Patients who have an isolated deviated nasal septum can be addressed in the office setting through various techniques. A targeted septoplasty can be performed under local anesthesia. A mucoperichondrial flap is elevated under endoscopic visualization directly overlying the spur to remove the deviated cartilage. Dissolvable nasal packing is placed adjacent to the elevated flap to minimize the risk of postoperative septal hematoma. Posterior bony deviations or spurs off the maxillary crest are less amenable to office-based procedures. In-office balloon septoplasty has been proposed, in which a balloon is inflated on each side of the nasal cavity sequentially to straighten deviated portions of cartilage, although the outcomes of this procedure have not been validated in the literature. When performed for nasal obstruction, septoplasty is often accompanied by inferior turbinate reduction, which can be accomplished with submucous resection or radiofrequency ablation in the office setting.

Removing nasal cavity polyps is easily performed in the office using a microdebrider ( Fig. 14.1 ). For patients who have had previous sinus surgery with large antrostomies, an in-office nasal polypectomy has the potential to improve symptoms and restore delivery of topical irrigation and medication to the sinuses. For those who have not had prior sinus surgery, a nasal polypectomy is unlikely to fully address their sinonasal disease. However, patients who have a contraindication to general anesthesia or refuse surgery in the operating room can be treated in this modality.

(A) Coronal CT scan of a patient with right nasal cavity polyposis. (B) In-office polypectomy with microdebrider. (C) Immediate postoperative right nasal endoscopy.

The maxillary sinus is the safest to access in the office setting and is therefore done so routinely ( Fig. 14.2 ). Indications for office-based maxillary antrostomy include chronic maxillary sinusitis or maxillary sinus recirculation. Recirculation occurs when two or more entrances to the sinus exist, allowing for the circular flow of mucus around a bridging connection of tissue. This phenomenon occurs if a maxillary antrostomy is not connected with the natural ostium or if there is scarring after surgery, resulting in mucus stasis and infection. This can even occur around an intact inferior turbinate when both middle meatal and inferior meatal antrostomies exist. These patients can be easily managed in the office setting without requiring a return trip to the operating room. Straight-through cutting instruments or a backbiter is used to divide the bridge of tissue and remove any residual uncinate process and even portions of the inferior turbinate to promote unidirectional sinus drainage.

(A) Patient with recurrent allergic fungal rhinosinusitis and nasal polyps undergoing in-office revision left maxillary antrostomy. (B) Postoperative outcome at 1 month.

Balloon sinuplasty may be used to enlarge the maxillary sinus outflow tract. This is more likely to be successful in patients with mild to moderate disease and should not be used for those with extensive polyps or severely inflamed mucosa.

While the ethmoid sinuses are commonly involved in chronic sinusitis, they are the least amenable to primary office-based surgery. This is because of the many bony partitions that make up the ethmoid cavity. Preoperative CT scans must be obtained to determine if significant bony partitions remain, which may be more easily managed in the operating room. When an ethmoidectomy is performed in the office, a microdebrider is used to remove polypoid disease. Through-cutting instruments, including Kerrison rongeurs and a straight Hosemann punch, can be used to remove bony partitions. Sequential application of additional local anesthetics must be performed as one progresses posteriorly within the ethmoid cavity. Removal of bone and skeletonization of the skull base and lamina papyracea in the office setting are challenging and associated with a higher risk. The use of image navigation should be considered when working in this region.

Patients who have had prior ethmoidectomy but develop recurrent nasal polyposis within the ethmoids are ideal candidates for in-office surgery, especially in situations in which general anesthesia carries elevated risks, such as in patients with cystic fibrosis.

The posterior location of the sphenoid sinus and its proximity to critical neurovascular structures make it less routinely instrumented in the office setting, but this is not a contraindication if the surgeon and patient feel comfortable.

The sphenoid sinus is most easily accessed via a transnasal route by lateralizing the middle and superior turbinates to visualize the face of the sphenoid sinus using a 0-degree rigid endoscope. Reliable landmarks make sphenoid work possible in the office setting. In individuals who have had a prior total ethmoidectomy, the sphenoid sinus can also be accessed in a transethmoid fashion, working lateral to the head of the middle turbinate. Patients who have had a prior sphenoidotomy but develop recurrent inflammatory disease obstructing outflow from the sinus are ideal candidates for an office-based procedure because limited bone removal is needed.

The sphenoid ostium is localized using a combination of landmarks, including the height of the roof of the maxillary sinus, medial to the superior turbinate, and approximately 1.5 cm superior to the roof of the choana. Image navigation may also be used for confirmation. When performing sphenoid sinus work, the preoperative CT scan must be carefully reviewed to determine the presence of sphenoethmoidal cells or bony dehiscence along the carotid or optic canals. Care should be taken to prevent injury to the posterior septal branch of the sphenopalatine artery along the face of the sphenoid sinus inferior to the sphenoid ostium. The sphenoidotomy should be enlarged medially, laterally, and superiorly more than in an inferior direction to prevent injury to this vessel.