal fold lesion (cyst, polyp, benign fibrous mass)	12	0
Laryngeal framework surgery for glottic insufficiency (type 1 thyroplasty or related procedures)	12	0
Botulinum toxin injections for neurologic voice disorders	12	0
Endoscopic treatment of subglottic or tracheal stenosis	12	0
in‐office laser treatment	12	0
Endoscopic treatment of laryngeal dysplasia or early glottic cancer	12	4
Endoscopic treatment of posterior glottic stenosis	12	4
In‐office steroid injection for stenosis	12	4
Flexible endoscopic evaluation of swallowing (FEES)	12	8.5
In‐office injection of medication of true vocal fold (steroid, antiviral)	12	8.5
Phonomicrosurgical treatment of Reinke's edema/polypoid corditis	8	8.5
Endoscopic cricopharyngeal surgery (dilation, Botox injection, myotomy)	8	8.5
Superior laryngeal nerve injection	8	8.5
In‐office injection augmentation of vocal fold via transoral approach	8	11
In‐office injection augmentation of vocal fold via cricothyroid approach	8	11
Videofluoroscopic swallow study (modified barium swallow study)	8	12
Cricotracheal resection	3.5	3.5
Saccular cyst/laryngocele	3.5	4.5
Endoscopic Zenker's surgery	3.5	5.75
Arytenoid adduction	3.5	7
Tracheal resection	3.5	7
Phonomicrosurgical treatment of vocal fold sulcus or scar	3.5	8.5
Transnasal esophagoscopy	3.5	10
In‐office injection augmentation of vocal fold via thyrohyoid approach	3.5	12
Chondrosarcoma of larynx	1	1
Open repair of laryngeal trauma	1	3.5
Open Zenker's surgery	1	3.5
Open cricopharyngeal surgery	1	3.5
Palatal/pharyngeal augmentation	1	3.5
Selective denervation/reinnervation for laryngeal dystonia	0	0
Endoscopic mucosal reconstitution surgery (Maddern or similar)	0	0
Pharyngeal reduction	0	0
Palatoplasty/pharyngoplasty	0	0.5
pH testing	0	0.5
Partial laryngectomy (vertical hemilaryngectomy, supracricoid laryngectomy, or similar)	0	1
Non‐selective laryngeal reinnervation	0	1
Laryngotracheal reconstruction/laryngotracheoplasty (anterior grafting procedure)	0	1
Posterior cricoid expansion (posterior grafting procedure)	0	1
In‐office airway balloon dilation	0	1
Pharyngeal and/or esophageal manometry	0	1
Other laryngeal imaging techniques (videokymography, high‐speed videoendoscopy, optical coherence tomography, depth‐kymography)	0	3.5
Total laryngectomy	0	3.5
Tracheoesophageal puncture (TEP)	0	3.5
Gender affirming voice surgery (feminization, masculinization, endoscopic and open approaches)	0	3.5
In‐office balloon dilation of esophagus	0	3.5

Note: For clarity of data analysis and visual presentation, responses have been adjusted so that estimated case numbers are as follows: 12 = 10+ cases observed and/or performed, 8 = 6–10 cases observed and/or performed, 3.5 = 2–5 cases observed and/or performed, 1 = 1 case observed and/or performed, and 0 = no cases observed and/or performed.

Directors were asked to estimate the number of particular procedures and surgeries a Fellow might experience during their fellowship year. Without significant variability between respondents, it was felt that the most commonly observed and/or performed procedures and operations were rigid transoral laryngoscopy, flexible laryngoscopy, laryngeal videostroboscopy, phonomicrosurgical treatment of recurrent respiratory papilloma, phonomicrosurgical treatment of benign vocal fold lesion (cyst, polyp, benign fibrous mass), laryngeal framework surgery for glottic insufficiency (type 1 thyroplasty or related procedures), Botulinum toxin injections for neurologic voice disorders, endoscopic treatment of subglottic or tracheal stenosis, awake steroid injection for stenosis, awake laser treatments, and superior laryngeal nerve injections. Without variability between respondents, the least commonly observed and/or performed procedures were other laryngeal imaging techniques (videokymography, high‐speed videoendoscopy, optical coherence tomography, depth‐kymography) and selective denervation/reinnervation for laryngeal dystonia. See Table 3 for a detailed, ranked list of Directors' estimates of their fellows' exposures to procedures during their fellowship year.

TABLE 3.

Directors' estimates of their Graduates' exposures to procedures and surgeries during their fellowship year.

Procedures & surgeries	Median	IQR
Rigid transoral laryngoscopy	12	0
Flexible laryngoscopy	12	0
Laryngeal videostroboscopy	12	0
Phonomicrosurgical treatment of recurrent respiratory papilloma	12	0
Phonomicrosurgical treatment of benign vocal fold lesion (cyst, polyp, benign fibrous mass)	12	0
Laryngeal framework surgery for glottic insufficiency (type 1 thyroplasty or related procedures)	12	0
Botulinum toxin injections for neurologic voice disorders	12	0
Endoscopic treatment of subglottic or tracheal stenosis	12	0
In‐office steroid injection for stenosis	12	0
In‐office laser treatment	12	0
Superior laryngeal nerve injection	12	0
Flexible endoscopic evaluation of swallowing (FEES)	12	4
Phonomicrosurgical treatment of vocal fold sulcus or scar	12	4
Phonomicrosurgical treatment of Reinke's edema/polypoid corditis	12	4
Endoscopic treatment of laryngeal dysplasia or early glottic cancer	12	4
Endoscopic treatment of posterior glottic stenosis	12	4
Endoscopic cricopharyngeal surgery (dilation, Botox injection, myotomy)	12	4
In‐office injection augmentation of vocal fold via thyrohyoid approach	12	4
In‐office injection augmentation of vocal fold via cricothyroid approach	12	4
In‐office injection of medication of true vocal fold (steroid, antiviral)	12	4
Videofluoroscopic swallow study (modified barium swallow study)	12	8.5
In‐office injection augmentation of vocal fold via transoral approach	12	8.5
Endoscopic Zenker's surgery	8	4
Gender affirming voice surgery (feminization, masculinization, endoscopic and open approaches)	8	8.5
Transnasal esophagoscopy	8	8.5
Open repair of laryngeal trauma	3.5	2.5
Non‐selective laryngeal reinnervation	3.5	3.5
Pharyngeal and/or esophageal manometry	3.5	3.5
Saccular cyst/laryngocele	3.5	4.5
Arytenoid adduction	3.5	4.5
Tracheal resection	3.5	4.5
Cricotracheal resection	3.5	4.5
Open Zenker's surgery	3.5	4.5
Open cricopharyngeal surgery	3.5	7
Palatal/pharyngeal augmentation	3.5	7
Partial laryngectomy (vertical hemilaryngectomy, supracricoid laryngectomy, or similar)	1	1
Chondrosarcoma of larynx	1	2.5
Tracheoesophageal puncture (TEP)	1	3.5
Endoscopic mucosal reconstitution surgery (Maddern or similar)	1	3.5
Laryngotracheal reconstruction/laryngotracheoplasty (anterior grafting procedure)	1	3.5
Posterior cricoid expansion (posterior grafting procedure)	1	3.5
Palatoplasty/pharyngoplasty	1	3.5
In‐office balloon dilation of esophagus	1	12
Other laryngeal imaging techniques (videokymography, high‐speed videoendoscopy, optical coherence tomography, depth‐kymography)	0	0
Selective denervation/reinnervation for laryngeal dystonia	0	0
Pharyngeal reduction	0	1
In‐office airway balloon dilation	0	1
Total laryngectomy	0	3.5
pH testing	0	3.5

Note: For clarity of data analysis and visual presentation, responses have been adjusted so that estimated case numbers are as follows: 12 = 10+ cases observed and/or performed, 8 = 6–10 cases observed and/or performed, 3.5 = 2–5 cases observed and/or performed, 1 = 1 case observed and/or performed, and 0 = no cases observed and/or performed.

3.4. Confidence to Practice

Over 90% of Graduate respondents “strongly agreed” or “agreed” with statements expressing confidence in their ability to assess and treat a variety of voice, upper airway, inducible laryngeal obstruction, and cough disorders. Just 75% of Graduates expressed similar levels of confidence in managing swallowing disorders. When asked to rate their confidence in performing surgical management of upper airway disorders: 98% expressed confidence in performing endoscopic treatment, while 58% expressed confidence in performing open/trans‐cervical treatment. For awake procedures: 100% expressed confidence in performing procedures with channeled endoscope (e.g., laryngeal biopsy, KTP or blue light laser, steroid injection via channel scope); 94% expressed confidence in performing trans‐cervical clinic procedures (e.g., vocal fold augmentation, trans‐cervical steroid injection for vocal fold scar or subglottic stenosis); and 59% expressed confidence in performing laryngeal botulinum toxin injection. Notably, while female Graduate respondents reported high overall confidence in managing laryngologic disorders, procedures, and operations, this was statistically significantly lower than male Graduate respondents (mean composite score 4.35 versus 4.62; p = 0.024). See Table 4 for a descriptive analysis of Graduates' ranked order of confidence to practice and to perform surgeries and procedures.

TABLE 4.

Fellowship Graduates' confidence to practice in the management of disorders and performance of operations and in‐office procedures.

Rank	Disorders	Median	IQR
1	Non‐neoplastic diseases of the larynx (papilloma, polyp, cyst, etc.)	5.0	0.0
2	Cough disorders	5.0	1.0
2	Neoplastic diseases of the larynx	5.0	1.0
2	Neurolaryngology‐related disorders (vocal tremor, laryngeal dystonia, Parkinsonian disorders, etc.)	5.0	1.0
2	Professional and singing voice disorders	5.0	1.0
2	Upper airway disorders	5.0	1.0
2	Vocal cord dysfunction (VCD)/paradoxical vocal fold motion (PVFM)/inducible laryngeal obstruction (ILO) disorders	5.0	1.0
3	Swallowing disorders	4.0	1.25

Rank	Operations	Median	IQR
1	Endoscopic surgical treatment of upper airway disorders	5.0	0.0
2	Endoscopic surgical treatment of swallowing disorders	5.0	2.0
3	Open surgical treatment of upper airway disorders	4.0	2.0
4	Open surgical treatment of swallowing disorders	4.0	3.0

Rank	In‐office procedures	Median	IQR
1	Awake clinic procedures with channeled endoscope (e.g., laryngeal biopsy, KTP or blue light laser, steroid injection via channel scope)	5.0	0.0
2	Awake trans‐cervical clinic procedures (e.g., vocal fold augmentation, trans‐cervical steroid injection for vocal fold scar or subglottic stenosis)	5.0	1.0
3	Laryngeal botulinum toxin injection	4.0	3.0

Note: Likert scale: 5 = strongly confident, 4 = confident, 3 = neutral, 2 = not confident, 1 = strongly not confident.

When asked if their fellowship program adequately prepares fellows to practice independently, over 90% of Directors report “strongly confident” or “confident” across all varieties of voice, upper airway, inducible laryngeal obstruction, and swallowing disorders. Less confidence is reported in the management of cough disorders (80%), performance of laryngeal Botulinum toxin injections (80%), and open/trans‐cervical treatment of swallowing disorders (76%). See Table 5 for a descriptive analysis of Directors' estimated confidence in training fellows to perform procedures and operations independently.

TABLE 5.

Directors' perception of Graduates' confidence to practice in the management of disorders and performance of operations and in‐office procedures.

Rank	Disorders	Median	IQR
1	Non‐neoplastic diseases of the larynx (papilloma, polyp, cyst, etc.)	5.0	0.0
1	Cough disorders	5.0	0.0
1	Neoplastic diseases of the larynx	5.0	0.0
1	Neurolaryngology‐related disorders (vocal tremor, laryngeal dystonia, Parkinsonian disorders, etc.)	5.0	0.0
1	Upper airway disorders	5.0	0.0
1	Vocal cord dysfunction (VCD)/paradoxical vocal fold motion (PVFM)/inducible laryngeal obstruction (ILO) disorders	5.0	0.0
2	Professional and singing voice disorders	5.0	1.0
2	Swallowing disorders	5.0	1.0

Rank	Operations	Median	IQR
1	Endoscopic surgical treatment of upper airway disorders	5.0	0.0
2	Endoscopic surgical treatment of swallowing disorders	5.0	1.0
2	Open surgical treatment of upper airway disorders	5.0	1.0
2	Open surgical treatment of swallowing disorders	5.0	1.0

Rank	In‐office procedures	Median	IQR
1	Awake clinic procedures with channeled endoscope (e.g., laryngeal biopsy, KTP or blue light laser, steroid injection via channel scope)	5.0	0.0
1	Awake trans‐cervical clinic procedures (e.g., vocal fold augmentation, trans‐cervical steroid injection for vocal fold scar or subglottic stenosis)	5.0	0.0
2	Laryngeal botulinum toxin injection	4.0	1.0

Note: Likert scale: 5 = strongly confident, 4 = confident, 3 = neutral, 2 = not confident, 1 = strongly not confident.

When comparing responses between Graduates and Directors regarding fellows' preparedness to practice independently, Directors expressed higher and more consistent levels of confidence for fellows' preparedness to practice across all disorders, awake procedures, and operations. Graduates reported statistically significantly lower confidence than Directors in treating neurolaryngology‐related disorders such as vocal tremor, laryngeal dystonia, Parkinsonian disorders, etc. (p = 0.005). Similarly, Graduates expressed statistically significantly lower confidence in performing botulinum toxin injections to the larynx (p = 0.011) and open surgical treatment of upper airway disorders (p = 0.012). The difference in confidence levels to perform open surgical treatment of swallowing disorders neared but did not meet statistical significance (p = 0.067). See Figure 1 for a detailed depiction of the comparison of confidence levels between Directors and Graduates.

FIGURE 1.

Boxplot comparing confidence levels between Graduates and Directors across various disorders and procedures. Each box illustrates the interquartile range (IQR) with the median marked inside. Whiskers extend to the minimum and maximum values, excluding outliers. The Mann–Whitney U statistic and associated p‐values are annotated above each comparison, indicating statistical differences between the two groups marked with an asterisk and bolded. Values nearing statistical significance are italicized. A higher median and greater spread suggest variability in confidence levels for certain procedures.

3.5. Post‐Graduate Practice

The current practice model for 80% of Graduates is noted as Academic. A majority note serving primarily patients from urban (71%) and suburban (63%) communities, whereas just 29% report serving some patients from rural communities. The most frequently represented geographical area of practice is the Midwest (31%), followed by the Northeast (25%), South (23%), West (19%), and Outside the US (1%).

When asked to compare their current practice to their fellowship experience, 56% of Graduates report seeing a similar proportion of voice disorder patients. Similarly, 53% of Graduates report that their exposure to breathing disorders in their current practice is similar to what they experienced during their fellowship. However, over half of Graduates (51%) report seeing more swallowing disorders in their current practice than during their fellowship. See Figure 2.

FIGURE 2.

Proportion of disorders seen in Graduates' current practices versus their fellowship experience. [Color figure can be viewed in the online issue, which is available at www.laryngoscope.com]

When comparing their current practice make‐up, Graduates report an almost even distribution of patients presenting with voice, airway, and swallowing disorders, whereas Directors have practices more heavily weighted in voice and airway disorders. See Figure 3 for a comparison of the practice composition between Graduates and fellowship Directors.

FIGURE 3.

Practice composition of fellowship Directors versus Graduates. Disorders are presented as median percentages of practice with error bars showing interquartile range (IQR).

4. Discussion

Recent trends in otolaryngology suggest a growing interest among residents to pursue subspecialty fellowship training [1, 2]. Applicants and program directors alike share enthusiasm for the pursual of laryngology fellowship for the mentorship opportunities offered in concentrated clinical and procedural/surgical exposure to voice, airway, and swallowing disorders [3, 4, 5]. With fellowship training programs growing to more than 30 over the last three decades in the United States, the American Laryngological Association (ALA) has put forth guidelines for developing and implementing postgraduate training including a Comprehensive Laryngology Curriculum [6, 7, 8]. However, the full scope of the fellowship experience in individual programs remains relatively unexplored, and laryngology fellowships remain unaccredited. This is in contrast to other subspecialty fellowships in otolaryngology including neurotology, pediatric otolaryngology, head and neck oncologic and endocrine surgery, and facial plastics and cosmetics—all of which can achieve accreditation by either the Accreditation Council for Graduate Medical Education (ACGME) or their respective subspecialty societies. Additionally, with a sizeable number of training programs available, many have expressed concerns about the substance and consistency of clinical and procedural exposure across programs. Thus, our study seeks to more holistically evaluate laryngology fellowship training by gathering insights from recent fellowship Graduates and their program Directors.

Taken altogether, the results of this survey study provide a reassuring picture of the current laryngology fellowship training experience. We were able to capture responses from a majority of contacted Graduates and Directors with 27 (84%) unique fellowship programs represented. Graduates and Directors report a high degree of confidence for fellows entering independent practice given the robust depth and breadth of exposure across most laryngologic disorders, procedures, and operations. Interestingly, Directors expressed higher and more consistent levels of confidence for fellows' preparedness to practice as compared to Graduates. While the authors are unable to find studies that directly compare these impressions in laryngology and other fellowships, prior studies evaluating surgery residency training suggest that learner self‐assessments of autonomy and performance are lower than paired attending assessments [9, 10, 11, 12, 13]. Multiple studies have identified gender discrepancy in self‐assessment with female residents reporting lower confidence scores [11, 13, 14], and we found this to be true in our study, as well.

Prior literature evaluating awake procedural training in laryngology fellowship is robust, and our study demonstrates similar findings that most Graduates receive abundant hands‐on instruction in core laryngologic procedures, particularly awake treatments for voice and airway disorders with resulting high confidence for performing these in independent practice [15, 16, 17]. Both Graduates and Directors reported substantial exposure and competence with laryngeal imaging techniques, awake in‐office interventions, and routine phonomicrosurgery for benign lesions, suggesting the field has successfully embraced these minimally invasive approaches as foundational in laryngology practice. Although both Graduates and Directors express high exposure to laryngeal botulinum toxin injections, Graduates report less confidence in this area. This has been noted in a prior study and possibly attributed to less independent fellow involvement [16]. We make note of the challenging nature of this procedure and its many technical nuances which may vary from patient to patient. Additionally, it is likely that most Graduates are exposed to a mature practice (which is filled primarily with tolerant and botulinum toxin‐responsive patients) in their fellowship training, but then become responsible for curating these types of favorable patients from a larger case mix during their own practice development. Nevertheless, this may be an area for further instruction in fellowship training.

A noteworthy area in which exposure appears more limited is the evaluation and management of swallowing disorders. Although nearly all Graduates reported strong preparation for voice and airway pathologies, only about three‐quarters expressed similar confidence in managing dysphagia. Interestingly, Directors also expressed more variable confidence for Graduate practice in this area. This feeling of lesser preparedness may be explained by less volume, as noted by most Graduates infrequently observing or performing swallowing‐related procedures/surgeries. It should be noted that there is significant variability among programs with some Directors reporting several cases in a year and others reporting none. These findings suggest an area for growth in many fellowship training programs, especially considering most Graduates have an equal distribution of voice, airway, and swallowing disorders in their practice and over 50% report seeing more swallowing disorders than in their fellowship year.

An additional potential gap in training can be found in open/transcervical approaches in both swallowing and airway disorders. Again, both Graduates and Directors felt similarly less confident in fellow preparedness for transcervical versus endoscopic approaches. On the whole, less frequent and more varied exposures to tracheal resection, cricotracheal resection, laryngotracheal reconstruction, and laryngectomy procedures were reported among both Graduates and Directors. Discrepancies in case type and volume have been noted in other nonaccredited fellowship programs, and prior studies suggest that Graduates are more confident in skills as a result of case volume and the practice patterns of their faculty [18, 19].

This survey study also evaluates the personnel and structure of laryngology fellowship training programs. While the majority of Directors identified as male, the gender distribution among Graduates was more balanced, with just over half identifying as male. This finding is in line with prior studies which suggest a diversifying laryngology workforce [20, 21]. Interestingly, all but one Director reported multiple laryngology faculty mentors in their program suggesting the apprenticeship training model is becoming less common within the field. This may be due in part to most Graduates pursuing careers at academic institutions, which not only provide opportunities for collaboration, research, and teaching but also house the majority of laryngology fellowship training programs [21]. The data show a steady increase in fellow confidence with greater autonomy across diagnostic, procedural, and operative care, a finding which has been noted in prior studies of the fellowship experience [16]. Notably, Graduates with a formal didactic curriculum, opportunities to teach learners, and interdisciplinary collaboration reported significantly higher confidence scores. These findings support program designs that integrate graduated autonomy—ideally offering monthly chances for fellows to lead laryngology‐focused clinics and ORs as primary surgeons. Incorporating structured education, subspecialist interaction, and teaching roles can further reinforce clinical capability and confidence.

When looking at the fellowship experience as a whole, our results suggest that more attention should be given to managing swallowing disorders and performing open/transcervical approaches to swallowing and upper airway disorders. This could occur at the program level by engaging with subspecialists like gastrointestinal doctors and thoracic surgeons or by encouraging externships or “fellow swaps” with esophagologists or laryngologists with higher case volume in areas felt to be less sufficient. Additionally or alternatively, hands‐on cadaver courses or simulations could be used to supplement deficient areas. For laryngeal botulinum toxin injections, programs could consider increasing hands‐on practice in live patients versus simulation trainings, which have shown efficacy in increasing accuracy and confidence in these procedures [22, 23]. Furthermore, programs could consider structured milestone assessments or standardized operative logs to ensure that fellows are not only exposed to but also achieve mastery of all essential skills.

At this time, fellowship Directors may attract prospective applicants by making case descriptions and volume more available. Moreover, programs with unique exposures, that is, total laryngectomy, laryngeal reinnervation, swallowing surgeries and related procedures like pH testing, open airway surgery, professional singing voice, or gender‐affirming procedures, etc., could highlight these areas so that applicants with specific interests or needs may seek out these programs with more favor. If academic laryngology divisions with active fellowships are seeking to grow and diversify their faculty cohort, it may be prudent to hire Graduates with differing areas of training which could provide opportunities to round out the educational experience for future fellows and other learners.

Although the overall response rate to the survey was high, several limitations of the study are possible. It is plausible that certain findings could reach significance if a larger or more diverse cohort of fellowship Graduates and Directors was surveyed. Survey results are subjective, and there may be elements of selection and recency bias among respondents. Procedural and operative experiences were not examined objectively, such as with case logs. This study was not designed to examine concepts around formalizing curricula or accreditation of the educational experience. It is expected that the fellowship experience will continue to evolve, supporting the need for further examination of issues brought up in this study.

5. Conclusion

Current laryngology fellowship training effectively prepares Graduates for independent practice, though some gaps remain in exposure to swallowing disorders, open/transcervical operations, and laryngeal Botox injections. Addressing these areas could enhance future training and better align with the demands of post‐fellowship practice. Fellowship programs should consider implementing structured curricula, interdisciplinary collaboration, and scheduled opportunities for independent clinic and OR leadership—practices that appear to meaningfully enhance clinical confidence and autonomy.

Conflicts of Interest

The authors declare no conflicts of interest.

Supporting information

Appendix S1: Graduate survey.

Appendix S2: Director survey.

Torrecillas V., Johns M. M. III, Merati A., Kupfer R., and Morrison R. J., “Trends in Laryngology Fellowship Training: A Survey Study of Graduates and Directors,” The Laryngoscope 136, no. 3 (2026): 1433–1443, 10.1002/lary.70223.