In this episode of Rhinology Roundtable, hosted by Dr. Ashleigh Halderman, we explore the complex relationship between allergy and chronic rhinosinusitis (CRS). Our expert guests, Dr. Elina Toskala and Dr. Stella Lee, discuss current evidence, testing strategies, and treatment approaches, emphasizing personalized care and the importance of understanding each patient's unique inflammatory profile.

Key topics covered:

• The distinction between allergy and CRS and common misconceptions
• Whether allergy causes CRS or acts as a disease modifier
• The significance of CRS phenotypes and endotypes in management
• When and how to test for allergies in CRS patients
• The role of allergy treatment, including immunotherapy, in modulating CRS
• Controversies surrounding allergic fungal rhinosinusitis and central compartment atopic disease
• Environmental factors affecting sinus health, including indoor air quality
• Practical tips on allergy testing methods and interpretation
• The impact of allergy control on surgical outcomes
• Considerations for immunotherapy in CRS, especially with biologic treatments

Timestamps:

00:00 - Introduction to the complex link between allergy and CRS
02:42 - Meet the experts: Dr. Toskala and Dr. Lee
03:05 - Common misconceptions about allergy and CRS
04:00 - The coexistence of allergy and CRS
06:19 - Does allergy cause CRS? Insights from experts
08:24 - The relationship between allergy, disease severity
10:06 - Modulation versus causation: How allergy influences CRS
12:21 - CRS phenotypes: Polyps, endotypes, and clinical relevance
15:02 - Differentiating allergy symptoms from CRS symptoms
17:26 - The importance of assessing environmental and lifestyle factors
26:14 - Geography and genetics in fungal rhinosinusitis prevalence
30:16 - How environmental factors, like air quality, impact sinus health
39:26 - The role of allergy in specific CRS phenotypes
43:03 - Allergy testing methods: skin prick vs. blood tests
49:19 - Treating allergy to modulate CRS symptoms and improve outcomes
69:03 - Immunotherapy: indications, benefits, and limitations for CRS
78:19 - Key takeaways

Resources & Links:

• American Rhinologic Society
• https://sinushealth.com/conditions/adult-sinusitis/
• https://sinushealth.com/conditions/allergic-rhinitis-allergies-or-hay-fever/
• https://onlinelibrary.wiley.com/doi/10.1002/alr.23090 (ICAR: Allergic Rhinitis)
• https://onlinelibrary.wiley.com/doi/10.1002/alr.22741 (ICAR: Rhinosinusitis)

Connect with the Experts:

• Dr. Elina Toskala - https://www.jeffersonhealth.org/find-a-doctor/t/toskala-elina-m
• Dr. Stella Lee - https://physiciandirectory.brighamandwomens.org/details/15252/stella-lee-otolaryngology_ears_nose_and_throat-boston

Most clinicians rely heavily on CT scans for diagnosing and managing sinusitis — but when is the right time to order one, and when can it be safely skipped? In this episode of Rhinology Roundtable, Dr. Ashleigh Halderman hosts top experts Dr. Kevin Welch and Dr. Amber Luong challenge conventional wisdom around imaging, revealing how nuanced decision-making has become. Discover how to optimize CT timing to improve patient outcomes, avoid unnecessary radiation, and better understand the dynamic nature of sinus disease. They break down:

• The evolving role of pre- and post-treatment scans in CRS management
• When to rely on symptoms, endoscopy, and imaging—individually or combined
• The impact of insurance policies and historical practices on imaging decisions
• How to interpret CT scans during active symptoms versus remission periods
• Strategies for odontogenic sinusitis and complex cases where imaging changes everything (like in the case of sinus headache)

If you're a trainee wondering what you will do when you start practicing after graduation, a clinician looking to optimize when you order imaging, or a specialist wanting to refine your approach, this episode provides practical insights rooted in decades of experience. You'll learn why some scans may be unnecessary, how to time them effectively, and how to integrate clinical cues with imaging findings. Understanding the proper timing and interpretation of CT scans can prevent missed diagnoses, reduce patient exposure to radiation, and streamline treatment pathways. Don't miss this deep dive into one of rhinology’s most debated topics—perfect for ENT residents, practicing rhinologists, and anyone eager to make evidence-based imaging decisions. Join the conversation and elevate your diagnostic game—your patients will thank you.

Show Notes

00:00 - Introduction  
00:21 - The "presidential sandwich" analogy and light-hearted trivia
01:18 - The history and legacy of CT scans in CRS management
03:44 - Indications for ordering CT scans during CRS workup
04:11 - Limitations of symptoms and findings without imaging
05:27 - When and why to order a scan to rule out or confirm sinusitis
06:22 - The role of objective imaging in surgical planning
07:04 - Correlation between nasal endoscopy and CT findings
08:08 - The utility of immediate in-office CT scans during patient visits
09:37 - Differentiating sinus-origin headaches versus other causes
11:18 - When sinus inflammation contributes to migraines and vascular headaches
12:00 - Identifying underlying sinus issues that may influence migraine treatment
14:13 - Incorporating previous imaging into current decision-making
16:03 - The influence of symptom severity and timing on ordering scans
17:42 - Scanning during active symptoms for better diagnostic clarity
18:25 - The shift away from routine post-treatment scans towards symptom-driven imaging
19:12 - Optimal timing for CT scans in relation to recent symptoms or treatments
28:46 - When re-imaging is necessary based on treatment response and symptoms
36:34 - Practical considerations, including insurance, ethics, and surgical planning
38:22 - Specific scenarios in odontogenic sinusitis and timing of pre- and post-therapy scans
43:17 - Final thoughts

Most nasal perforations are caused by trauma, drug use, or prior surgery—yet many patients endure persistent symptoms and struggle to find effective treatment. In this episode, Dr. Amar Miglani from the Mayo Clinic shares pioneering techniques and strategic insights into repairing even the most challenging septal perforations. Discover how to assess perforation size, inflammation, and mucosal health with practical tips on imaging, exam, and patient selection. Learn about the latest flap techniques—bipedicle, anterior ethmoid artery, and posterior septal modifications—and how to choose the right approach for each case.
You'll also hear the surprising impact of climate and habits like nose picking or cocaine use on perforation formation, plus effective conservative strategies, from topical ointments to nasal silicone buttons. Drs Halderman and Miglani emphasize the importance of patient counseling, realistic expectations, and shared decision-making.  

00:00 - Introduction to septal perforations and their challenges 02:00 - Causes and etiology of septal perforations 04:40 - Signs of cocaine and other drug-induced perforations 06:27 - Infectious causes, including rhinoscleroma 08:24 - Classifying perforations: inflammatory, post-surgical, and others 10:07 - Symptoms: whistling, crusting, bleeding, obstruction 12:34 - Examination techniques: endoscopy, photo documentation, CT measurement 15:00 - Imaging specifics and measurement tips during surgery 16:46 - Impact of perforation on nasal projection and external appearance 18:06 - Habitual nose picking and nasal neuroses considerations 20:09 - Lab work and autoimmune workup recommendations 22:35 - Communicating surgical risks and realistic outcome expectations 24:18 - Surgical approaches: endoscopic, flap choices, and repair techniques 28:00 - Use of septal buttons and innovative solutions like 3D printing 30:12 - Patient selection criteria: symptoms, mucosa quality, comorbidities 32:43 - Postoperative healing timeline and residual symptoms 34:12 - Counseling on outcomes — "not perfect but better" 36:45 - Managing complex cases with autoimmune or prior surgeries 39:05 - Informed consent: discussing risks, recovery, and expectations 40:34 - Surgical techniques: open vs endoscopic, flap selection 43:15 - Graft materials and securing repairs: sutures and sheeting 46:26 - Postoperative care, packing, antibiotics, and follow-up 48:45 - Timeline for healing, feeling of new baseline 49:05 - Takeaways: rewarding procedure, comprehensive nose management

• American Rhinologic Society
• Surgical techniques for septal perforation repair - Journal of Otolaryngology
• 3D printed septal buttons — Custom Medical Solutions
• Ponaris nasal oil

Many cases of unilateral maxillary sinusitis are caused by dental issues that often go unnoticed—until severe complications like brain abscesses occur. In this eye-opening episode, Dr. John Craig teams up with international experts Dr. Alberto Saibene – rhinologist from the University of Milan, and Dr. Rod Tataryn Endodontist in private practice from Spokane, WA to unravel the misunderstood world of odontogenic sinusitis. This episode breaks down crucial signs: persistent foul smell, unilateral symptoms, and subtle dental clues that highlight an ongoing bacterial invasion. Dr.’s Craig, Saibene, and Tataryn share decades of experience on clinical features, from vital pulp tests to radiographic signs, helping you identify hidden dental sources before they escalate. Whether you’re an ENT, general practitioner, or dentist, learn how to build multidisciplinary networks that facilitate faster diagnoses and targeted treatments—potentially avoiding devastating consequences like orbital infections or brain abscesses.

• Definition and differentiation of odontogenic sinusitis versus maxillary mucositis
• Clinical presentation and key symptoms of ODS
• Imaging features and the significance of dental pathology on CT scans
• Uncomplicated vs. complicated ODS
• The role of dental evaluation: vital pulp testing, radiographic clues, and the significance of missing teeth or prior procedures
• Differential diagnosis
• Treatment approaches: dental intervention, sinus surgery, and the role of antibiotics
• The impact of endodontic health including vital vs. necrotic pulp and failed root canal therapies
• Surgical decision-making
• Strategies for building effective dental and ENT networks for better patient outcomes

Timestamps:

00:00 - Introduction 02:21 - Definition of odontogenic sinusitis 03:36 - Infectious nature 04:30 - Mucosal thickening vs. true sinusitis 06:33 - Uncomplicated vs. complicated odontogenic sinusitis including risk of orbital and intracranial complications 08:17 - Typical presentation: symptoms and presentation to ENT versus dental providers 09:22 - Recognizing clinical features 11:16 - Imaging clues: teeth, periapical lesions, and the importance of multi-plane CT review 12:44 - Differential diagnosis considerations 14:23 - The importance of dental history and evaluation: vital pulp testing and imaging 16:51 - Common dental pathologies on CT: implants, grafts, and periapical lesions 20:05 - The significance of missing teeth and previous dental procedures 21:13 - Differential diagnosis 22:29 - Role of dental evaluation in confirming odontogenic source 24:41 - When to consider root canal failure or residual infection 26:22 - Common endodontic issues 28:14 - Challenges in general dental practice 29:54 - Treatment strategies: when to observe, when to operate 30:59 - Effectiveness of proper dental and sinus treatments 35:47 - Antibiotic therapy 37:06 - The role of dental source control before sinus surgery 38:58 - Surgical approaches 50:16 - Building multidisciplinary networks 57:09 - Final pearls

Resources & Links:

• American Association of Endodontists
• Fusobacterium and Pathogenic Bacteria in Sinus Disease (Yoshida study)
• From Dentigerous Cysts to Odontogenic Sinusitis. Otolaryngology Clinics of North America 2024; 57(6). PMID 39214735
• Yoshida et al study PMID 35434313

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

• Systematic Review on Medications Affecting Salivary Glands (PubMed)

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

• PMID 40105501: Defining the Appropriate Length of Antimicrobial Therapy for Skull Base Osteomyelitis
• PMID 36648119: Central Skull Base Osteomyelitis: A Case Series from a Tertiary Care Center Over 5 Years

• Dr. Erin McKean - | University of Michigan
• Dr. Jacob Hunter - Thomas Jefferson University

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.

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.