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.”
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September 2025That 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 afterward 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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