Rhinology Roundtable

Episod

• Postnasal Drip 05.06.2026 49min

  Understanding Post-Nasal Drainage: Insights from Rhinology and Laryngology ExpertsMost 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 mucusThe critical importance of comprehensive history-taking and nuanced examination, including flexible laryngoscopyPractical, evidence-based strategies including a mucus management handout that has transformed patient careThe latest on reflux, sleep apnea, and how common ENT treatments may be contributing, not curing, these symptomsWhen to consider imaging, swallow studies, and collaboration with GI or sleep specialistsTimestamps:00:00 - Introduction to post-nasal drainage and its clinical importance02:12 - The role of ENT and interdisciplinary approach in managing drainage03:03 - Nuanced history-taking and detective work 04:16 - The significance of mucus quality vs. quantity 05:33 - Impact of previous radiation therapy and mucosal changes07:17 - Pathophysiology overview08:13 - Aging-related changes in swallowing and mucosa09:27 - Medication effects: antihypertensives, antidepressants, anticholinergics11:03 - Recognizing signs of salivary gland hypofunction and dehydration12:05 - Differential diagnosis: rhinitis, sinusitis, CSF leak, etc13:17 - Reflux, sleep apnea, and anatomical variations like the Shar-Pei larynx15:31 - Sensory disorders and upper airway cough syndrome16:48 - Physiological effects of CPAP 18:04 - The role of medications in causing dry mouth and mucus alterations19:02 - Management strategies and medication review21:00 - Reassessment of longstanding reflux treatment habits22:28 - Emerging therapies and the natural approach toward reflux management25:36 - Practical lifestyle modifications for managing mucus 27:23 - When and how to perform targeted examinations and imaging30:02 - Empiric treatment trials, including nasal sprays and allergy testing33:34 - The significance of nasal endoscopy and findings on physical exam35:50 - Recognizing when symptoms lack visible nasal secretions and differential considerations37:25 - The value of CT scans and the role of allergy testing39:20 - The non-surgical management: education, hydration, and over-the-counter options42:21 - The mucus management handout: a versatile tool for patient empowerment44:35 - Collaborative approach in patient management 46:35 - Closing thoughtsResources & Links:Mucus Management Handout https://www.dropbox.com/scl/fi/kzbm4d3hzekwurm3c2v10/Mucus-Management-Handout.pdf?rlkey=k93aw9sfculwmla7a6cagwx21&st=9lnb05jo&dl=0Systematic Review on Medications Affecting Salivary Glands (PubMed) 
• Skull Base Osteomyelitis 22.05.2026 1j

  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 comorbidities03:14 - Navigating the limited evidence and guideline gaps07:33 - Differentiating lateral vs central skull-base disease09:25 - Symptoms suggestive of lateral and central involvement15:01 - Diagnostic delays and clues in history and exam17:43 - Importance of experience and pattern recognition21:17 - Imaging strategies: CT, MRI, nuclear scans, and PET26:10 - Role of endoscopy and nasopharyngeal assessment28:49 - Cultures, biopsies, and microbiological techniques31:33 - Approaches for deep infections34:53 - Drainage procedures and managing pockets of pus36:16 - Pathogens involved and microbiological testing40:13 - Interpreting culture results and contaminants43:53 - Antibiotic management, duration, and follow-up46:40 - Laboratory markers and their limitations49:54 - Imaging for monitoring treatment response53:24 - When to consider surgery and source control58:58 - The role of glycemic control and immunosuppression63:54 - Rare interventions and experimental therapies67:11 - Use of hyperbaric oxygen and adjuncts70:15 - Expert advice for clinicians: key tips and considerationsResources FDG PET for OsteomyelitisPMID 40105501: Defining the Appropriate Length of Antimicrobial Therapy for Skull Base OsteomyelitisPMID 36648119: Central Skull Base Osteomyelitis: A Case Series from a Tertiary Care Center Over 5 YearsDr. Erin McKean - | University of MichiganDr. Jacob Hunter - Thomas Jefferson University
• The Last Cell Standing: How Far Should You Go? 08.05.2026 41min

  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 22.04.2026 50min

  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.