Patients themselves may have strong preferences about avoiding general anes­thesia and prefer to have their sinus procedure performed in the ofce setting. Conversely, others may express signicant anxiety about pain or awareness during an ofce-based procedure and request “to be knocked out.” Those who self-report difculty tolerating dental procedures or who have not had success with local anes­thetic in the past may be poor candidates for in-ofce procedures. However, patients who express concern about anxiety or pain during the procedure can be reassured that the procedural pre-medication regimen adequately addresses anxiety concerns and the local anesthetic protocol will assure that they will have minimal pain or discomfort during the procedure. Some patients may express that they “want to be knocked out” for their procedure. It is reasonable to clarify that desire with the patient, as they typically are not requesting general anesthesia, but instead are expressing their wish to manage pain and anxiety during their procedure. Setting appropriate and realistic expectations with patients prior to the procedure is critical. Patients should be counseled that they will feel pressure, even when local anesthesia is working well to eliminate pain, and they will also hear portions of the procedure, like lateral out-fracturing of the inferior turbinate or medialization of the middle turbinate. In order to assure a predictable patient experience, surgeons should fol­low a standard anesthetic protocol, both with regard to anxiolytic and analgesic pre-procedure medication regimen and local anesthesia protocol. This is particu­larly important as a surgeon is beginning to transition procedures from the operating room to the ofce. Following a standard protocol will increase the likelihood of success, as the variables related to patient anxiety and comfort will be better man­aged, allowing the surgeon to focus on the procedure itself. Tables 14.1 and 14.2 detail the author’s preferred anesthesia protocol and local anesthetic administration protocol, respectively.

Depending on the navigation system, there may be no cost associated with regis­tering patients, so staff can be trained to upload CT images and register all sched­uled patients, with cost only being incurred if the surgeon chooses to use navigation during the procedure. The navigation systems have various capabilities that allow the surgeon to pre-mark surgical targets, critical structures to be avoided and plan pathways into the targeted sinuses. These pre-planning software features allow the surgeon to map their surgical plan and can be particularly useful in the teaching set­ting. The Stryker Scopis system (Stryker, Plymouth, MN) features an augmented reality option, where the surgeon can pre-plan the surgical pathway and then utilize the hybrid optical and electromagnetic properties to follow the pre-planned surgical pathway to the targeted sinus. Other systems, like the Acclarent TruDi (Acclarent, Irvine, CA), have software that uses articial intelligence to identify known struc­tures and calculate likely surgical pathways.

Patient monitoring is dependent on type of anesthesia (local, oral sedation, IV seda­tion) and varies by state. Surgeons should conrm their state monitoring require­ments, as well as any state specic accreditation requirements. In our practice, we do not utilize IV sedation, and our sedation goal, according to the American Society of Anesthesiologists Continuum of Depth of Sedation, is Minimal Sedation

Anxiolysis, dened as “a drug-induced state during which patients respond nor­mally to verbal commands. Although cognitive function and physical coordination may be impaired, airway reexes, and ventilatory and cardiovascular functions are unaffected [18].” We routinely record pre and post procedure vital signs and monitor pulse oximetry throughout the procedures. Depending on patient comorbidities, state requirements, type of anesthesia, and surgeon preference, some surgeons may choose or be required to monitor blood pressure and EKG throughout their proce­dures [15, 17]. Surgeons should be prepared for potential complications related to anesthesia, including allergic reaction and medication toxicity, and be prepared to manage immediate complications.

To create a comfortable experience for patients, the surgeon and staff should con­sider playing relaxing music, or music of the patients choosing, and covering the eyes to limit irritation from bright endoscopic lights and anxiety caused by seeing surgical instruments. Instruct patients to wear comfortable clothing, and place them in a comfortable position, with a pillow or other support under the lower legs and a gel pillow under their head. If the room is small, and becomes warm due to equip­ment and staff, having a fan to keep the patient comfortable can also be helpful. Although ultimately patient position is the surgeon’s preference, placing patients in a supine position may limit drainage into the oropharynx, as secretions will pool in the nasopharynx and can be easily suctioned.

In order to successfully perform ofce-based rhinology procedures and particu­larly ofce-based image guidance, it is imperative to train nursing and medical staff on the surgical equipment, navigation systems, typical order of surgical pro­cedures and surgeon preferences. It is also important to remind staff that the patients are awake throughout the procedure, so using gentle terms to describe surgical instruments (asking for the local anesthetic, not the needle or injection) can alleviate patient anxiety. Also, if a complication or unforeseen event occurs, it is critical for staff to avoid comments that may increase patient anxiety. Although many surgeons may prefer a dedicated staff member, or champion, to assist in their cases, cross-training throughout many staff can help reduce challenges related to illness, vacation or staff changes. Regular staff training and retraining, as well as “mock” cases and navigation system troubleshooting guides can improve staff con­dence and comfort during procedures. The author’s preferred procedure protocol is detailed in Table14.3.

quate space for monitors and navigation systems and that they are set up appro-