BackTable ENT & Allergy

Septal perforations can be deceptively challenging, with a wide range of etiologies, symptoms, and treatment options to consider. In this episode of BackTable ENT and Allergy podcast, hosts Dr. Ashley Agan and Dr. Gopi Shah interview Dr. Oswaldo Henriquez, a board-certified otolaryngologist and rhinologist at WellStar Health System in Atlanta, to explore the complexities of evaluating and managing nasal septal perforations. The conversation covers how perforation size and location shape symptoms, the most common causes including iatrogenic trauma and chronic nose picking, and a thorough, stepwise approach to diagnosis and treatment.

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Timestamps00:00 - Introduction03:01 - Septal Perforations Overview07:58 - Causes and Risk Factors13:26 - History Red Flags and Differential Diagnosis16:28 - Exam and Documentation Tips21:22 - Labs Biopsy and Imaging Workup31:19 - Conservative Care and Septal Buttons34:20 - Surgery Candidacy and Counseling41:35 - Surgical Techniques Landscape47:38 - Scaffolds and Grafts49:07 - Septal Blood Supply Map53:00 - CAT Scan Planning Tips55:15 - AEA Flap Technique01:05:22 - Real Case Walkthrough01:10:41 - Postop Care and Swelling01:20:44 - Pitfalls and Success Rates01:24:09 - Wrap Up

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More about this episodeDr. Henriquez outlines the key components of a comprehensive workup, including endoscopic exam, measurement, biopsy, and CT imaging for surgical planning. He discusses management options from conservative care and septal buttons to advanced endoscopic pedicled flap repairs, sharing insight on surgical techniques, success rates, splinting, and post-op care. The episode provides practical tips for physicians at any career stage looking to refine their approach to septal perforations, from diagnosis through recovery.

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ResourcesENT Animationshttps://www.youtube.com/@Dr.IsamAlobid

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BackTable ENT & Allergy is the go-to podcast for otolaryngologists, allergists, and head and neck surgeons.

Download the free BackTable app to get early access to new episodes, cases, and courses curated by physicians in your specialty.► https://www.backtable.com/app

For years, an indeterminate thyroid biopsy meant diagnostic surgery but molecular testing is now changing that reality entirely. On this episode of the BackTable ENT podcast, Dr. Ashley Agan interviews endocrinologist Dr. Erik Alexander about how molecular testing and a systematic, layered approach to thyroid nodule evaluation are reducing diagnostic surgeries and enabling more individualized patient care.

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This podcast is supported by

Veracytehttps://www.veracyte.com/

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Timestamps

00:00 - Introduction02:48 - Incidence, Presentation, and Workup of Thyroid Nodules 06:26 - Hormonal Impact and Indications for FNA 10:49 - FNA workflow and Bethesda Categories 16:10 - Role of Molecular Testing for Indeterminate Nodules19:59 - Evolution of Molecular Testing and Afirma 23:51 - Basics of DNA based Testing and RNA based Testing 28:34 - Comparing DNA based and RNA Based Testing 32:10 - Utility of Molecular Testing and Sampling Techniques 35:55 - Cost Coverage and Practical Limits39:20 - Clinical Implications and Future Impact42:00 - Final Takeaways

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More about this episode

Together they walk through the full evaluation pathway, including ultrasound risk stratification using the TI-RADS criteria, the role of TSH testing, and how FNA indications have shifted from biopsying every solid nodule to a more selective, risk-adapted approach. The discussion covers the Bethesda classification system and addresses why the one-third of patients landing in indeterminate categories (Bethesda III, IV, and V) have historically been the most challenging and most overtreated group. The conversation then explores molecular diagnostics as an additional layer of risk assessment, highlighting key differences between DNA-based mutation panels and RNA-based expression classifiers. Dr. Alexander also discusses practical considerations like insurance coverage, sampling technique, turnaround time, and the future potential of molecular testing to move beyond diagnosis toward individualized prognosis.

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Resources

American College of Radiology: TI-Rads Guidelines https://edge.sitecorecloud.io/americancoldf5f-acrorgf92a-productioncb02-3650/media/ACR/Files/RADS/TI-RADS/TI-RADS-Assessment-Categories.pdf

American Thyroid Association - Nodule Guidelineshttps://pmc.ncbi.nlm.nih.gov/articles/PMC4739132/

Bethesda System for Reporting Thyroid Ctyopathology https://www.ncbi.nlm.nih.gov/books/NBK278969/table/thyroid-nod-canc-eld.T.bethesda_system_f/

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BackTable ENT & Allergy is the go-to podcast for otolaryngologists, allergists, and head and neck surgeons.

Download the free BackTable app to get early access to new episodes, cases, and courses curated by physicians in your specialty.

► https://www.backtable.com/app

Not all chronic cough, globus, or voice changes are due to reflux, so how do you distinguish laryngopharyngeal symptoms (LPS) from true laryngopharyngeal reflux disease (LPRD)? In this episode of the BackTable ENT & Allergy podcast, Dr. Ashley Agan interviews laryngologist Dr. Inna Husain about how nuanced diagnostic definitions and a careful clinical approach can improve patient outcomes and avoid both under- and overdiagnosis. Together, they discuss the differences between GERD and LPRD, review the importance of detailed patient histories, endoscopic findings, and the evolving role of biomarkers like pepsin.

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Timestamps

00:00 - Introduction02:14 - LPS Versus LPR Basics06:34 - GERD Versus LPRD11:28 - Clinic Workup and Scoping18:02 - San Diego Consensus Debate24:14 - Testing Over Empiric PPIs31:45 - Managing Proven Reflux34:59 - Stroboscopy Before Surgery36:10 - Pepsin Therapies and Tests39:54 - What Counts as Abnormal Reflux44:24 - Tapering Off PPIs Safely50:12 - Long Term Plan and Dietitians55:39 - GLP One Drugs and Reflux57:34 - Menopause Rhinitis and Hormones01:00:09 - Final Pearl For ENTs

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More about this episode

They outline contemporary workup strategies, including the San Diego Consensus on Bravo testing, 24-hour pH impedance, and alternatives for negative reflux testing. The conversation covers management strategies, from selective PPIs and lifestyle tailoring to emerging therapies and the impact of GLP-1 drugs, helping ENT specialists refine their approach to complex laryngopharyngeal complaints.

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Resources

San Diego Consensus for LPS and LPRD:https://doi.org/10.14309/ajg.0000000000003482

Dr. Inna Husainhttps://innahusainmd.com/

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BackTable ENT & Allergy is the go-to podcast for otolaryngologists, allergists, and head and neck surgeons.

Download the free BackTable app to get early access to new episodes, cases, and courses curated by physicians in your specialty.

► https://www.backtable.com/app

With such a wide range of presentations and severity, how do laryngologists approach the diagnosis and treatment of unilateral vocal fold paralysis? In this episode of the BackTable ENT and Allergy Podcast, Dr. Rebecca Howell, Laryngologist at the University of Cincinnati, joins Dr. Stephen Schoeff to discuss the evaluation and management of unilateral vocal fold paralysis.

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Timestamps

00:00 - Introduction02:18 - Classic Symptoms of Vocal Fold Paralysis 04:15 - Etiology and Imaging Workup08:40 - Injection Timing and Materials23:20 - Permanent Options and Framework Surgery28:41 - Arytenoid Adduction Risks and When to Add Adduction30:56 - Awake Thyroplasty Technique compared to Sedation and OR Setup35:48 - Reinnervation and Bilateral Medialization Choices42:10 - Vocal Fold Long-term Injectables51:54 - Closing Remarks

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More about this episode

Dr. Howell reviews the spectrum of patient presentations and common causes, including thoracic surgery, ACDF, thyroid surgery, intubation injuries, and idiopathic cases. She explains when to pursue imaging from brainstem to chest, how to set realistic recovery expectations, and the benefits of early intervention. The episode covers office-based injection augmentation, the pros and cons of injectable materials, and treatment durability, as well as risks like calcium hydroxylapatite. Long-term care options are discussed, including framework surgery, arytenoid adduction, bilateral approaches for vocal fold atrophy, reinnervation, and patient selection considerations.

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Resources

Pathophysiology of Iatrogenic and idiopathic vocal fold paralysis may be distinct - Ted Mau: https://pubmed.ncbi.nlm.nih.gov/31498451/

Vocal Fold augmentation with injectable calcium hydroxylapatite - Clark Rosen: https://pubmed.ncbi.nlm.nih.gov/15331112/

Using High-Speed Videoendoscopy to Analyze Laryngeal closure parameters during normal swallow - Rebecca Howell: https://pubmed.ncbi.nlm.nih.gov/39659169/

Arytenoid abduction for bilateral vocal fold immobility - Gayle Woodson: https://pubmed.ncbi.nlm.nih.gov/22001662/

Laryngeal Reinnervation for Unilateral Vocal Fold Paralysis - Randal Paniello : https://profiles.wustl.edu/en/publications/laryngeal-reinnervation-for-unilateral-vocal-fold-paralysis/

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BackTable ENT & Allergy is the go-to podcast for otolaryngologists, allergists, and head and neck surgeons.

Download the free BackTable app to get early access to new episodes, cases, and courses curated by physicians in your specialty.

► https://www.backtable.com/app

Pediatric thyroid nodules are rare, but their risk of malignancy is significantly higher than in adults, raising the stakes for accurate diagnosis and multidisciplinary management. In this episode of the BackTable ENT Podcast Dr. Gopi Shah and co-host Dr. Jeff Hyzer interview Dr. Wen Jiang, pediatric otolaryngologist at Rady Children’s Hospital in San Diego, for an in-depth discussion on the evaluation and management of thyroid nodules in children.

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Timestamps

00:00 - Introduction 02:27 - Thyroid Nodule Risks and Care Team 06:47 - Age-related Differences in Nodule Presentation and Outcomes08:50 - Initial workup 13:42 - Ultrasound Interpretation16:07 - Lymph Node Mapping and CT19:58 - Incidental Findings24:14 - Role of FNA, Molecular Testing, and Radiofrequency Ablation32:40 - Molecular Testing Results and Counseling 38:04 - Neck Dissection Strategy40:44 - Hypocalcemia Protocol Considerations44:01 - Parathyroid and Recurrent Laryngeal Nerve Dissection Tips 47:33 - Postop Care and Follow-up 51:25 - Using Radioactive Iodine and Targeted Therapy 54:55 - AI’s and Ultrasound and Final Thoughts

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More about this episode

Dr. Jiang highlights the key differences between pediatric and adult thyroid nodules. She describes her multidisciplinary approach including collaboration with radiology, pathology, endocrinology and nuclear medicine. The discussion reviews the initial workup for pediatric thyroid nodules and why ultrasound remains the primary diagnostic tool. She also discusses situations where CT with contrast can be helpful for surgical planning. This episode explores the growing role of reflex molecular testing in guiding management decisions and outlines the impacts of molecular testing results. Dr. Jiang shares her approach to patient counseling along with management of calcium and PTH after surgery. The conversation concludes with emerging applications of molecular diagnostics and AI models for improving thyroid ultrasound interpretation.

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Resources

Dr. Jiang's Research on Pediatric Thyroid Nodule Management - https://pubmed.ncbi.nlm.nih.gov/26770219/

Bethesda System for Thyroid Cytopathology - https://pmc.ncbi.nlm.nih.gov/articles/PMC7182964/

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BackTable ENT & Allergy is the go-to podcast for otolaryngologists, allergists, and head and neck surgeons.

Download the free BackTable app to get early access to new episodes, cases, and courses curated by physicians in your specialty.

► https://www.backtable.com/app