Rhinology Roundtable

Postnasal Drip

Understanding Post-Nasal Drainage: Insights from Rhinology and Laryngology Experts Most cases of post-nasal drainage are dismissed as benign or overlooked, but beneath the surface lies a complex, under-researched challenge affecting millions. In this eye-opening episode of Rhinology Roundtable, host Dr. Ashleigh Halderman pulls back the curtain on post-nasal drainage—a symptom that can feel like drowning in mucus despite normal exam findings. Joining her is renowned laryngologist Dr. Kathleen Tibbetts from Thomas Jefferson University, who reveals surprising insights that challenge conventional thinking. From the pivotal role of mucus quality over quantity, to how medications, aging, and sleep apnea subtly sabotage the body's ability to clear secretions, this episode is packed with actionable knowledge. You'll learn: * How systemic factors like dehydration, medication side effects, and aging contribute to sticky, hard-to-clear mucus * The critical importance of comprehensive history-taking and nuanced examination, including flexible laryngoscopy * Practical, evidence-based strategies including a mucus management handout that has transformed patient care * The latest on reflux, sleep apnea, and how common ENT treatments may be contributing, not curing, these symptoms * When to consider imaging, swallow studies, and collaboration with GI or sleep specialists Timestamps: 00:00 - Introduction to post-nasal drainage and its clinical importance 02:12 - The role of ENT and interdisciplinary approach in managing drainage 03:03 - Nuanced history-taking and detective work 04:16 - The significance of mucus quality vs. quantity 05:33 - Impact of previous radiation therapy and mucosal changes 07:17 - Pathophysiology overview 08:13 - Aging-related changes in swallowing and mucosa 09:27 - Medication effects: antihypertensives, antidepressants, anticholinergics 11:03 - Recognizing signs of salivary gland hypofunction and dehydration 12:05 - Differential diagnosis: rhinitis, sinusitis, CSF leak, etc 13:17 - Reflux, sleep apnea, and anatomical variations like the Shar-Pei larynx 15:31 - Sensory disorders and upper airway cough syndrome 16:48 - Physiological effects of CPAP 18:04 - The role of medications in causing dry mouth and mucus alterations 19:02 - Management strategies and medication review 21:00 - Reassessment of longstanding reflux treatment habits 22:28 - Emerging therapies and the natural approach toward reflux management 25:36 - Practical lifestyle modifications for managing mucus 27:23 - When and how to perform targeted examinations and imaging 30:02 - Empiric treatment trials, including nasal sprays and allergy testing 33:34 - The significance of nasal endoscopy and findings on physical exam 35:50 - Recognizing when symptoms lack visible nasal secretions and differential considerations 37:25 - The value of CT scans and the role of allergy testing 39:20 - The non-surgical management: education, hydration, and over-the-counter options 42:21 - The mucus management handout: a versatile tool for patient empowerment 44:35 - Collaborative approach in patient management 46:35 - Closing thoughts Resources & Links: * Mucus Management Handout https://www.dropbox.com/scl/fi/kzbm4d3hzekwurm3c2v10/Mucus-Management-Handout.pdf?rlkey=k93aw9sfculwmla7a6cagwx21&st=9lnb05jo&dl=0 [https://www.dropbox.com/scl/fi/kzbm4d3hzekwurm3c2v10/Mucus-Management-Handout.pdf?rlkey=k93aw9sfculwmla7a6cagwx21&st=9lnb05jo&dl=0] * Systematic Review on Medications Affecting Salivary Glands [https://pubmed.ncbi.nlm.nih.gov/27853957] (PubMed)

Skull Base Osteomyelitis

Skull base osteomyelitis can humble even the most experienced clinicians. Unlike so many other disease processes, once the diagnosis is made, that’s when the real uncertainty begins. The lack of robust literature or clinical guidelines leaves treating physicians with few places to turn for answers. This episode sheds light on the complexities of diagnosing and managing skull-base osteomyelitis. Led by Dr. Ashleigh Halderman and featuring expert colleagues Dr. Erin McKean and Dr. Jacob Hunter, it emphasizes the importance of vigilance, multidisciplinary collaboration, and nuanced decision-making in treatment. * Diagnostic challenges include subtle imaging changes, delayed symptoms, and often inconclusive biopsies; high suspicion is crucial. * Empiric antibiotic therapy often lasts for months; duration and cessation are guided by clinical symptoms, not just imaging, with close monitoring. * The typical 6 weeks of IV antibiotics treatment course for osteomyelitis frequently falls woefully short when the skull base is involved * Imaging follow-up with MRI is clinically preferred for its superior anatomic detail, although resolution of abnormal findings lags clinical improvement. * Surgical intervention is generally limited to diagnosis; outright eradication surgically is rare. * Emerging imaging techniques like PET scans offer promising sensitivity and specificity but are not yet standard. * Uncertainty remains around optimal treatment duration and criteria for stopping therapy, underscoring the importance of clinical judgment. 00:00 - Introduction 02:18 - Spectrum of disease presentation and comorbidities 03:14 - Navigating the limited evidence and guideline gaps 07:33 - Differentiating lateral vs central skull-base disease 09:25 - Symptoms suggestive of lateral and central involvement 15:01 - Diagnostic delays and clues in history and exam 17:43 - Importance of experience and pattern recognition 21:17 - Imaging strategies: CT, MRI, nuclear scans, and PET 26:10 - Role of endoscopy and nasopharyngeal assessment 28:49 - Cultures, biopsies, and microbiological techniques 31:33 - Approaches for deep infections 34:53 - Drainage procedures and managing pockets of pus 36:16 - Pathogens involved and microbiological testing 40:13 - Interpreting culture results and contaminants 43:53 - Antibiotic management, duration, and follow-up 46:40 - Laboratory markers and their limitations 49:54 - Imaging for monitoring treatment response 53:24 - When to consider surgery and source control 58:58 - The role of glycemic control and immunosuppression 63:54 - Rare interventions and experimental therapies 67:11 - Use of hyperbaric oxygen and adjuncts 70:15 - Expert advice for clinicians: key tips and considerations Resources * FDG PET for Osteomyelitis [https://pubmed.ncbi.nlm.nih.gov/30153084/] * PMID 40105501 [https://pubmed.ncbi.nlm.nih.gov/40105501/]: Defining the Appropriate Length of Antimicrobial Therapy for Skull Base Osteomyelitis * PMID 36648119 [https://pubmed.ncbi.nlm.nih.gov/36648119/]: Central Skull Base Osteomyelitis: A Case Series from a Tertiary Care Center Over 5 Years * Dr. Erin McKean - | University of Michigan [https://medicine.umich.edu/dept/ent/erin-mckean-phd] * Dr. Jacob Hunter - Thomas Jefferson University [https://hospitals.jefferson.edu/about/departments-and-services/otolaryngology.html]

The Last Cell Standing: How Far Should You Go?

In this episode of “Rhinology Roundtable,” host Dr. Ashleigh Halderman is joined by renowned rhinologists Dr. Roy Casiano from the University of Miami Department of Otolaryngology Head and Neck Surgery and Dr. Jim Palmer from the University of Pennsylvania Department of Otolaryngology Head and Neck Surgery.  They discuss the importance of complete sinus surgery exploring how geographic differences and training eras influence surgical approaches. The conversation delves into the evolution of sinus surgery techniques, the role of biologics, and the need for standardized surgical practices. The guests emphasize continuous learning, collaboration, and self-evaluation to improve surgical outcomes. The episode concludes with insights on the future of rhinology and the importance of comprehensive patient care.

Sinus & Cents - Billing in Rhinology

Unlock the secrets to proper medical billing in rhinology and safeguard your practice from costly mistakes. If you've ever felt overwhelmed by coding nuances, this episode will transform your understanding—saving you time, money, and compliance headaches. Most rhinologists underestimate how critical correct billing is. Dr. Ashleigh Halderman hosts Dr. Seth Brown, a leading ENT specialist and billing expert, exposes common pitfalls—like misusing the 25 modifier, coding complex skull base surgeries, or improperly billing for scopes. In this episode, we break down: * The misunderstood magic of CPT modifier 25 and 79, including real-world examples on when and how to use them. * How to document complex cases like skull base surgeries to ensure fair reimbursement, including strategies for negotiating RVUs with hospitals. * Practical tips for documenting medical decision-making at the appropriate level, ensuring your coding reflects the true complexity of patient care. * Common reasons for claim denials—like unbundling, incorrect codes, or overusing diagnostic procedures—and how to address them proactively.