The number and type of in-office rhinology procedures continue to grow and expand, with more otolaryngologists incorporating these procedures into their practices. Technological advances, availability of local and topical anesthetics, good outcomes in terms of efficacy and safety, physician familiarity and comfort with doing the procedures on an awake patient, improved patient experience and reduced cost, and a general trend in medicine toward patient-centered care all contribute to this growth.
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September 2025In a 2016 survey of American Rhinologic Society (ARS) members on practice patterns regarding office-based rhinology procedures, 63% of the respondents reported an increase in the number of office-based procedures they performed over the last five years. Published in 2019, the survey found that sinonasal debridement was the most commonly performed procedure (99%), followed by polypectomy (77%) and balloon sinus ostial dilation (56%). Some members also reported performing more complex procedures, including ethmoidectomies (35%), antrostomies (31%), sphenoidotomies (24%), frontal sinusotomies without the balloon (21%), and steroid-eluting sinus implants (30%) (Am J Rhinol Allergy. doi:10.1177/1945892418804904).
Since that survey, the list of new procedures introduced into and more widely used in the office setting has grown to include Eustachian tube balloon dilation, radiofrequency of the posterior nasal nerve, cryoablation of the posterior nasal nerve, radiofrequency nasal valve remodeling, and nasal valve implantation, according to Jivianne T. Lee, MD, professor of rhinology and endoscopic skull base surgery in the department of head and neck surgery at the University of California, Los Angeles (UCLA) and the ARS vice president who led the 2019 survey. The biggest advances, she said, are in the arena of chronic rhinitis, where new technologies and devices, such as temperature-controlled radiofrequency ablation and cryoablation, permit in-office treatment.
Patient selection is critical. Those who have a lower pain tolerance and/or have anxiety with medical procedures would not be ideal candidates and would probably be best served by undergoing general anesthesia. —Jivianne T. Lee, MD
“There is no question that the office armamentarium has expanded considerably since 2019,” she said. “It is so incredible how there’s been a renaissance of technology and advances where we can treat some of these conditions in the office setting.”
She added that in-office procedures have become so common that the Centers for Medicare and Medicaid Services (CMS) has assigned specific procedure codes over the past couple of years.
A more recent survey published in 2024 adds further data on the growth of in-office rhinology procedures internationally (Surgeries. doi.org/10.3390/surgeries5020039). Conducted by collaborators in the Rhinology section of the Young Otolaryngologists of International Federation of Oto-rhino-laryngological Societies (YO-IFOS), the survey showed that among 172 otolaryngologists from 26 countries who responded, the list of in-office rhinology procedures ranged from the simpler, more commonly performed procedures, like polypectomy and turbinate reduction/turbinectomy, to increasingly more complex and less commonly performed procedures like Eustachian tuboplasty, septoplasty/caudal deviation, sphenoidotomy, and frontal sinus surgery.
Advantages and Risks
The shift to performing more rhinology procedures in office versus in an operating room is driven by a number of advantages, but surgeons and patients need to be aware of potential risks. Respondents in the 2024 survey listed the key reasons to consider when deciding whether to do a procedure in the office (Table 1).
David W. Jang, MD, associate professor and division chief of rhinology and endoscopic skull base surgery at Duke University in Durham, N.C., underscored the benefits for patients—avoiding the risks of general anesthesia and reducing out-of-pocket expenses—and for practitioners—having a flexible operating schedule versus having to rely on a hospital or surgery center’s schedule.
He emphasized, however, that longer and more complex surgeries, like frontal sinusotomy, are better done under general anesthesia in the operating room to maintain safety and ensure optimal outcomes.
If an in-office procedure is considered, he said he ensures that an emergency plan is in place in case of complications. “For example, staff will have equipment and supplies ready in case of severe bleeding, and there will also be a protocol to call EMS and transport patients to a nearby hospital that is equipped to handle ENT emergencies,” he said.
In addition, he emphasized the need to assess bleeding risk when considering an in-office procedure. “Bleeding can be difficult to manage in the office, especially in an awake patient,” he said, adding that patients with poor lung function are also at high risk because bleeding can lead to aspiration.
Noting that bleeding is always a risk with sinus surgery, William C. Yao, MD, associate professor, chief of rhinology and anterior skull base surgery, and residency program director of the department of otorhinolaryngology–head and neck surgery at UT Health Houston–McGovern Medical School, pointed out that the risk of bleeding is actually lower without the use of general anesthesia. “With the use of local anesthesia, we are able to avoid one side effect of general inhalational anesthesia, which is vasodilation leading to increased bleeding,” he said. He said he has cautery devices in the office in case of bleeding.
Dr. Lee underscored a key advantage of in-office procedures: reduced recovery time for the patient. “For most of these cases, patients only have to take the day off for the procedure and no additional time,” she said. “It is becoming similar to going to the dentist, where you receive a shot of local anesthesia, have the procedure done, and resume your normal activities by the next day.”
For Dr. Lee, the main risk is patient discomfort. “Patient selection is critical. Those who have a lower pain tolerance and/or have anxiety with medical procedures would not be ideal candidates and would probably be best served by undergoing general anesthesia,” she said.
Patient Selection, Anesthetic Use, Managing Awake Patients
Although the type of procedure largely determines suitability for the in-office setting, patient selection is a close second. Edward D. McCoul, MD, MPH, the director of rhinology and sinus surgery in the department of otorhinolaryngology at Ochsner Health System in New Orleans, said a key criterion he uses for patient eligibility is how well a patient tolerates diagnostic nasal endoscopy. “If a patient is wincing or grimacing or has a vasovagal reaction during a basic 30-second endoscopy, that patient is probably not a good candidate for an in-office procedure,” he said.
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He counsels patients he thinks can tolerate a procedure while awake by using the analogy of going to the dentist. He tells them, “Imagine you’re going to the dentist to get a tooth filled. The procedure will be something like that, where you’ll be given an anesthetic to numb you, and then you’ll feel awkward manipulations in your nose for a few moments.”
That said, he doesn’t give many medications. Although in the past he’s provided a narcotic or benzodiazepine, he no longer gives any systemic medicine. “I know I may get some pushback from my colleagues, but I’ve come to the point where I can do what I do and the patient is reasonably comfortable while I’m doing it, and afterwards there is no pain a Tylenol can’t handle,” he said.
He routinely gives a topical anesthetic or spray in the nose, and in some cases uses a liquid injection, for example, for a turbinate or nasal valve procedure. But for other procedures like nerve ablations or sinus or Eustachian balloons, he doesn’t use an injection. “I have a needle and local ready, but hardly ever use it because most patients are sufficiently numb with a topical,” he said.
For a routine endoscopic examination, however, he has stopped using a topical spray, such as lidocaine and a decongestant, after hearing that colleagues had stopped their use with good results. “I’ve gained skill but also an appreciation of how to maneuver things and conduct examinations so I don’t cause unnecessary discomfort,” he said, adding that nine out of 10 people say the procedure only feels funny but doesn’t hurt.
Dr. Yao also uses routine nasal endoscopy as the guide to determine which patients are good candidates for in-office procedures. For patients who get overexcited or can’t stay steady during an endoscopy exam, he’ll recommend against doing a procedure in the office. He says only about one in 10 to 15 patients fit this description.
Like Dr. McCoul, he doesn’t use any sedation. He typically only uses a 6% tetracaine applied to a cotton ball and inserted into the nose. To ensure it coats the entire area, he leaves it in the nose for about 20 minutes or until the entire nose is numb. He then injects lidocaine. “Then I can pretty much do an entire sinus surgery without them feeling anything,” he said, reiterating that sedation is not important for most patients. For patients who have some anxiety, he’ll sometimes use a short-term benzodiazepine like Ativan to take the edge off. The disadvantage to that, he said, is that it then requires the patient to have a ride home.
Dr. Yao advises surgeons to be cautious of local anesthetic toxicity. While he acknowledges that tetracaine is effective, he points out that there is a limit to how much it can be safely administered to patients. Exceeding this limit can result in a serious condition known as local anesthetic toxicity, which may cause events such as seizures and cardiac arrhythmias.
He noted that early signs of toxicity include ringing in the ears, a clammy sensation, and nausea. “When you observe these symptoms, that is a warning sign indicating the need to stop the procedure,” he said.
To avoid this, he said it’s important to know a patient’s weight and make sure to calculate the dose in advance, as concentration and local anesthesia preparations differ depending on where it is sourced. On the other hand, he said it is difficult to know how much of the topical anesthetic is being absorbed intranasally. “How much is being absorbed in the body becomes a bit of a black box,” he said, “so we have to be aware of the first signs of local anesthetic toxicity.”
For Dr. Lee, the ideal candidate has a high pain tolerance and is highly motivated to avoid general anesthesia. “That is when all the stars align,” she said. She also does not premedicate her patients with any type of sedation and just uses a local and topical anesthetic. “That is why recovery is so quick,” she said. “The patient usually can drive to and from the procedure just like going to the dentist.”
Tips for Surgeons Considering In-Office Procedures
Dr. McCoul emphasized that operating on an awake patient requires some nuance that only experience can provide. Typically, he said, surgeons become familiar with the devices and instruments for procedures, use them first in procedures done in the lower-stress setting of the operating room, and then, only after becoming proficient with the procedure, move it into the in-office setting.
The nuance of in-office procedures involves commitment to patient comfort and knowing how to maintain it while doing manipulations in the nose, he said, noting that it’s wrong to assume that patients will find this too uncomfortable. “It is possible to make a person comfortable even if you’re sticking things into their nose, as long as you avoid unnecessary contact with the walls of the nose and don’t apply unnecessary force, and also be mindful that the nose is still attached to a person,” he said.
Dr. Lee emphasized the need to calm the patient as much as possible. She usually plays background music and gives the patient their own handheld suction so that they can suction their mouth as needed during the procedure. This helps give patients a sense of control and something to do. “Anything to take their mind off of what you’re doing,” she said. She also said surgeons new to this may be pleasantly surprised by the value patients place on being given the option of an in-office procedure. Reflecting on her own initial reluctance over a decade ago when she first performed these procedures, she recalled concerns about complications like bleeding. She said overcoming that initial reluctance is the hardest part, but once you become comfortable and familiar with in-office procedures, they can be a great option for both your practice and your patients.
Dr. Yao underscored the learning curve to performing in-office procedures that require using a shared decision-making model. “Taking an extra few minutes talking to a patient and presenting options and then talking about the advantages of in-office procedures, which for the patient include reduced direct costs such as for anesthesia and facility fees, is valuable,” he said.
On a more practical note, Dr. Jang encouraged otolaryngologists to have a business plan that accounts for capital costs, disposables, and time, as well as a safety plan in case of complications. He also emphasized establishing a safe and effective anesthetic protocol, which can often be tailored to the procedure and the patient. “Anesthetic protocols can vary anywhere from topical anesthetic only, all the way to having an anesthesiologist administer general anesthesia in your office,” he said. “The protocol will depend on the patient, the doctor’s comfort level, and the extent of the procedure.”
“Educate yourself by attending courses, and speaking to and observing colleagues,” he added.
The Future of In-Office Procedures
All the surgeons agreed that in-office rhinology procedures will continue to grow over the next decade, both because of technological advances and the shifting economics of healthcare. “I think there is plenty of interest in this,” Dr. McCoul said. “We’ll see treatments that can be applied in-office, such as the application of a dissolvable apparatus that may have a medicine on it, such as an antibacterial agent, which may provide a benefit to people with sinus and nasal problems.”
He also noted that there is less incentive to do procedures in the operating room if they can be done in the office setting, given the economics of healthcare in the U.S. and worldwide.
Dr. Jang thinks in-office procedures will become more common as payers realize this approach is more cost-friendly, but he emphasized that outcomes for office procedures and new technologies need to be carefully assessed.
Dr. Yao agrees that more in-office procedures will be done in the future as people become increasingly familiar with them and as technology improves. He thinks the big battle will be reimbursement from insurance companies. “The challenge is the associated cost that comes with new technologies, and, in general, insurance coverage lags behind the development of new devices/materials,” he said. “Therefore, one will also have to be fiscally responsible.” Simply put, “having insurance coverage helps deliver care to a wider patient base,” he said.
Mary Beth Nierengarten is a freelance medical writer based in Minnesota.
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