The Last Cell Standing: How Far Should You Go?

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.