Rhinology Roundtable

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.