The decision regarding placement in the office versus in the operating room with a brief general anesthesia is largely determined by the patient. Generally, smaller prostheses are easily placed at the office, but a very anxious and apprehensive patient is allowed the option of a brief procedure in the operating room. I prefer to do procedures in the operating room for patients who have a very large perforation (Fig. 5.1) with prostheses that will entail significant manipulation to pass through a small nostril or if there will be opening of adhesions (Fig. 5.2) or a bony capsule (Fig. 5.3) in order to expose some of the margins of the perforation. A general anesthetic also makes it much easier to remove and replace a large prosthesis for trimming, though 3D sizing has markedly reduced the need for any adjustment in the size of the flanges at the time of placement.

In the office, anesthesia is provided with 0.5% phenylephrine mixed with 4% lidocaine as a spray and then applied to the mucosa with pledgets. If this does not provide adequate anesthesia, I use pledgets to apply 4% cocaine solution to the margins of the perforation. In the operating room, appropriate briefing, patient identification, patient consent, and protocol are followed for rhinologic procedures under general anesthesia. Oxymetazoline spray is used for decongestion of the tissues. Injection of the margins of the perforation that could cause bleeding is not necessary and is avoided. If crusting or dried blood is present on the margins of the perforation, cleaning is done using small pledgets with 1:2,000 epinephrine solution, which also provides further vasoconstriction. Pledgets can also be soaked in gentamicin or other antibiotic solution and used to clean the intranasal surfaces. Nasal irrigation with an antibiotic solution can also be done by the patient prior to an office placement or by the surgeon when the patient is under general anesthesia with a protected airway.