Rhinology Roundtable

Ashleigh Halderman
  • 5.0 (5)
  • Education

Rhinology Roundtable: where expertise meets honesty, and the conversations go beyond the slides. Rhinology Roundtable — brought to you by the American Rhinologic Society — is where the real conversations happen. This isn’t another recap of what you already heard at national meetings or read in journals. Instead, Rhinology Roundtable pulls back the curtain on the unspoken, the under-discussed, and the clinically nuanced topics that shape everyday practice but rarely make it to the podium or the page. Join candid, unscripted discussions between colleagues as they tackle high-yield clinical dilemmas, gray-zone decision-making, and the practical realities of rhinologic care. From controversial management strategies to “what we actually do” in clinic and the OR, this podcast delivers insights you won’t find in textbooks. Whether you’re a seasoned rhinologist, a general otolaryngologist, or a trainee looking for real-world perspective, expect thoughtful debate, expert opinion, and actionable takeaways — all in a conversational format that feels like sitting in on a trusted peer discussion.

  1. 8h ago

    In-Office Procedures in Rhinology

    In this episode of Rhinology Roundtable, Dr. Ashleigh Halderman talks with Dr. Greg Davis and Dr. Leah Hauser about the expanding role of awake, in-office procedures in rhinology and otolaryngology. They discuss how to decide which procedures belong in the clinic or operating room, how to identify patients who are likely to tolerate office treatment, and the importance of thoughtful anesthesia, trained staff, consistent workflows, and protected scheduling. The conversation also explores the practical side of office-based care: reimbursement and insurance denials, patient comfort, and how procedure durability can differ between office and OR approaches. Their central message is that successful in-office care depends not only on the procedure itself, but also on honest conversations with patients and systems that make the work safe, repeatable, and sustainable.   Advice From the Episode Start with low-risk, high-yield office procedures before expanding into more complex cases.Use a patient’s nasal endoscopy tolerance and general anxiety level as practical screening tools.Standardize room setup and teach staff the exact sequence for each procedure.Cluster procedure blocks so office work does not destabilize the entire clinic day.Check actual reimbursement after the procedure, not just the billed amount.Seek hands-on training in a lab or on asleep patients before performing a new office procedure on an awake patient.

  2. Sep 25

    Immunodeficiencies in Sinusitis

    Immunodeficiencies in Sinusitis On this episode of Rhinology Roundtable, host Dr. Ashleigh Halderman, and guests Dr. Angela Donaldson, and Dr. Sandra Lin discuss a topic where evidence-based guidance is sorely lacking. Topics covered include when to consider immune deficiency in a patient with either recurrent acute or chronic sinusitis, and why evaluating immunodeficiency requires more than checking a few lab values. They review the most common immunodeficiencies rhinologists/otolaryngologists should be aware of, timing of and length of antibiotic courses in acute sinusitis in patients with ID, the importance of culture-directed treatment, and options for treatment including topical antibiotics, immunoglobulin replacement, and the role of surgery. Key topics Which patients with either acute or chronic sinusitis may need to be considered for immune testingThe role of culture guided therapy for this unique patient populationThe role of CBC and quantitative IgG, IgA, and IgM testingWhy normal immunoglobulin levels do not exclude specific antibody deficiencyHow pneumococcal serotype testing and vaccine challenge assess immune functionWhen IgG subclasses are useful—and why they remain controversialHow rituximab, CAR T-cell therapy, transplant medications, and other treatments can cause secondary immune dysfunction and recurrent sinusitisHow immunodeficiency affects antibiotic choice, duration, and culture strategyWhen immunoglobulin replacement should be consideredWhy surgery may need to wait until immune therapy has had time to workHow surgery can improve drainage and access for topical treatment without curing the underlying immune problem but also improve quality of life and reduce the length and frequencies of episodesWhen more extensive procedures, such as mega antrostomy, may be appropriateKey takeaways A single low immunoglobulin value is not enough to diagnose clinically significant immune deficiency.Functional antibody responses can reveal problems that quantitative testing misses.Recalcitrant sinus disease may reflect inflammation, infection, immune dysfunction, or a combination of all three.Surgery is an adjunctive treatment, not a cure, for patients with immune deficiency-related sinus disease.Patients with recurrent, severe, unusual, or treatment-resistant infections may warrant an immune evaluation.

  3. Sep 11

    The Truth About Sinus Headache

    Let’s start with some numbers. Between 0.5-2% of upper respiratory viral illnesses convert to true acute bacterial rhinosinusitis. Only 3-6% of the general population is thought to have chronic rhinosinusitis. An astounding 34.6% of people have a primary headache disorder. That is 1 person in 3.    The “sinus headache” may be the most costly misdiagnosis rhinologists see. It is made by patients themselves, primary care providers, and even neurologists. The literature has shown that 80-90% of patients with “sinus headache” actually meet the International Headache Society criteria for migraine or possible migraine. Labeling this wrong means patients can continue to struggle with symptoms for years while effective headache treatment is delayed.   If your patients (or you) experience “sinus headaches” or even recurrent “sinus infections” where headache is the primary symptom, this episode is for you. Dr. Ashleigh Halderman is joined by Dr. Mark Mehle, a comprehensive otolaryngologist and author of Sinus Headache, Migraine, and the Otolaryngologist, and Dr. David Jang Associate Professor of Rhinology at Duke University, both leaders in migraine in otolaryngology.  Together, they unpack the evidence, the controversy, and the practical bedside clues that help separate true sinus disease from primary headache disorders. You'll discover: Why facial pressure, congestion, rhinorrhea, pain/pressure worsened by bending forward, and weather sensitivity do not automatically mean sinusitisHow trigeminal and autonomic pathways make migraine feel like nasal diseaseWhy true chronic rhinosinusitis requires objective evidence, not symptoms aloneThe role of nasal endoscopy, CT imaging, and why a negative scan is more useful than a positive one for ruling out sinusitis as the cause of headacheWhich history clues point more toward migraine, including photophobia, phonophobia, nausea, motion sensitivity, ear pain/pressure, dizziness, and pain worsening with activityHow recurrent acute sinusitis is often actually migraineHow allergies, rhinitis, and chronic sinusitis can lower the threshold for migraine symptoms without being the root causeWhat medications you can start patients on that may help alleviate their symptomsHelpful Links: Migraine in Otolaryngology Society International Headache Society American Migraine Foundation Development of the Sinus Headache Screener (SHS)   The SNNOOP10

  4. Aug 28

    Chronic Non-Allergic Rhinitis

    Clear, watery runny nose is only the beginning. The real question in chronic rhinitis is what is actually driving the symptoms, and the answer changes everything from diagnosis to treatment to whether a patient should ever need a procedure. Host Dr. John Craig is joined by two experts in the field, fellow rhinologists and skull base surgeons Dr. Michael Chang from Stanford University and Dr. Omar Ahmed from Houston Methodist for a clinically focused roundtable on the messy reality of non-allergic and mixed rhinitis. They break down why this diagnosis is still a diagnosis of exclusion, why history matters more than most endoscopies, and why so many patients sit in the overlap between allergic and non-allergic disease. You’ll discover: Why non-allergic rhinitis is really a bucket of different pathways, not one simple diseaseWhich symptoms most strongly point to non-allergic disease versus allergyHow often clear anterior rhinorrhea, post-nasal drip, congestion, sneezing, and itching actually show up in real practiceWhen allergy testing changes the game and when it may be less usefulWhy nasal endoscopy is essential for ruling out other causes, but rarely proves rhinitis on its ownHow ipratropium, azelastine, capsaicin, and mometasone rinses fit into the treatment ladderWhat Atrovent response may predict about office ablation outcomesThe conversation gets especially useful when the group gets into procedures. They compare in-office ablation, cryoablation, radiofrequency treatment, and posterior nasal neurectomy, and they do not shy away from the uncomfortable truth that recurrence, technique, and symptom selection matter a lot. They also dig into newer ideas like anterior nasal nerve treatment and why the future of rhinitis care may be moving beyond the posterior nose. If you treat runny noses, post-nasal drip, or patients who have already failed the usual sprays, this episode gives you the current thinking, the practical algorithm, and plenty of new ideas to apply in clinic tomorrow.   Timestamps 00:00 - Welcome to Rhinology Roundtable and episode setup 00:33 - Why this episode focuses on non-allergic rhinitis 01:28 - Speaker disclosures and why unbiased discussion matters 02:25 - What non-allergic rhinitis actually is 05:51 - Mixed rhinitis as the real-world pattern most clinicians see 07:59 - Why symptoms matter more than labels 08:46 - Classic symptom profile of non-allergic rhinitis 10:08 - Why postnasal drip is harder to interpret than anterior rhinorrhea 15:25 - When to test for allergies 17:03 - Key symptom differences between allergic and non-allergic 18:09 - Mucus viscosity and the feeling of watery versus sticky drainage 20:18 - How often allergy testing changes the diagnosise 24:54 - Endoscopy as a rule-out tool, not a definitive rhinitis test 27:03 - Medical therapy starts with clear runny nose and ipratropium 28:43 - How strong is the response to ipratropium spray? 30:00 - When azelastine gets added 32:05 - Capsaisin as an underused option with real evidence behind it 33:44 - How long to trial ipratropium before calling it a success or failure 36:35 - How many patients improve enough to avoid surgery 41:06 - When symptoms move from medical management to procedures 42:49 - Office ablation versus operative neurectomy 44:12 - Real-world outcomes after cryoablation and recurrence patterns 48:14 - Radiofrequency versus cryoablation durability 49:49 - Outcomes after repeat procedures and why technique matters 52:39 - Ipratropium response as a predictor for ablation outcomes 55:24 - Why postnasal drip remains the hardest symptom to study and treat 58:40 - What anterior nasal nerves are and why they matter 60:07 - Why rhinitis is entering a rapid innovation phase

  5. Aug 14

    Pediatric Sinusitis: What’s Really Viral, What’s Bacterial, and When to Escalate

    This episode of Rhinology Roundtable, the podcast of the American Rhinologic Society, hosted by Dr. Ashleigh Halderman breaks down pediatric sinusitis from the first diagnostic crossroads to surgical decision-making. The conversation focuses on how children differ from adults, why adenoids matter so much, and how to sort out chronic symptoms, recurrent infections, and the cases where an immune or systemic workup is needed. Joining the discussion are Dr. Chadi Makary Professor, Vice Chair of Clinical Services, and Chief of Rhinology at West Virginia University, and Dr. Sarah Maurrasse Assistant Professor, Assistant Program Director, and Pediatric otolaryngologist at Yale School of Medicine. Our experts share practical, age-specific guidance on diagnosis, imaging, antibiotics, surgery, and long-term management. Key topics Pediatric sinusitis is not just adult sinusitis in smaller faces: Younger children often have a more infectious, adenoid-driven disease process rather than the inflammatory endotypes seen in adults.Adenoids are central to the pediatric story: Enlarged or infected adenoids can cause obstruction, mucus stasis, bacterial colonization, and biofilms.Chronic sinusitis is relatively uncommon in kids: What looks like chronic disease is often back-to-back viral infections that never fully clear. True chronic sinusitis is harder to diagnose because kids have fewer reliable symptoms.Cough matters more in children than facial pain: Day and night cough is highlighted as a major diagnostic clue in pediatrics. Headache and facial pain are less reliable, especially in younger kids who may not verbalize them well.Age changes the algorithm: Around ages 12 to 13, the disease starts to look more adult-like, and adenoidectomy may be less of a default first step.CT is used selectively: Imaging is more likely when symptoms and endoscopy do not match, when older children have more adult-like disease, or when a FESS decision is on the table.Polyps trigger a broader workup: If polyps are seen, the discussion shifts toward cystic fibrosis, allergy, immune evaluation, and possibly other systemic disease.Medical therapy is still first-line: Intranasal steroids, saline sprays, and rinses are used frequently.Surgery is usually stepwise: In younger children, adenoidectomy is typically the first operation. FESS is reserved for selected casesImmune workup should be considered in refractory cases: CBC, immunoglobulins, vaccine titers, allergy testing, and targeted referral to immunology. Many patients improve after addressing under-response to pneumococcal vaccination.Quality of life is a major outcome: Even when surgery does not eliminate viral infections, it can shorten illnesses and reduce severity, which the guests describe as a meaningful win for families. Timestamps 02:38 - Guest introductions: Dr. Chadi McCary and Dr. Sarah Maras 04:12 - Why adenoids are a major confounder 06:56 - Pediatric disease is more infectious than adult CRS 11:45 - Why cough is a core pediatric symptom 16:35 - Objective evidence and why scope comes before CT 19:11 - When to image 27:28 - Polyps in kids 32:14 - Saline rinses, sprays, and realistic compliance 37:45 - Antibiotic choice and duration for acute exacerbations 40:11 - When to consider surgery 42:11 - Immune workup 48:03 - Goals of surgery 51:53 - Post-op expectations 56:14 - Antibiotics in immunodeficient children 58:21 - Surgery in immune deficiency

  6. Jul 31

    Exploring the Link Between Allergies and Chronic Rhinosinusitis

    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 misconceptionsWhether allergy causes CRS or acts as a disease modifierThe significance of CRS phenotypes and endotypes in managementWhen and how to test for allergies in CRS patientsThe role of allergy treatment, including immunotherapy, in modulating CRSControversies surrounding allergic fungal rhinosinusitis and central compartment atopic diseaseEnvironmental factors affecting sinus health, including indoor air qualityPractical tips on allergy testing methods and interpretationThe impact of allergy control on surgical outcomesConsiderations for immunotherapy in CRS, especially with biologic treatmentsTimestamps: 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 Societyhttps://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-mDr. Stella Lee - https://physiciandirectory.brighamandwomens.org/details/15252/stella-lee-otolaryngology_ears_nose_and_throat-boston

  7. Jul 17

    The Art of Timing: Imaging in Sinusitis

    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 managementWhen to rely on symptoms, endoscopy, and imaging—individually or combinedThe impact of insurance policies and historical practices on imaging decisionsHow to interpret CT scans during active symptoms versus remission periodsStrategies 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

  8. Jul 3

    Septal Perforations

    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 SocietySurgical techniques for septal perforation repair - Journal of Otolaryngology3D printed septal buttons — Custom Medical SolutionsPonaris nasal oil

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About

Rhinology Roundtable: where expertise meets honesty, and the conversations go beyond the slides. Rhinology Roundtable — brought to you by the American Rhinologic Society — is where the real conversations happen. This isn’t another recap of what you already heard at national meetings or read in journals. Instead, Rhinology Roundtable pulls back the curtain on the unspoken, the under-discussed, and the clinically nuanced topics that shape everyday practice but rarely make it to the podium or the page. Join candid, unscripted discussions between colleagues as they tackle high-yield clinical dilemmas, gray-zone decision-making, and the practical realities of rhinologic care. From controversial management strategies to “what we actually do” in clinic and the OR, this podcast delivers insights you won’t find in textbooks. Whether you’re a seasoned rhinologist, a general otolaryngologist, or a trainee looking for real-world perspective, expect thoughtful debate, expert opinion, and actionable takeaways — all in a conversational format that feels like sitting in on a trusted peer discussion.

Information

  • Creator
    Ashleigh Halderman
  • Years Active
    2026
  • Episodes
    13
  • Rating
    Clean
  • Copyright
    © 2026 Ashleigh Halderman
  • Show Website
    Rhinology Roundtable

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