Is nasal obstruction the overlooked culprit behind CPAP intolerance? On this episode of BackTable ENT & Allergy, Dr. Gopi Shah interviews Dr. Atul Malhotra and Dr. Michael Hutz to examine the critical but often underappreciated role of the nose in obstructive sleep apnea management. They discuss how nasal obstruction can undermine CPAP adherence, why relying solely on AHI may miss key issues, and how identifying the true cause of intolerance can lead to more personalized and effective therapy.

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This podcast is supported by

Aerin Medical
https://vivaer.com/

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Timestamps

00:00 - Introduction
04:05 - OSA Presentation and AHI Limitations
08:13 - Understanding CPAP Intolerance and Nasal Obstruction
15:24 - Evaluating Nasal Obstruction
20:32 - Nasal Anatomy and Workup
27:47 - DICE Technique and Assessing Dynamic Nasal Collapse
32:51 - Medical and Non-Surgical Management
37:29 - Surgical Options and VivAer
43:39 - Nasal Procedures and CPAP Success
51:57 - Nasal Surgery and Heart Outcomes
55:23 - Beyond CPAP: Nasal Breathing, Myofunctional Therapy, and Collaborative Care
01:04:51 - Wrap Up

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More about this episode

The physicians review practical strategies for evaluating nasal obstruction, from targeted patient questionnaires, physical exams, nasal endoscopy, and selective imaging. The doctors also detail medical and surgical treatment options, from allergy management and nasal sprays to septoplasty, turbinate reduction, functional rhinoplasty, and temperature-controlled radiofrequency (VivAer). Throughout the episode, they highlight how comprehensive nasal evaluation and intervention can significantly improve CPAP comfort and adherence.

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Resources

Dr. Atul Malhotra - https://providers.ucsd.edu/details/22362/sleep-medicine-pulmonology-(lung)

Dr. Michael Hutz- https://doctors.rush.edu/details/19100

CPAP treatment persistence following nasal procedures in obstructive sleep apnea - https://www.tandfonline.com/doi/pdf/10.1080/13696998.2026.2671550

Design and rationale for treating Obstructive Sleep Apnea using Targeted Hypoglossal Nerve Stimulation trial - https://www.sciencedirect.com/science/article/pii/S1551714422001306

The Impact of Mouth-Taping in Mouth-Breathers with Mild Obstructive Sleep Apnea - https://pmc.ncbi.nlm.nih.gov/articles/PMC9498537/

VATRAC Trial of VivAer - https://aerinmedical.com/company/news-and-media/aerin-medical-announces-positive-two-year-outcomes-from-the-vatrac-trial-of-vivaer/

---

BackTable ENT & Allergy is the go-to podcast for otolaryngologists, allergists, and head and neck surgeons.

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What if the next major advance in ENT surgery isn’t a new instrument, but a better-integrated operating room? In this episode of the BackTable ENT & Allergy Podcast, Cleveland Clinic rhinologist and skull base surgeon Dr. Raj Sindwani joins Dr. Gopi Shah and Dr. Ashley Agan to discuss how reducing cognitive load, improving workflows, and creating a more efficient OR environment can enhance the surgical experience.

---

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This podcast is supported by

Stryker
https://www.stryker.com/us/en/ent.html

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Timestamps

00:00 - Introduction
03:50 - Where Surgery Happens: Choosing the Right Site for Service
06:27 - Quality Safety And Throughput
09:48 - Reducing Cognitive Load In Surgery
15:34 - Building an Efficient OR Ecosystem And Culture
23:06 - Tech Adoption and Team Training
26:19 - Smarter Surgical Navigation and Augmented Reality
37:02 - Navigation Accuracy, Registration, and Smart Coaching
40:29 - Inside the Stryker RISE Platform
49:55 - Integration Challenges and Voice-Control Safety
56:36 - Surgical Ergonomics and Injury Prevention
01:09:14 - The Future of Surgical Innovation and AI in the OR

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More about this episode

Dr. Sindwani explores how minimizing unnecessary friction, improving team dynamics, and thoughtfully integrating technology can help surgical teams focus on what matters most: patient care. The conversation examines the operating room as an ecosystem where people, processes, and technology all contribute to patient outcomes. Dr. Sindwani shares strategies for reducing extrinsic cognitive load, including standardizing room setup, minimizing interruptions, and optimizing the surgical environment.
He also discusses advances in sinus and skull base navigation, augmented reality guidance, and Stryker’s RISE platform, highlighting how integrated technology can simplify workflow, improve ergonomics, and reduce distractions in the OR. Throughout the episode, Dr. Sindwani emphasizes the importance of thoughtful technology adoption, team collaboration, and designing the operating room of the future around safety, efficiency, and the needs of both patients and surgeons.

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Resources

Dr. Raj Sindwani
https://providers.clevelandclinic.org/provider/raj-sindwani/4268990

Stryker ENT
https://www.stryker.com/us/en/ent.html

Stryker RISE Platform
https://www.stryker.com/us/en/portfolios/medical-surgical-equipment/integration-and-connectivity/or-integration/rise.html

Technological Advances in Sinus and Skull Base Surgery by Dr. Raj Sindwani
https://www.oto.theclinics.com/article/S0030-6665(17)30050-6/fulltext

Ergonomics in ENT Practice NIH Article
https://pmc.ncbi.nlm.nih.gov/articles/PMC11455805/

---

BackTable ENT & Allergy is the go-to podcast for otolaryngologists, allergists, and head and neck surgeons.

Download the free BackTable app to get early access to new episodes, cases, and courses curated by physicians in your specialty.

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Have you considered performing a cochlear implant while your patient is awake? In this episode of the Backtable ENT & Allergy Podcast, Dr. Walter Kutz and Dr. Brandon Isaacson sit down with Dr. Sarah Mowry to explore her protocol for cochlear implants under local anesthesia, an approach especially relevant for older adults concerned about the cognitive risks of general anesthesia. Dr. Mowry shares her criteria for patient selection, preoperative counseling strategies, and how she adapts the OR setup to maximize comfort and communication during awake surgery.

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Timestamps

00:00 - Introduction
02:06 - Why to Consider Awake Cochlear Implants
05:32 - Indications for Awake CI
08:50 - Local Blocks and Pain Control
10:58 - Counseling and Expectations
14:40 - Preventing Intraoperative Vertigo and Converting to General Anesthesia
17:17 - Set Up and Communication with Patient
19:14 - Lesser Occipital Nerve Block and Potential Role of Processed EEG
26:32 - Pitch Matching for Single-Sided Deafness, CI, and Anxiety Considerations
29:00 - Feedback from Patients and Electrode Choice
31:30 - Advice to Surgeons and Closing Remarks

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More about this episode

The conversation covers her anesthesia protocol, including lesser occipital and postauricular nerve blocks, minimizing propofol, and using topical 2% lidocaine in sensate areas like the facial recess and epitympanum. Dr. Mowry discusses practical strategies of using warmed irrigation to reduce intraoperative vertigo and contingency plans for conversion to general anesthesia. She discusses electrode considerations and the potential role of processed EEG to titrate anesthesia depth and practical tips for surgeons interested in adopting awake cochlear implantation. Throughout, they highlight the importance of individualized patient care, multidisciplinary teamwork, and the growing role of local anesthesia in otologic surgery.

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Resources

Cochlear Implantation Under Local Anesthesia With Conscious Sedation in the Elderly: First 100 Cases
https://pubmed.ncbi.nlm.nih.gov/32663339/

Cochlear implantation under local anesthesia in 117 cases: patients' subjective experience and outcomes
https://pubmed.ncbi.nlm.nih.gov/34487218/

---

BackTable ENT & Allergy is the go-to podcast for otolaryngologists, allergists, and head and neck surgeons.

Download the free BackTable app to get early access to new episodes, cases, and courses curated by physicians in your specialty.

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Did you know that congenital CMV-related hearing loss can develop several years after birth? On the BackTable ENT & Allergy Podcast, hosts Dr. Gopi Shah and Dr. Jeff Hyzer interview pediatric otolaryngologist Dr. Albert Park about the latest evidence on congenital CMV and its role in pediatric sensorineural hearing loss. The discussion covers diagnosis, risk factors, screening protocols, testing strategies, antiviral treatment, genetic workup, long-term surveillance, and future directions for early detection and prevention.

---

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---

Timestamps

00:00 - Introduction
02:47 - Basics of CMV Infections and Hearing Loss Presentation
07:57 - CMV Screening Workflow
11:33 - Saliva vs. Urine Based Screening
14:00 - Early Workup and Communication
19:37 - Late Onset Workup and Use of Antivirals
24:39 - Treatment with Antiviral Medications
27:22 - Head Ultrasound vs. MRI
30:06 - Role of Genetic Testing
32:47 - Surveillance and Progression Risk
37:29 - CI Outcomes and Predictors
42:18 - BAHA and Older Candidates
45:44 - Awareness, Prevention Efforts, and Education
54:25 - Vaccines and Universal Screening Pitfalls
57:40 - Advocacy and Closing Thoughts

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More about this episode

Dr. Park explains the differences between congenital and acquired CMV, reviews epidemiology and, and highlights that hearing loss may be present at birth or develop later in childhood. He discusses Utah’s evolution from hearing-targeted CMV testing to universal NICU screening, emphasizing the importance of diagnosis within the first 21 days of life. The conversation covers saliva versus urine testing, dried blood spot testing, and the role of a multidisciplinary team in evaluation and management. Dr. Park also reviews antiviral treatment strategies, imaging and genetic testing considerations, audiologic surveillance, and cochlear implantation outcomes. Finally, he discusses ongoing advocacy efforts, emerging prenatal screening technologies, and future directions and challenges for CMV prevention and early detection.

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Resources

Nance & Morton NEJM Paper Cited - 20% of Congenital SNHL linked to Congenital CMV
https://www.nejm.org/doi/full/10.1056/NEJMra050700

Dr.Kimberlin’s work supporting antiviral treatment for 6 months
https://www.nejm.org/doi/full/10.1056/NEJMoa1404599?utm_source=openevidence

Dr.Vossen’s antiviral therapy research
https://pubmed.ncbi.nlm.nih.gov/38336204/

AAP Red Book
https://publications.aap.org/redbook

Dr. Smith’s Research - Genetic Testing for Congenital Bilateral Hearing Loss in the Context of Targeted Cytomegalovirus Screening
https://pubmed.ncbi.nlm.nih.gov/31985074/

Dr.Park’s Research Congenital Cytomegalovirus Testing Outcomes From the ValEAR Trial
https://pubmed.ncbi.nlm.nih.gov/38415855/

Dr.Park’s Research - Analysis of an Expanded Targeted Early Cytomegalovirus Testing Program
https://pubmed.ncbi.nlm.nih.gov/36884018/

Dr.Foulon - Hearing Loss With Congenital Cytomegalovirus Infection
https://pubmed.ncbi.nlm.nih.gov/31266824/

Research about the use of Vaclovir to reduce vertical transmission
https://pubmed.ncbi.nlm.nih.gov/32919517/

Dr.Gantt’s research on the Ping-Pong Effect
https://pubmed.ncbi.nlm.nih.gov/29889809/

---

BackTable ENT & Allergy is the go-to podcast for otolaryngologists, allergists, and head and neck surgeons.

Download the free BackTable app to get early access to new episodes, cases, and courses curated by physicians in your specialty.

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Every leader has a story. The experiences, mentors, and moments along the way shape not only who we become, but how we lead. In this episode of BackTable ENT and Allergy, Drs. Ashley Agan and Gopi Shah interview internationally renowned rhinologist Dr. Troy Woodard about his leadership journey and the lessons learned along the way. Together, they explore how leadership is about actions rather than titles, the value of national involvement, and the importance of embracing change and personal growth throughout a career.

---

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---

Timestamps

00:00 - Introduction
02:20 - From Fan Moment to Bio
04:15 - Early Leadership Roots
06:40 - Lead Without a Title
08:43 - Finding Leadership Itch
14:56 - Burnout and the Pivot
19:16 - Coaching and Victim Mindset
22:31 - FMLA Reset and Purpose Shift
27:11 - Letting Go to Grow
30:14 - Listening Tour at Buffalo
33:59 - DEI and Minority Leadership
35:47 - Mentorship and Leaky Pipeline
39:48 - Purpose Through Outreach
44:28 - Respectful Change Leadership
47:25 - Emotional Intelligence Growth
50:27 - Advice for New Leaders
52:53 - Handling Dream Crushers
56:50 - Imposter Syndrome Breakthrough
01:01:01 - Leadership Impact and Closing Remarks

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More about this episode

Dr. Woodard describes early leadership roles, being raised by a single mother, the mentors who impacted his career, and how responsibility and service shaped his work ethic. He explains that leadership doesn’t require a title and recounts pivoting from limited departmental opportunities to national involvement through the Academy and ARS, including advocacy work. Woodard discusses burnout, executive coaching, emotional intelligence, delegation, mentorship and ultimately, how recognizing and embracing a changing purpose mid-career is a normal part of professional growth. Now Chair of Otolaryngology-Head and Neck Surgery at the University at Buffalo, he practices “listening tours,” mentors faculty, and emphasizes how diversity drives excellence while highlighting mentorship and pipeline development.

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Resources

Dr. Troy Woodard’s Public Email
[email protected]

---

BackTable ENT & Allergy is the go-to podcast for otolaryngologists, allergists, and head and neck surgeons.

Download the free BackTable app to get early access to new episodes, cases, and courses curated by physicians in your specialty.

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When should recurrent sinus infections trigger an allergy or immune workup? In this episode of the BackTable ENT and Allergy podcast, Dr. Karen Kaufman of Kaufman Allergy, Asthma, & Immunology in Vienna, Virginia, sits down with Dr. Ashley Agan to discuss chronic sinusitis evaluation, allergy testing, immunotherapy, immune deficiency screening, and building a private practice.

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---

Timestamps

00:00 - Introduction
02:53 - Chronic Sinusitis Basics
06:44 - Sinusitis Types and Polyps
10:18 - Testing and Treatment Plan
18:40 - When to Suspect Immunodeficiency
25:44 - Allergy Testing Methods
38:39 - Why Go Solo
43:10 - Practice Growth, Visibility, Team Building, and Systems
51:55 - ENT and Allergy Collaboration
55:50 - Closing Remarks

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More about this episode

Dr. Kaufman explains how to distinguish chronic sinusitis from other causes of nasal and facial symptoms, when to evaluate for allergy and immune dysfunction, and how sinusitis phenotypes influence treatment decisions. She also shares her experience launching a private practice during the pandemic and discusses strategies for practice growth through community engagement, increased visibility, and social media.

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Resources

Dr. Karen Kaufman - https://kaufmanallergy.com/

Jeffery Modell Foundation 10 Warning Signs of Primary Immunodeficiency - https://www.uhhospitals.org/-/media/files/rainbow/services/allergy-and-immunology/10warningsigns.pdf

---

BackTable ENT & Allergy is the go-to podcast for otolaryngologists, allergists, and head and neck surgeons.

Download the free BackTable app to get early access to new episodes, cases, and courses curated by physicians in your specialty.

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Septal perforations can be deceptively challenging, with a wide range of etiologies, symptoms, and treatment options to consider. In this episode of BackTable ENT and Allergy podcast, hosts Dr. Ashley Agan and Dr. Gopi Shah interview Dr. Oswaldo Henriquez, a board-certified otolaryngologist and rhinologist at WellStar Health System in Atlanta, to explore the complexities of evaluating and managing nasal septal perforations. The conversation covers how perforation size and location shape symptoms, the most common causes including iatrogenic trauma and chronic nose picking, and a thorough, stepwise approach to diagnosis and treatment.

---
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---

Timestamps
00:00 - Introduction
03:01 - Septal Perforations Overview
07:58 - Causes and Risk Factors
13:26 - History Red Flags and Differential Diagnosis
16:28 - Exam and Documentation Tips
21:22 - Labs Biopsy and Imaging Workup
31:19 - Conservative Care and Septal Buttons
34:20 - Surgery Candidacy and Counseling
41:35 - Surgical Techniques Landscape
47:38 - Scaffolds and Grafts
49:07 - Septal Blood Supply Map
53:00 - CAT Scan Planning Tips
55:15 - AEA Flap Technique
01:05:22 - Real Case Walkthrough
01:10:41 - Postop Care and Swelling
01:20:44 - Pitfalls and Success Rates
01:24:09 - Wrap Up

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More about this episode
Dr. Henriquez outlines the key components of a comprehensive workup, including endoscopic exam, measurement, biopsy, and CT imaging for surgical planning. He discusses management options from conservative care and septal buttons to advanced endoscopic pedicled flap repairs, sharing insight on surgical techniques, success rates, splinting, and post-op care. The episode provides practical tips for physicians at any career stage looking to refine their approach to septal perforations, from diagnosis through recovery.

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Resources
ENT Animations
https://www.youtube.com/@Dr.IsamAlobid

---

BackTable ENT & Allergy is the go-to podcast for otolaryngologists, allergists, and head and neck surgeons.

Download the free BackTable app to get early access to new episodes, cases, and courses curated by physicians in your specialty.
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For years, an indeterminate thyroid biopsy meant diagnostic surgery but molecular testing is now changing that reality entirely. On this episode of the BackTable ENT podcast, Dr. Ashley Agan interviews endocrinologist Dr. Erik Alexander about how molecular testing and a systematic, layered approach to thyroid nodule evaluation are reducing diagnostic surgeries and enabling more individualized patient care.

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This podcast is supported by

Veracyte
https://www.veracyte.com/

---

Timestamps

00:00 - Introduction
02:48 - Incidence, Presentation, and Workup of Thyroid Nodules
06:26 - Hormonal Impact and Indications for FNA
10:49 - FNA workflow and Bethesda Categories
16:10 - Role of Molecular Testing for Indeterminate Nodules
19:59 - Evolution of Molecular Testing and Afirma
23:51 - Basics of DNA based Testing and RNA based Testing
28:34 - Comparing DNA based and RNA Based Testing
32:10 - Utility of Molecular Testing and Sampling Techniques
35:55 - Cost Coverage and Practical Limits
39:20 - Clinical Implications and Future Impact
42:00 - Final Takeaways

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More about this episode

Together they walk through the full evaluation pathway, including ultrasound risk stratification using the TI-RADS criteria, the role of TSH testing, and how FNA indications have shifted from biopsying every solid nodule to a more selective, risk-adapted approach. The discussion covers the Bethesda classification system and addresses why the one-third of patients landing in indeterminate categories (Bethesda III, IV, and V) have historically been the most challenging and most overtreated group. The conversation then explores molecular diagnostics as an additional layer of risk assessment, highlighting key differences between DNA-based mutation panels and RNA-based expression classifiers. Dr. Alexander also discusses practical considerations like insurance coverage, sampling technique, turnaround time, and the future potential of molecular testing to move beyond diagnosis toward individualized prognosis.

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Resources

American College of Radiology: TI-Rads Guidelines
https://edge.sitecorecloud.io/americancoldf5f-acrorgf92a-productioncb02-3650/media/ACR/Files/RADS/TI-RADS/TI-RADS-Assessment-Categories.pdf

American Thyroid Association - Nodule Guidelines
https://pmc.ncbi.nlm.nih.gov/articles/PMC4739132/

Bethesda System for Reporting Thyroid Ctyopathology
https://www.ncbi.nlm.nih.gov/books/NBK278969/table/thyroid-nod-canc-eld.T.bethesda_system_f/

---

BackTable ENT & Allergy is the go-to podcast for otolaryngologists, allergists, and head and neck surgeons.

Download the free BackTable app to get early access to new episodes, cases, and courses curated by physicians in your specialty.

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Not all chronic cough, globus, or voice changes are due to reflux, so how do you distinguish laryngopharyngeal symptoms (LPS) from true laryngopharyngeal reflux disease (LPRD)? In this episode of the BackTable ENT & Allergy podcast, Dr. Ashley Agan interviews laryngologist Dr. Inna Husain about how nuanced diagnostic definitions and a careful clinical approach can improve patient outcomes and avoid both under- and overdiagnosis. Together, they discuss the differences between GERD and LPRD, review the importance of detailed patient histories, endoscopic findings, and the evolving role of biomarkers like pepsin.

---

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---

Timestamps

00:00 - Introduction
02:14 - LPS Versus LPR Basics
06:34 - GERD Versus LPRD
11:28 - Clinic Workup and Scoping
18:02 - San Diego Consensus Debate
24:14 - Testing Over Empiric PPIs
31:45 - Managing Proven Reflux
34:59 - Stroboscopy Before Surgery
36:10 - Pepsin Therapies and Tests
39:54 - What Counts as Abnormal Reflux
44:24 - Tapering Off PPIs Safely
50:12 - Long Term Plan and Dietitians
55:39 - GLP One Drugs and Reflux
57:34 - Menopause Rhinitis and Hormones
01:00:09 - Final Pearl For ENTs

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More about this episode

They outline contemporary workup strategies, including the San Diego Consensus on Bravo testing, 24-hour pH impedance, and alternatives for negative reflux testing. The conversation covers management strategies, from selective PPIs and lifestyle tailoring to emerging therapies and the impact of GLP-1 drugs, helping ENT specialists refine their approach to complex laryngopharyngeal complaints.

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Resources

San Diego Consensus for LPS and LPRD:
https://doi.org/10.14309/ajg.0000000000003482

Dr. Inna Husain
https://innahusainmd.com/

---

BackTable ENT & Allergy is the go-to podcast for otolaryngologists, allergists, and head and neck surgeons.

Download the free BackTable app to get early access to new episodes, cases, and courses curated by physicians in your specialty.

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With such a wide range of presentations and severity, how do laryngologists approach the diagnosis and treatment of unilateral vocal fold paralysis? In this episode of the BackTable ENT and Allergy Podcast, Dr. Rebecca Howell, Laryngologist at the University of Cincinnati, joins Dr. Stephen Schoeff to discuss the evaluation and management of unilateral vocal fold paralysis.

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Timestamps

00:00 - Introduction
02:18 - Classic Symptoms of Vocal Fold Paralysis
04:15 - Etiology and Imaging Workup
08:40 - Injection Timing and Materials
23:20 - Permanent Options and Framework Surgery
28:41 - Arytenoid Adduction Risks and When to Add Adduction
30:56 - Awake Thyroplasty Technique compared to Sedation and OR Setup
35:48 - Reinnervation and Bilateral Medialization Choices
42:10 - Vocal Fold Long-term Injectables
51:54 - Closing Remarks

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More about this episode

Dr. Howell reviews the spectrum of patient presentations and common causes, including thoracic surgery, ACDF, thyroid surgery, intubation injuries, and idiopathic cases. She explains when to pursue imaging from brainstem to chest, how to set realistic recovery expectations, and the benefits of early intervention. The episode covers office-based injection augmentation, the pros and cons of injectable materials, and treatment durability, as well as risks like calcium hydroxylapatite. Long-term care options are discussed, including framework surgery, arytenoid adduction, bilateral approaches for vocal fold atrophy, reinnervation, and patient selection considerations.

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Resources

Pathophysiology of Iatrogenic and idiopathic vocal fold paralysis may be distinct - Ted Mau: https://pubmed.ncbi.nlm.nih.gov/31498451/

Vocal Fold augmentation with injectable calcium hydroxylapatite - Clark Rosen: https://pubmed.ncbi.nlm.nih.gov/15331112/

Using High-Speed Videoendoscopy to Analyze Laryngeal closure parameters during normal swallow - Rebecca Howell: https://pubmed.ncbi.nlm.nih.gov/39659169/

Arytenoid abduction for bilateral vocal fold immobility - Gayle Woodson: https://pubmed.ncbi.nlm.nih.gov/22001662/

Laryngeal Reinnervation for Unilateral Vocal Fold Paralysis - Randal Paniello : https://profiles.wustl.edu/en/publications/laryngeal-reinnervation-for-unilateral-vocal-fold-paralysis/

---

BackTable ENT & Allergy is the go-to podcast for otolaryngologists, allergists, and head and neck surgeons.

Download the free BackTable app to get early access to new episodes, cases, and courses curated by physicians in your specialty.

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