Proper room setup and equipment must be in place for a successful in-office procedure. When selecting a room, one must consider the space and layout of the room. Ensuring that the patient, surgeon, assistants, and any equipment in the room can be comfortably accommodated is crucial. Ideally, a designated procedure room in the office may be beneficial as it can be systematically organized for routine surgeries with necessary instruments readily available. To maximize efficiency, physicians may have separate patient preparation rooms where a patient will be given preliminary anesthesia and anxiolytics before being transferred to the procedure room when ready.

The necessary equipment required for each procedure will vary; however, an otolaryngology procedure room, at the least, must consist of a procedure chair, video tower, camera, nasal endoscope, Mayo instrument stand, and a strong suction apparatus.

Basic necessities include towels, gloves, paper towels, gauze, irrigation basins, and a sharps container. Instrument sets may vary depending on the procedure, but commonly used instruments include nasal speculums, nasal suctions, bayoneted forceps, Alligator forceps, Blakesley forceps, Thru-cutting forceps, and Cottle or Freer elevators ( Fig. 2.1 ). Cotton pledges or cotton balls for administration of topical medications can be helpful.

Common instruments needed during in-office procedures including forceps, elevators, curette, probe, and Hosemann punch.

Finally, medications are always necessary for a procedure and complication preparedness. Items such as saline, local anesthetics, decongestants, analgesics, hemostatic agents, emergency medications, and other procedure-specific medications must be prepared before surgery.

To standardize the setup protocol, a procedure-specific preparation checklist for office-based surgery can be of great benefit. Using such checklists has shown decreased surgical complications. Last, in the case of unplanned circumstances, it is valuable to have all instruments and medications readily available to address unexpected adverse events.

Physicians must have an appropriate room arrangement as this can dictate the comfort level of the surgeon, patient, and other assistants. An adjustable procedure chair adds to patient comfort and can facilitate access for the surgeon. Before beginning a procedure, it is vital that patients are satisfied with their position, as this will enhance their experience. The degree of chair recline will depend on the procedure being done; however, ideally, a position that minimizes postnasal drainage of fluids is advantageous. Be mindful to keep the patient in the most neutral and naturally aligned position possible to prevent musculoskeletal discomfort or injury.

An in-office procedure room layout should mimic an operating room with the video screen directly in front of the surgeon and instruments within easy reach. The video tower should be on the side of the procedure chair opposite to the surgeon ( Fig. 2.2 ). The instrument tray should be adjacent to the surgeon or next to the assistant if one is present. Similar to a scrub technician in the operating room, having a trained assistant to coordinate instruments during procedures may be helpful as this can decrease procedure duration.

Example of an in-office procedure room layout. Adjustable procedure chair with a recommended video monitor location.

Although many modifications are in place to reduce pain and discomfort for the patient, the surgeon should not suffer. Studies have shown that 86.9% of endoscopic abdominal surgeons have experienced physical discomfort related directly to the surgery. With continuous standing during surgeries, studies show that using a gel mat to stand on is highly beneficial to reduce discomfort and preserve energy levels. The use of proper ergonomics is vital to maintain endurance and reduce strain during surgery performance.

Similar to other endoscopic procedures, the dissociation of the visual and motor axes produces physical strain on the surgeon. Therefore, proper positioning of the video tower and the height of the procedure chair can reduce fatigue. Some studies recommend adjusting the video monitor to a height between 15 and 45 degrees below eye level to minimize musculoskeletal fatigue from head flexion and extension and limiting the rotation arc of the surgeon’s head to less than 15 degrees.

Another tool that is popular in otolaryngology is the surgical headlight with loupes. Although most in-office procedures are short, the surgeon should consider limiting time with a headlight as this may produce excess strain. Overall, practicing proper ergonomics during surgery can help enhance the surgeon’s experience.

Proper patient evaluation and selection are essential factors that can dictate the success and experience of an in-office procedure. Diseases that bring a complex or severe pathology are challenging to manage and carry a higher risk of complications in the office. Office surgeries that are longer in duration have been correlated with a higher incidence of postoperative complications and unplanned hospital admissions. Therefore, carefully selecting patients for candidacy for an in-office procedure is critical to success.

A patient’s age, comorbidities, and disabilities must be appropriately assessed before electing for an in-office surgery. For example, pediatric patients or patients with developmental delays may be more appropriate for the operating room because of difficulties with compliance. Similarly, alongside a proper physical exam, it is crucial to review a patient’s past medical history for allergies, vagal reactions, bleeding disorders, and medications to ensure an in-office procedure is suitable.

Patient counseling and education are vital to setting expectations and visualizing the proposed procedure. Discuss anticipated pain, sensations, discomfort, and outcomes related to the surgery as many of these are inevitable. This conversation will provide appropriate insight into the patient’s willingness and tolerability to the in-office procedure.

Finally, a patient’s personality must be evaluated to ensure they have the most comfortable and painless experience possible. Overly anxious or pain-sensitive patients may not have a good outcome or experience under local anesthesia, so a procedure in the operating room with general anesthesia may be preferable. Careful evaluation of the patient’s tolerance for office examinations and endoscopy can be helpful in guiding selection. This survey is vital to the preoperative checklist for an in-office procedure.

One of the least invasive methods to minimize anxiety and pain is to ensure the patient is in a comfortable position. Survey the patient before beginning the surgery to ensure they are comfortable in the procedure chair. Be sure to ask the patient if they need to use the restroom before initiating the procedure as this may increase anxiety and distress during the procedure. Furthermore, drape the patient, if necessary, to prevent fluids, blood, or instruments from touching the patient’s skin in unwanted areas to avoid unnecessary distress.

To reduce patient anxiety during a procedure, studies have shown that environmental modifications can serve as a great way to create a patient-centered environment. This can begin with a holistic approach by creating a relaxing ambiance in the room. Managing factors such as noise, lighting, and smell can influence the experience. Fluorescent lights have been shown to cause discomfort in patients with anxiety, and dimming the lights may help with their comfort.

Aromatherapy has an emerging popularity in reducing preoperative patient anxiety and stress levels. More than 25 essential oils have been identified to have antianxiolytic effects. Among these, lavender oil is the most widely studied. Lavender oil can be administered via inhalation, oral, and skin applications to increase positive feelings for patients and decrease anxiety. One study measured patient anxiety levels before and after the use of periprocedural aromatherapy and anxiety levels had dropped by about 24% compared to control patients. Incorporating therapy candles and aroma diffusers may magnify a positive patient experience.

Music therapy is widely used to improve emotional well-being. One study regarding minor oral surgeries examined the effect of music on patient anxiety. For example, 92% of their patients reported that music reduced their anxiety levels, and, for some, even pain and overall heart rate levels decreased. And 90% of these patients stated they would like music playing during their next visit. In addition, much of the equipment used during a procedure often creates unpleasant noise, which may heighten anxiety and pain responses during a patient’s surgery and can be masked by the use of music. Multiple studies have shown similar positive effects with music during awake procedures, and the use of music may promote a positive patient experience. ^,

Similar to noise during surgery, a surgeon’s bright headlight may intensify patient anxiety and discomfort levels during the procedure. Blocking this external stimulus with an eye mask can induce patient relaxation. Studies have shown that using an eye mask reduces the requirement and dosing for sedatives, such as midazolam, during anesthesia. With the headlight being an otolaryngologist’s essential tool, this addition can create a more relaxing environment.

When pharmacologically managing anxiety, benzodiazepines can typically be used. Short-acting medications such as lorazepam at 1 to 2 mg given roughly 1 hour before the procedure can be a great choice to reduce patient anxiety. However, it is essential to remember that benzodiazepines take time to metabolize. The patient should be cautioned against operating motor vehicles or heavy equipment until the medication has cleared their system. Studies have shown impairment in reaction skills at 12 hours after administering lorazepam. Recent studies also show that the endogenous hormone melatonin can have a similar effect with fewer side effects. It has been suggested that 0.4 mg/kg of melatonin provides reasonable anxiolysis compared with midazolam without the impairment of cognitive and psychomotor function experienced with benzodiazepines. This alternative may serve as a great choice to relieve patient anxiety. However, as with any medication, dosage and its use should be evaluated in a case-specific manner to ensure best practices.