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/

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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/

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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/

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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/

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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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Pediatric thyroid nodules are rare, but their risk of malignancy is significantly higher than in adults, raising the stakes for accurate diagnosis and multidisciplinary management. In this episode of the BackTable ENT Podcast Dr. Gopi Shah and co-host Dr. Jeff Hyzer interview Dr. Wen Jiang, pediatric otolaryngologist at Rady Children’s Hospital in San Diego, for an in-depth discussion on the evaluation and management of thyroid nodules in children.

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Timestamps

00:00 - Introduction
02:27 - Thyroid Nodule Risks and Care Team
06:47 - Age-related Differences in Nodule Presentation and Outcomes
08:50 - Initial workup
13:42 - Ultrasound Interpretation
16:07 - Lymph Node Mapping and CT
19:58 - Incidental Findings
24:14 - Role of FNA, Molecular Testing, and Radiofrequency Ablation
32:40 - Molecular Testing Results and Counseling
38:04 - Neck Dissection Strategy
40:44 - Hypocalcemia Protocol Considerations
44:01 - Parathyroid and Recurrent Laryngeal Nerve Dissection Tips
47:33 - Postop Care and Follow-up
51:25 - Using Radioactive Iodine and Targeted Therapy
54:55 - AI’s and Ultrasound and Final Thoughts

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More about this episode

Dr. Jiang highlights the key differences between pediatric and adult thyroid nodules. She describes her multidisciplinary approach including collaboration with radiology, pathology, endocrinology and nuclear medicine. The discussion reviews the initial workup for pediatric thyroid nodules and why ultrasound remains the primary diagnostic tool. She also discusses situations where CT with contrast can be helpful for surgical planning. This episode explores the growing role of reflex molecular testing in guiding management decisions and outlines the impacts of molecular testing results. Dr. Jiang shares her approach to patient counseling along with management of calcium and PTH after surgery. The conversation concludes with emerging applications of molecular diagnostics and AI models for improving thyroid ultrasound interpretation.

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Resources

Dr. Jiang's Research on Pediatric Thyroid Nodule Management - https://pubmed.ncbi.nlm.nih.gov/26770219/

Bethesda System for Thyroid Cytopathology - https://pmc.ncbi.nlm.nih.gov/articles/PMC7182964/

---

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.

► https://www.backtable.com/app

From clinic to the OR, storytelling quietly shapes every decision in clinical care. This episode of BackTable ENT & Allergy examines how narrative medicine and the stories at the heart of each patient encounter can elevate your clinical practice, enhance empathy, and deepen the doctor-patient relationship. Pediatric ENT Dr. Gopi Shah interviews Dr. Alessandra (Alessa) Colaianni, a head and neck surgical oncologist at the University of North Carolina, about the power and relevance of narrative medicine in modern surgical care.

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Timestamps

00:00 - Introduction
05:53 - What is Narrative Medicine?
11:36 - Narrative Medicine in Clinic
17:28 - Narrative Medicine in the OR
21:09 - Patient Case Presentation and Boundaries
25:05 - Writing For Reflection and the impact of AI
29:35 - Resources And Podcasts
33:19 - Final Takeaways

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More about this episode

Dr. Colaianni is a published writer whose work has been featured in the New York Times, New Yorker, and the New England Journal of Medicine. She describes her lifelong interest in writing and shares how earning a master’s degree in the history and philosophy of science at the University of Cambridge during medical school helped her reconnect with the humanistic side of medicine. She reframes narrative medicine not as an extra task, but as an approach already woven into daily clinical work through history-taking, listening, and documentation. The conversation explores the influence of patient identity, socioeconomic context, and the “characters” in each patient’s story on clinical decisions and care. Dr. Colaianni reflects on the role of storytelling in surgical training, the apprenticeship model, and how thoughtful boundaries can foster meaningful doctor-patient relationships. The episode concludes with a discussion of AI’s potential impact on empathy and recommended reading for further exploration of narrative medicine.

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Resources

Dr.Colaianni’s published work
https://www.alessandracolaianni.com

Columbia University Division of Narrative Medicine
https://www.mhe.cuimc.columbia.edu/division-narrative-medicine

Columbia University Narrative Medicine Youtube channel
https://www.youtube.com/@columbiauniversitynarrativ8472

The Nocturnists podcast
https://thenocturnists.org/podcast

Autobiography of a Face by Lucy Grealey
https://www.amazon.com/Autobiography-Face-Lucy-Grealy

The Empathy Exams by Leslie Jameson
https://www.graywolfpress.org/books/empathy-exams

The Collected Schizophrenias Essays by Esmé Weijun Wang
https://www.graywolfpress.org/books/collected-schizophrenias

My Own Country: A Doctor’s Story by Abraham Verghese
https://www.amazon.com/My-Own-Country-Doctors-Story

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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.

► https://www.backtable.com/app

From the clinic to the camera, discover how an allergist turned social media into a patient education powerhouse. On this week’s episode of the BackTable ENT & Allergy Podcast, allergist Dr. Zachary Rubin of Oak Brook Allergists joins host Dr. Basil Kahwash to discuss his path from fellowship training to becoming a widely followed social media educator and author of the New York Times bestselling book “All About Allergies”. He explains how the COVID-19 pandemic and the rapid spread of online medical misinformation inspired him to educate the public through social media, developing an authentic on-camera style and consistent brand that has expanded his reach far beyond the clinic.

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Timestamps

00:00 - Introduction
05:21 - Learning the Creator Playbook
10:10 - Authenticity and Creating a Personal Brand
16:51 - Writing for Patients and Clinicians
20:41 - Balancing Clinic and Content Creation
26:15 - How to Start Your Public Voice
29:11 - Professional Boundaries and Handling Criticism Online
36:34 - How Patients Following Your Content Impacts the Clinic
43:08 - The Unexpected Doors Content Creation Can Open
48:44 - Future of Public Health
53:09 - Final Advice

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More about this episode

The conversation explores strategies for communicating complex medical topics, such as using metaphors to improve public understanding, and the importance of professionalism, boundaries, and safety in the online space. Dr. Rubin offers advice on avoiding individualized medical advice, managing online harassment, and navigating the nonfiction publishing world. He also discusses the impact of advocacy and media engagement for both patients and healthcare professionals, showing how physicians can leverage media to make a difference well beyond their practice.

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Resources

Dr. Zachary Rubin
https://www.oakbrookallergists.com/our-team/zachary-e-rubin-md/

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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.

► https://www.backtable.com/app

Behind every smooth surgery is a team member you may not see in the spotlight—but without them, the operation doesn’t run. In this episode of the BackTable ENT podcast, Jose Flores, a surgical technologist at Rady Children’s Hospital in San Diego and ENT service coordinator, joins host Dr. Gopi Shah to discuss the importance of the surgical technologist’s role in the OR and how it directly impacts patient care.

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SYNPOSIS

Jose discusses his journey from being a medical assistant to finding his calling in the operating room, specifically in ENT. They explore the critical yet often overlooked role of OR scrub techs, the necessity of proper preparation and organization, and the importance of good communication and teamwork within the surgical team. Jose also shares personal experiences and advice for both new surgical techs and medical students, emphasizing the rewarding nature of working in pediatric ENT.

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TIMESTAMPS

00:00 - Introduction
01:29 - Jose Flores’s Journey to Becoming a Surgical Tech
05:41 - Daily Responsibilities and Preparation
10:11 - Communication and Teamwork in the OR
15:30 - Building Strong Surgical Tech Relationships
18:51 - Advice for New Surgical Techs
21:25 - The Role of Techs in Quality and Safety
23:15 - Giving and Receiving Feedback
27:02 - Fostering Respect and Recognition
30:40 - Final Thoughts and Contact Information

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RESOURCES

Jose Flores’s Story:
https://vimeo.com/1096085041

Could that routine epistaxis actually be the first sign of a challenging skull base tumor? This week’s episode of the BackTable ENT Podcast is part two of the sinonasal tumor and skull base involvement discussion. Host Dr. Satyan Sreenath is joined again by Dr. Joao Paulo Almeida, Dr. Zara Patel, and Dr. Garret Choby for a case-based deep dive into the multidisciplinary management of complex sinonasal tumors.

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Timestamps

00:00 - Introduction
01:20 - Case 1: Juvenile Nasopharyngeal Angiofibroma
05:03 - Considerations for Pre-Operative Embolization
08:10 - Disaster Scenario: High Volume Loss
09:21 - Operative Approach
18:10 - Post-Op Imaging Considerations
21:00 - Case 2: Invasive Keratinizing Squamous Cell Carcinoma
24:40 - Operative Approach vs. Neoadjuvant Treatment Strategies
28:30 - Importance of Diagnostic Nasal Endoscopy
30:15 - Operative Approach
32:37 - Lumbar Drain Considerations
40:35 - Closing Thoughts

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More about this episode

The panel works through advanced cases presenting with epistaxis, using them to highlight key principles in evaluation, imaging, staging, and operative planning. They first discuss a 16-year-old male with a large juvenile nasopharyngeal angiofibroma extending to the skull base and middle cranial fossa, focusing on vascular supply, preoperative embolization, surgical strategy near the carotid, and planning for intraoperative hemorrhage and postoperative surveillance. They also emphasize the importance of thorough endoscopic evaluation and early referral to experienced centers.

They then review a 72-year-old female with invasive, HPV-negative keratinizing squamous cell carcinoma involving the anterior cranial fossa and dura. The conversation addresses tumor board decision-making, neoadjuvant considerations, endoscopic craniofacial resection, reconstruction strategies, and management of delayed positive margins. It highlights how accurate histopathology and coordinated multidisciplinary care guide outcomes in these complex cases.

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Resources

Joao Paulo Almeida, MD, PhD
https://medicine.iu.edu/faculty/68351/almeida-joao-paulo

Satyan B. Sreenath, MD
https://medicine.iu.edu/faculty/60724/sreenath-satyan

Zara M. Patel, MD
https://med.stanford.edu/profiles/zara-patel

Garret W. Choby, MD
https://providers.upmc.com/provider/garret-w-choby/2592344

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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.

► https://www.backtable.com/app

Pathology, anatomy, and staging: how do these three pillars come together to guide sinonasal tumor management? In this episode of the BackTable ENT Podcast, host Dr. Satyan Sreenath is joined by Dr. Joao Paulo Almeida, Dr. Zara Patel, and Dr. Garret Choby to discuss a multidisciplinary approach to sinonasal tumors, emphasizing the triad of pathology, anatomy, and staging to guide treatment.

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Timestamps

00:00 - Introduction
02:04 - First Principles of Workup
05:23 - Case 1: Maxillary Sinus Mass
06:23 - Imaging and Biopsy Strategy
08:11 - Inverted Papilloma Pathology and Surgical Planning
20:28 - Case 2: Unilateral Disease Red Flags
24:34 - MRI Clues for Malignancy
31:47 - Video Walkthrough of Endonasal Resection
38:51 - Surveillance
41:41 - Key Papers
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More about this episode

The panel reviews key workup considerations, including in-office biopsy and the use of CT and MRI to distinguish tumor from retained secretions and guide operative planning. They walk through two illustrative cases of inverted papilloma. The first involves a left maxillary sinus mass treated with an endoscopic medial maxillectomy using a Denker-type approach, with emphasis on complete attachment-site eradication. The second case highlights an elderly patient with frontal and anterior ethmoid disease abutting the orbit and skull base, requiring meticulous endoscopic technique, careful management of the anterior ethmoid artery, and thoughtful handling of bone and periorbita.

The discussion also covers imaging features suggestive of malignant transformation, as well as emerging AI-based CT and MRI tools that show high accuracy in distinguishing benign inverted papillomas from those associated with squamous cell carcinoma. The episode concludes with postoperative surveillance strategies and key consensus and review publications.

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Resources
Joao Paulo Almeida, MD, PhD
https://medicine.iu.edu/faculty/68351/almeida-joao-paulo

Satyan B. Sreenath, MD
https://medicine.iu.edu/faculty/60724/sreenath-satyan

Zara M. Patel, MD
https://med.stanford.edu/profiles/zara-patel

Garret W. Choby, MD
https://providers.upmc.com/provider/garret-w-choby/2592344

---

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.

► https://www.backtable.com/app

What if you could build a skull base practice outside academia, without sacrificing complexity, income, or fulfillment? On this episode of the BackTable ENT Podcast, Dr. Kibwei McKinney from SSM Health St. Anthony Hospital in Oklahoma City joins guest host Dr. Dennis Tang to discuss building a rhinology and skull base surgery practice outside academia.

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Timestamps

01:30 - Introduction and Career
04:55 - Private Practice vs. Academics
10:38 - Defining Skull Based Surgery
15:10 - Patient Pool and Logistics in Academics vs Private Practice
19:03 - Marketing and Referral Sources
24:58 - Case Management and the O.R. in Private Practice
29:30 - Balanced Workload and Intentional Care
32:10 - Billing and Coding
38:55 - Lifestyle Benefits of Private Practice
44:21 - Strategic Advice and Advantages or Disadvantages of Private Practice.
47:38 - Common Misconceptions
50:00 - Advice and Closing Thoughts

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More about this episode

Dr. McKinney walks through his training journey, from dedicated research years to time in private-practice rhinology and a skull base fellowship, before ultimately starting his academic career in Oklahoma. He shares how shifting family priorities and the growing push for clinical productivity led him to step away from academia and into an employed private-practice model focused exclusively on rhinology and skull base surgery, without ER call. Along the way, he dives into what that transition really looks like, including the autonomy he’s gained, the role of marketing support, how he builds referrals through direct communication, and the operational differences of working without residents. He also touches on postoperative care structure, billing and coding, insurance challenges, and the impact on his overall lifestyle.

Check out this episode to hear Dr. McKinney’s perspective on why skull base surgery in private practice can be not only technically feasible and financially viable, but also emotionally sustainable, creating space for truly patient-centered care and the ability to pursue the work with genuine passion.

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Resources

Dr. Kibwei McKinney
https://www.getcare.ssmhealth.com/find-a-doctor/doctor-details/kibwei-mckinney-md