Show Notes
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.
More from Rhinology Roundtable
Induction chemotherapy for sinonasal malignancies is not just "chemo before surgery" - it's a test of tumor biology, a chance to preserve critical structures, reduce morbidity, and sometimes the decision that determines what treatment comes next. Dr. Ashleigh Halderman is joined by Dr. Mat Geltzeiler from Oregon Health Science University and Dr. Garret Choby from the University of Pittsburgh Medical Center for a practical, high-stakes conversation about how leading experts actually think through the approach to treatment for these rare cancers. (Seriously, how many times can 3 people say “nuanced” in one conversation??) From SNUC and sinonasal squamous cell carcinoma to olfactory neuroblastoma, adenocarcinoma, and mucosal melanoma, they break down where induction helps, where it doesn't, and why histology and biomarkers are changing the entire playbook. You'll discover: Why induction means something different from neoadjuvant therapy When 2 cycles is enough, and when a third cycle changes everything How MRI, symptoms, and anatomic response all factor into reassessment Why non-responders may need a completely different strategy Where immunotherapy fits in mucosal melanoma Why SNUC is no longer one disease, and why that matters The conversation gets especially useful when the panel gets specific about real-world decision points: borderline resectability, orbital involvement, perineural spread, skull base disease, and the tradeoffs between a bigger surgery, chemoradiation, and quality of life. They also tackle the lingering uncertainty in the literature, including why randomized survival data are unlikely to ever be definitive in such rare tumors. This episode is essential listening for rhinologists, head and neck surgeons, medical and radiation oncologists, and trainees who want a clear framework for one of the most nuanced decisions in sinonasal oncology. If you manage complex skull base disease, or want to understand why the same diagnosis can lead to very different treatment paths, this one belongs on your playlist.
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 testing The role of culture guided therapy for this unique patient population The role of CBC and quantitative IgG, IgA, and IgM testing Why normal immunoglobulin levels do not exclude specific antibody deficiency How pneumococcal serotype testing and vaccine challenge assess immune function When IgG subclasses are useful—and why they remain controversial How rituximab, CAR T-cell therapy, transplant medications, and other treatments can cause secondary immune dysfunction and recurrent sinusitis How immunodeficiency affects antibiotic choice, duration, and culture strategy When immunoglobulin replacement should be considered Why surgery may need to wait until immune therapy has had time to work How 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 episodes When more extensive procedures, such as mega antrostomy, may be appropriate Key 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.
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.
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 disease Which symptoms most strongly point to non-allergic disease versus allergy How often clear anterior rhinorrhea, post-nasal drip, congestion, sneezing, and itching actually show up in real practice When allergy testing changes the game and when it may be less useful Why nasal endoscopy is essential for ruling out other causes, but rarely proves rhinitis on its own How ipratropium, azelastine, capsaicin, and mometasone rinses fit into the treatment ladder What Atrovent response may predict about office ablation outcomes The 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.
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.