New Application: Pediatric Otolaryngology
Review Committee for Otolaryngology
ACGME
515 North State Street, Suite 2000, Chicago, Illinois 60654  312.755.5000  www.acgme.org
PROGRAM PERSONNEL AND RESOURCES
Program Director
Is there a supervision policy that specifies lines of responsibility for fellows and faculty members, as
well as for residents and other learners? [PR II.A.3.e)] .....................................................☐ YES ☐ NO
Faculty
Indicate whether appropriately-qualified faculty members from the disciplines listed below will
participate in the program. [PR II.B.7.a)-m)]
1. Anesthesiology............................................................................................................. ☐ YES ☐ NO
2. Audiology and speech pathology ................................................................................. ☐ YES ☐ NO
3. Child and adolescent psychiatry ................................................................................... ☐ YES ☐ NO
4. Gastroenterology ......................................................................................................... ☐ YES ☐ NO
5. Medical genetics .......................................................................................................... ☐ YES ☐ NO
6. Neonatology................................................................................................................. ☐ YES ☐ NO
7. Neurology .................................................................................................................... ☐ YES ☐ NO
8. Pathology ..................................................................................................................... ☐ YES ☐ NO
9. Plastic surgery ............................................................................................................. ☐ YES ☐ NO
10. Prenatal and fetal medicine .......................................................................................... ☐ YES ☐ NO
11. Pulmonology ................................................................................................................ ☐ YES ☐ NO
12. Radiology ..................................................................................................................... ☐ YES ☐ NO
13. Sleep medicine ............................................................................................................ ☐ YES ☐ NO
Resources
1. Briefly describe the inpatient and outpatient facilities available to the program [PR II.D.1.a)]
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2. Indicate whether the following are available at the participating sites. [PR II.D.1.b)-e)]
An emergency department
Neonatal intensive care unit
Pediatric intensive care unit
Facilities for the diagnostic
assessment of infants and children
with otolaryngologic disorders,
including:
Audiologic assessment
Voice assessment
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Pediatric Otolaryngology
©2015 Accreditation Council for Graduate Medical Education (ACGME)
Updated 8/2015
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Speech assessment
Language assessment
Developmental assessment
Facilities to support clinical research
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3. Describe how fellows will be provided with prompt reliable systems for communication and
interaction with supervising physicians. [PR II.D.2.]
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FELLOW APPOINTMENTS - OTHER LEARNERS
Briefly describe how the program director will ensure the presence of other learners, including
otolaryngology residents, residents from other specialties, unaccredited pediatric otolaryngology
fellows, other subspecialty fellows, PhD students, and nurse practitioners, will not interfere with the
appointed fellows’ education. [PR III.C.]
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EDUCATIONAL PROGRAM
Patient Care
1. Indicate the settings and activities in which fellows will demonstrate competence in each of the
following areas of patient care. Also indicate the method(s) used to assess competence.
Competency Area
Settings/Activities
Assessment Method(s)
Evaluating neonates, infants,
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children, and adolescents 18
years and younger with
congenital abnormalities,
infectious and inflammatory
disorders, and inherited and
acquired conditions of the head
and neck, including hearing loss
and other communication
impairments
[PR IV.A.2.a).(2).(a)]
Diagnosing and managing the Click here to enter text.
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medical and surgical treatment
of the aerodigestive tract, ear,
nose, sinus, throat, voice and
speech, and head and neck,
and disorders of neonates,
infants, children, and
adolescents 18 years and
younger
[PR IV.A.2.a).(2).(b)]
Performing procedures, with an emphasis on neonates, infants, children younger than three years
of age, and children and adolescents with significant co-morbidities as defined by American
Pediatric Otolaryngology
©2015 Accreditation Council for Graduate Medical Education (ACGME)
Updated 8/2015
Page 2 of 9
Competency Area
Settings/Activities
Assessment Method(s)
Society of Anesthesiology (ASA) status, in the following surgical domains: [PR IV.A.2.a).(2).(c).(i)(ix)]
Closed and open airways
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Congenital anomalies
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Endoscopic airways
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Facial plastics
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Facial trauma
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Head and neck surgery
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Otology
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Rhinology
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Complex and uncommon
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pediatric procedures
infrequently encountered in
the general practice of
otolaryngology
2. For each participating site, include all operations performed on the pediatric otolaryngology service
during the most recently-completed academic year. [PR IV.A.2.a).(3)]
PROCEDURE(S)
CPT Code(s)
Congenital Anomalies Domain
Branchial cleft
42810; 42815
anomaly excision
Thyroglossal duct
60280; 60281
cyst excision
Dermoid cyst/
30117; 30118;
Glioma/
30124; 30125
Encephalocele
excision
Hemangioma,
11440; 11441;
lymphatic or
11442; 11443;
vascular
11444; 11446;
malformation
38550; 38555
excision
Ranula excision
42408; 42409;
42450
Head and Neck Surgery Domain
Drainage deep neck 21501; 41015;
abscess (age < 3
41016; 41017;
years or ASA > II)
41018; 42300;
42305; 42320
Retropharyngeal 42720
space (RP)
abscess
Parapharyngeal
space (PPS)
abscess
– internal
approach
Site #1
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Site #5
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Total
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Pediatric Otolaryngology
©2015 Accreditation Council for Graduate Medical Education (ACGME)
Updated 8/2015
Page 3 of 9
PROCEDURE(S)
CPT Code(s)
Retropharyngeal 42725
space (RP)
abscess
Parapharyngeal
space (PPS)
abscess
– external
approach
Excision
30118; 31040
angiofibroma or
other
nasopharyngeal
tumor
Parotidectomy
42410; 42415;
42420; 42425;
42426
Submandibular
42440
gland excision
Thyroidectomy
60210; 60212;
60220; 60225;
60240; 60252;
60254; 60260;
60270; 60271
Otology Domain
Mastoidectomy
61530; 61596;
69501; 69502;
69505; 69511;
69530; 69601;
69602; 69603;
69604; 69605;
69635; 69636;
69637; 69641;
69642; 69643;
69644; 69645;
69646; 69670;
69955
Ossicular
69632; 69633;
reconstruction
69636; 69637;
69642; 69644;
69646
Cochlear implant
69930
Osseo-integrated
69710; 69714
implant
Closed Airway Procedure Domain
Tracheostomy (age 31601
< 3 years)
Open Airway Procedure Domain
Thyrotomy
31300; 31320
(Laryngofissure)
Laryngoplasty /
31580; 31582;
Laryngotracheoplas 31584; 31587;
ty
31588
Cricotracheal /
31780
Tracheal resection
and repair
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Pediatric Otolaryngology
©2015 Accreditation Council for Graduate Medical Education (ACGME)
Updated 8/2015
Page 4 of 9
PROCEDURE(S)
CPT Code(s) Site #1
Endoscopy with Intervention Domain
Laryngoscopy and 31400; 31527;
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intervention
31528; 31529;
31530; 31531;
31535; 31536;
31540; 31541;
31545; 31546;
31560; 31561;
31570; 31571;
31599
Bronchoscopy and 31623; 31624;
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intervention
31625; 31630;
31631; 31635;
31636; 31638;
31640; 31641;
31656
Esophagoscopy
43201; 43202;
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and intervention
43204; 43215;
43216; 43217;
43219; 43220;
43226; 43228
Rhinology Domain
Sinonasal
31237; 31240;
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endoscopic (age < 31254; 31255;
13 years or ASA > 31256; 31267;
II)
31276; 31287;
31288
Endoscopic
31290; 31291;
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sinonasal, extended 31292; 31293;
31294
Repair choanal
30540; 30545
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atresia
Facial Plastics Domain
Otoplasty
69300
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Cleft repair – lip
40700; 40701;
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40702; 40720;
40761
Cleft repair – palate 42200; 42205;
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42210; 42215;
42220; 42225;
42226; 42227;
42235
Pharyngoplasty /
42225; 42950
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Pharyngeal flap
Mandibular
21195
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osteotomy
Placement
21110
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mandibular
craniofacial
distraction device
Reconstruction
21230; 14061
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microtic ear, any
stage
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Pediatric Otolaryngology
©2015 Accreditation Council for Graduate Medical Education (ACGME)
Updated 8/2015
Page 5 of 9
PROCEDURE(S)
Repair complex
lacerations (all
sites, including
intraoral)
CPT Code(s)
13120; 13121;
13122; 13131;
13132; 13133;
13150; 13151;
13152; 13153
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Medical Knowledge
Indicate the activities (lectures, conferences, journal clubs, clinical teaching rounds, etc.) in which
fellows will demonstrate proficiency in their knowledge of the following area. Also indicate the
method(s) that will be used to assess fellow proficiency.
Proficiency Area
Settings/Activities
Medical and surgical
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management of neonatal, infant,
childhood, and adolescent
diseases of the head and neck to
a level appropriate for
unsupervised practice as defined
by the didactic curriculum.
[PR IV.A.2.b).(1)]
Assessment Method(s)
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Practice-based Learning and Improvement
1. Briefly describe one planned quality improvement activity or project that will allow the fellow to
demonstrate an ability to analyze, improve, and change practice or patient care. Describe planning,
implementation, evaluation, and provisions of faculty member support and supervision that will
guide this process. [PR IV.A.2.c).(1)] (Limit response to 400 words)
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2. Briefly describe one example of a learning activity in which fellows engage to develop the skills
needed to use information technology to locate, appraise, and assimilate evidence from scientific
studies and apply it to their patients' health problems. [PR IV.A.2.c).(2)] (Limit response to 400
words)
The description should include:
 Locating information
 Appraising information
 Assimilating evidence information (from scientific studies)
 Applying information to patient care
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Interpersonal and Communication Skills
Briefly describe one learning activity in which fellows demonstrate competence in interpersonal and
communication skills that result in the effective exchange of information and collaboration with patients,
their families, and health professionals. [PR IV.A.2.d)] (Limit response to 400 words)
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Pediatric Otolaryngology
©2015 Accreditation Council for Graduate Medical Education (ACGME)
Updated 8/2015
Page 6 of 9
Professionalism
1. Briefly describe the learning activity(ies), other than lecture, by which fellows demonstrate a
commitment to carrying out professional responsibilities and an adherence to ethical principles. [PR
IV.A.2.e)] (Limit response to 400 words)
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2. Briefly describe one learning activity in which fellows demonstrate competence in advocating for
quality patient care when facilitating patient management in the home, school, or institutional
setting. [PR IV.A.2.e).(1)] (Limit response to 400 words)
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Systems-based Practice
Describe the learning activity(ies) through which fellows 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. [PR IV.A.2.f)] (Limit response to 400
words)
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Curriculum Organization and Fellow Experiences
1. List the conferences for all participating sites in the program. Include the date/time, leader, and
topic. Add rows as necessary. [PR IV.A.3.a)]
Conference
Site #
Date/Time
Leader
Topic
2. Describe how fellows will participate in the above conferences. What kind of responsibility will
fellows have for preparation and presentation? How will attendance be documented? [PR
IV.A.3.a).(3)-(5)]
Pediatric Otolaryngology
©2015 Accreditation Council for Graduate Medical Education (ACGME)
Updated 8/2015
Page 7 of 9
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3. Describe how fellows will participate in a multidisciplinary, interdisciplinary team to manage and
treat conditions for at least three of the following: cochlear implant, craniofacial disorders, tumors, or
vascular anomalies. [PR IV.A.3.b).(1)]
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EVALUATION
Formative Evaluation
How will the program director ensure the balanced progress of each fellow towards achieving
experience with a variety and complexity of surgical procedures? [PR V.A.2.d)]
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Program Evaluation and Improvement
1. Describe how the program will review program goals and objectives and program effectiveness in
achieving them. [PR V.C.4.]
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2. Will at least one fellow participate in these reviews? [PR V.C.4.] ................................. ☐ YES ☐ NO
If “NO,” explain.
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FELLOW DUTY HOURS IN THE LEARNING AND WORKING ENVIRONMENT
Clinical Responsibilities
Describe the composition of the surgical team and how work will be assigned to the caregiver team
members based on each individual’s level of education, experience, and competence. [PR VI.E.2.-3.]
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Teamwork
1. Describe how fellows will collaborate with surgical residents, and with faculty members, other
physicians outside of their specialty, and non-traditional health care providers, to best formulate
treatment plans for an increasingly diverse patient population. [PR VI.F.2.]
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2. Describe how the program director will ensure that fellows assume personal responsibility to
complete all tasks to which they are assigned (or which they voluntarily assume) in a timely fashion.
[PR VI.F.3.]
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Pediatric Otolaryngology
©2015 Accreditation Council for Graduate Medical Education (ACGME)
Updated 8/2015
Page 8 of 9
3. Describe how lines of authority will be defined by the program, and how all fellows will have a
working knowledge of expected reporting relationships to maximize quality care and patient safety.
[PR VI.F.4.]
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Pediatric Otolaryngology
©2015 Accreditation Council for Graduate Medical Education (ACGME)
Updated 8/2015
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