Key points

Introduction

There is good evidence that patients with recalcitrant chronic rhinosinusitis (CRS) benefit from surgical therapy compared with medical therapy. Delaying surgical intervention not only affects symptomatology, but productivity as well. The costs associated with lost productivity for CRS patients can be substantial. Consequently, patients often seek immediate solutions whenever possible. For a number of reasons, including rapid return to work, avoidance of general anesthesia, decreased procedural costs, patient factors, or the simplicity of the procedure, patients or surgeons may prefer that procedures be performed in an office setting. There is no standard algorithm for determining whether a patient should be managed by an in-office procedure; therefore, a surgeon must provide an individualized approach to each patient based on their clinical presentation and objective findings. Depending on the presenting problem, surgeon skill set, and required equipment, many patients can successfully tolerate sinonasal surgery in the office setting under local anesthesia. A solid grasp of the complex sinonasal anatomy and its relationship to vital structures, in addition to an understanding of the pathophysiology of presenting symptoms, will allow the surgeon to choose the best surgical approach to address the problem. Most in-office procedures are first mastered in the operating room before the clinic setting, which results in a better patient experience. With time and experience, a competent and skilled surgeon is able to provide patients with outcomes in the clinic setting comparable with those of the operating room for specific procedures.

Introduction

There is good evidence that patients with recalcitrant chronic rhinosinusitis (CRS) benefit from surgical therapy compared with medical therapy. Delaying surgical intervention not only affects symptomatology, but productivity as well. The costs associated with lost productivity for CRS patients can be substantial. Consequently, patients often seek immediate solutions whenever possible. For a number of reasons, including rapid return to work, avoidance of general anesthesia, decreased procedural costs, patient factors, or the simplicity of the procedure, patients or surgeons may prefer that procedures be performed in an office setting. There is no standard algorithm for determining whether a patient should be managed by an in-office procedure; therefore, a surgeon must provide an individualized approach to each patient based on their clinical presentation and objective findings. Depending on the presenting problem, surgeon skill set, and required equipment, many patients can successfully tolerate sinonasal surgery in the office setting under local anesthesia. A solid grasp of the complex sinonasal anatomy and its relationship to vital structures, in addition to an understanding of the pathophysiology of presenting symptoms, will allow the surgeon to choose the best surgical approach to address the problem. Most in-office procedures are first mastered in the operating room before the clinic setting, which results in a better patient experience. With time and experience, a competent and skilled surgeon is able to provide patients with outcomes in the clinic setting comparable with those of the operating room for specific procedures.

Procedure room setup

The ability to perform any of the procedures described herein requires proper procedural setup. The surgeon should be able to perform the procedure comfortably and all assistants involved should be aware of their role in the procedure. Most surgical procedures are performed with the patient sitting semirecumbent in an examination chair. There must be room to place the chair supine in case the patient has a vasovagal attack from instrumenting the nasal cavity. For right-handed surgeons, the surgeon will be to the right of the patient, and the video tower should be ergonomically placed to the left of the patient for comfortable viewing over a prolonged period of time. The assistant is best placed wherever they can most easily provide equipment to the surgeon while closely monitoring the patient ( Fig. 1 ). The equipment needed on the assistant’s tray depends on the procedure, but in general it can include a straight and curved suction, straight and angled forceps (either cutting or noncutting), cotton pledgets, and additional topical and local anesthetic. We also have powered instrumentation available in the office for procedural use. The senior author routinely uses pediatric endoscopes in the office to allow for easy instrumentation in an awake patient. A 30° rigid endoscope allows appropriate visualization into all sinuses. A 0° can be used as well, but may not provide appropriate visualization into the frontal recess/sinus, anterior or far lateral portions of the maxillary sinus, or inferior portions of the sphenoid sinus. Additional equipment requirements are discussed with each procedure.

Office room setup for procedures.

In case of an emergency, the room should be set up to facilitate additional personnel. All individuals involved in the care of the patient should know the protocol if an emergency arises. The room should be equipped with a blood pressure machine and continuous oxygen saturation monitoring. An automated external defibrillator and oxygen tank should be located nearby in case of an emergency. As in any procedure room or operating suite, a “crash cart” with appropriate medication to run a code (ie, epinephrine, atropine) should be available.

Patient selection

Not all patients are comfortable undergoing procedures while awake, and it is important for the surgeon to gauge well in advance whether the patient is capable of tolerating the procedure. A thorough and honest discussion with the patient about the level of discomfort they may experience is paramount to selecting patients appropriately. If, despite your preoperative due diligence, it becomes apparent during a procedure that a patient cannot tolerate instrumentation regardless of a reasonable amount of local and/or regional anesthetic, the procedure can always be aborted and electively performed in the operating room at a later date. Procedures may be aborted owing to discomfort from poor access; therefore, it is important to recognize that simple and straightforward procedures performed in the operating room can become substantially more difficult in patients with a deviated septum or narrow nose. Consequently, in general, it is a contraindication to perform in-office procedures in patients who have demonstrated access issues on prior endoscopy. Other possible contraindications include allergy to local anesthetic, and if a patient has scarring from prior surgeries that does not allow for appropriate intranasal localization based on traditional endoscopic landmarks. Just as when operating in a traditional setting, after thorough discussion of the risks, benefits, and alternatives of a procedure, informed consent to perform the procedure should always be obtained.

Also, similarly to when proceeding with patients in the operating room, surgeons should ensure that patients are medically fit to undergo the procedure. Some comorbidities that would increase a patient’s cardiovascular risk were they to undergo the stress of general anesthesia may show these patients to be better suited for an office procedure instead. In contrast, coagulopathies can be a relative contraindication to operating in an office setting where controlling blood loss is not as simple as cauterization; generally, the pain associated with thermal cauterization would be too great in an awake patient. Those who are taking medications such as aspirin or clopidogrel should stop their medications 7 to 10 days before the procedure. However, if patients have a history of coronary artery bypass, guidelines indicate they should continue with at least aspirin without interruption. When taking patients off blood thinning agents, it is always prudent to discuss the potential cardiovascular risk of that action with their primary doctors or cardiologists. Nonsteroidal anti-inflammatory drugs should also be discontinued 7 days before the procedure. Regardless of whether the patient is inherently more likely to bleed or not, in any procedure where greater than minimal blood loss is expected, the controlled environment of the operating room is likely best to ensure control of the airway if compromise occurs.

Last, in our current health care system where insurance coverage is highly variable for particular procedures, and can differ depending on the location (operating room vs office) and the specific equipment or device being used, these logistical factors may sometimes also come into play in patient selection. If coverage is denied, like in any other circumstance where this happens, it then should lead to a conversation between the provider and patient based on the specific practice protocol that generally determines who would be responsible for the cost going uncovered by the insurance company. This is never a conversation that should be left for after the procedure is performed—cost should always be an upfront, completely transparent topic and the patient should never be left feeling surprised about this aspect of care.

Intranasal preparation

The anesthetic component is arguably the most critical component in doing in-office procedures successfully. The degree of anesthesia varies depending on the procedure, but having patience and properly anesthetizing the nasal cavity allows the surgeon to best perform the procedure in a comfortable and cooperative patient.

There are many techniques for anesthetizing the nose both topically and with local injections. Our technique is to initially decongest and topically anesthetize with 4% lidocaine and 1% phenylephrine, then place pledgets or cotton swabs soaked in lidocaine and phenylephrine at the surgical site intranasally at the onset of the patient encounter for at least 5 to 10 minutes to allow maximal time for anesthesia and decongestion before beginning any form of instrumentation. Topical application of lidocaine and epinephrine allow for better visualization and, equally important, decongestion decreases inadvertent mucosal trauma and bleeding because there is more room for instrumentation. There are other topical agents available such as 4% cocaine and tetracaine. Cocaine was commonly used in the past because it acted as a topical anesthetic and vasoconstrictor simultaneously but a number of surgeons have strayed away from it owing to adverse cardiac effects such as severe bradycardia and ventricular ectopy. If cocaine is to be used, it is important to obtain a cardiac history before use. Tetracaine is a common alternative to lidocaine. Tetracaine acts longer and in combination with a vasoconstrictor provides comparable results to our use of lidocaine and phenylephrine. Areas of expected dissection can be further injected with 1% lidocaine and 1:100,000 epinephrine. Injection is optimally performed slowly with a small needle (≤25 gauge). It is important to consider injecting areas that the scope or instruments may touch along the nasal cavity (ie, lateral nasal wall if performing a septoplasty with sharp spur) to limit patient discomfort owing to instrumentation. As always, one must withdraw before injection to prevent intravascular injection of local anesthetic.

If intravenous sedation is required to perform the procedure, appropriate staff and monitoring equipment are necessary in the office. Owing to limitations in monitoring after sedation, we prefer to perform only procedures requiring topical or injection anesthetic in our office setting.

Office-based polypectomy

Procedure

Before and after surgical treatment, surgeons should also provide medical management of CRS with nasal polyps. Although this is not within the scope of this article, the longevity of success of office-based polypectomy depends on medical management.

Appropriate equipment is required to perform this procedure successfully in the office. The most common instrument used to remove polyps is the microdebrider. The ability to simultaneously suction and sharply cut polyps has revolutionized the treatment of CRS. Electrically powered microdebriders frequently used in the operating rooms are commonly used in the clinic setting as well ( Fig. 2 ), but other mechanical and suction-powered options have recently been made available and can be also be used with high efficacy ( Fig. 3 ). The use of coblation to remove nasal polyps has shown some promising results with respect to mucosal healing and decreased blood loss in human subjects, but has not been as adopted widely.

Electrically powered microdebrider.

( Courtesy of Medtronic, Minneapolis, MN; with permission. © Medtronic, Inc.)

Suction-powered microdebrider.

( Courtesy of Laurimed, Redwood City, CA; with permission.)

The intranasal preparation has been mentioned and the surgical technique is similar to the approach in the operating room, except that the patient is sitting in a relatively upright chair, awake with local anesthesia alone. Hemostasis is improved through the avoidance of general anesthetics that cause vasodilation and the position of the head being elevated. Isolated polyps can be addressed with through-cutting instruments, but extensive polyps are addressed with powered instrumentation. Polyps are removed in an anterior to posterior and inferior to superior fashion. Removal of pedunculated nasal polyps should have minimal bleeding and cause minimal discomfort to patients. If bleeding does occur or the patient experiences discomfort, the use of pledgets soaked in 1% lidocaine with 1:1000 epinephrine will help with both visualization and pain control. The ethmoid and sphenoid sinuses are best addressed with straight instruments, and the maxillary and frontal sinuses with curved instruments.