Rhinology Roundtable

On this episode of Rhinology Roundtable, we explore how to successfully integrate advanced practice providers (APPs) into rhinology practices. Host Dr. Ashleigh Halderman speaks with members of the Rhinology Advance Practice Providers section of the ARS Emily Moldoff NP-C from Brigham and Women’s and Lindsay Wyant PA-C from Oregon Health Science University about the importance of defining the role before hiring and APP, providing structured, hands-on training and supportive feedback, and gradually building clinical independence. They also discuss the importance of trust, mentorship, professional development, and why retention depends on respect, autonomy, manageable workloads, and a genuine sense of partnership, not simply asking APPs to see more patients.  

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 therapyWhen 2 cycles is enough, and when a third cycle changes everythingHow MRI, symptoms, and anatomic response all factor into reassessmentWhy non-responders may need a completely different strategyWhere immunotherapy fits in mucosal melanomaWhy SNUC is no longer one disease, and why that mattersThe 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.

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 EpisodeStart 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.

Immunodeficiencies in SinusitisOn 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 topicsWhich 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 takeawaysA 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.  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 SocietyInternational Headache SocietyAmerican Migraine FoundationDevelopment of the Sinus Headache Screener (SHS) The SNNOOP10