Patient selection is the most important consideration of in-office polypectomy. There are some patients who simply will not be able to tolerate an awake procedure, and it is important to be able to screen for this to save both the patient and the physician time. Shared decision-making is crucial, and the physician should have an honest conversation with every patient they are considering for polypectomy. Every patient should be walked through the benefits and risks of the procedure and exactly what they will experience while staying awake. While polyps themselves are essentially insensate, patients must be able to tolerate manipulation of multiple instruments in the nose for an extended period of time, which can cause mild discomfort even after adequate topical anesthesia.

The best way to screen potential candidates at the initial visit is usually with a rigid nasal endoscopy. If patients are unable to tolerate an endoscopy or unable to tolerate aerosolized oxymetazoline/lidocaine, then the decision can quickly be made that they should not undergo in-office polypectomy. If the patient can tolerate rigid nasal endoscopy, the next step is to ask how well patients do with similar awake, in-office invasive procedures. Most will be able to endorse if they can tolerate an awake procedure under local anesthesia, using their dental experiences as a reference.

The patient should understand that in-office procedures are still governed by cost and fee structures, which may be similar or different from those performed in an operating room setting, and that the patient’s individual expenses may be dictated by individual plan benefits and contracts with third-party payers. A decision regarding whether the patient wishes to proceed with the in-office procedure should be made before the scheduled in-office polypectomy, to minimize the risk of unexpected cancellations and poor clinic efficiency. This will also give patients ample time to think about whether they would like to proceed with considerations of not only cost but also the recovery and work or activity limitations afterward.

Patient anatomy and past medical history are also key factors in selection. If the patient has a deviated septum or turbinate hypertrophy, it can become increasingly difficult to introduce instruments without causing trauma to the surrounding tissue. If there is significant scarring, a deviated septum, or other factors that prevent access, then strong consideration should be made to take the patient to the operating room. An up-to-date computed tomography scan is critical for these patients as a majority of them have undergone endoscopic sinus surgery in the past and may have anatomic variations that could decrease appropriate visualization. Last, contraindications to in-office polypectomy, such as a dehiscent lamina papyracea or low-lying anterior ethmoid artery polypoid disease, will make identifying these features almost impossible without imaging.

When evaluating past medical history, a focus should be made on factors that would cause undue risk to the patient while in the office. A history of significant lung or cardiac disease could potentially push the provider to an in-office procedure due to the stress placed on the body during a general anesthetic. However, if that same patient is on anticoagulation or has a coagulation disorder that could be considered to be a contraindication to an in-office approach, it can be difficult to adequately control significant nasal epistaxis in the clinic setting and could possibly lead to an emergent operation or an unintended hospital admission. Conversely, some anticoagulated patients may be better suited for a procedure done under local anesthetic, avoiding the vasodilatory effects of inhalational and other anesthetics. If the decision is made to proceed with in-office polypectomy on a patient on anticoagulation, there should be a discussion with the prescribing physician on an appropriate timeline for discontinuing and restarting the medication following the procedure. The patient should also be informed of the increased risk of bleeding.

A significant amount of clinic space and equipment is required to ensure that in-office nasal polypectomy can be properly performed ( Figs. 16.1– 16.4 ). A private space should be used that allows the provider maneuverability and room for all required equipment. This is commonly done in a procedure room that is larger than standard clinic rooms and contains materials commonly used for the procedures. This includes instruments such as straight and up through-cutting forceps, a Freer elevator, suctions (both straight and curved), straight and up grasping forceps, the backbiter, curved frontal instrumentation, curved probes, and curved curettes. A vacuum debrider is a mainstay instrument for this procedure and allows for fast and efficient removal of most polyps. Straight and curved blades should be available depending on the location and size of nasal polyps. Multiple different angled endoscopes should be available. At minimum, the 0-, 30-, and 70-degree endoscopes should be available for use in the clinic if needed. One of the most commonly used is the Microdebrider (Medtronic, Minneapolis, MN). The PolypVac (Laurimed, Redwood City, CA) is no longer in production but if available can also be used for polyp removal. The authors’ preference for polyp removal is to begin with the 30-degree endoscope and the 40-degree microdebrider blade and then switch between the other listed instruments if needed.

Patient positioning and room setup are key to ensuring that the patient and surgeon are comfortable throughout the entire procedure. Patients are often slightly reclined both for their benefit and to make endoscopy easier to perform. Suction canisters, the video endoscopy tower with accompanying light source, and rigid instrumentation should be easily accessible for the surgeon. Asking patients if they would like to be blindfolded or if they would like to listen to music during the procedure is a small act that can do wonders for patient anxiety. Additionally, a preprocedural dose of lorazepam can also be given; however, patients anxious enough to require this to tolerate the in-office procedure should also be considered for management in the operating room under systemic anesthesia. The use of a preprocedural anxiolytic should be discussed with the patient prior to the date of the procedure as this would require an additional person to aid the patient in returning home.

Some providers use in-office navigation systems. More recently, these have been both more accessible and more feasible as the equipment has decreased in size, making it less burdensome to use in a clinic setting. While not in use at the authors’ institution, this certainly could allow a more efficient completion of a polypectomy and provide a further level of safety in knowing where the lamina and skull base are in patients with extensive polyposis. Several manufacturers sell navigated systems that are designed to be stored in a single cart that can be easily positioned around your other equipment.

Beyond equipment synergy, a well-trained support staff in the office is a tremendous asset in ensuring that procedures are run efficiently, especially during routine nonprocedure clinical visits. Exceptional staff will assist with patient positioning, getting the equipment and room appropriately set up, and start the anesthetic process by placing medicated nasal pledgets or atomized spray. A baseline understanding of the steps of the procedure and what the patients should expect to see and hear also allows them to talk with the patient prior to the procedure and help allay expected anxiety.