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)

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

• 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.