Partially in response to diminishing healthcare reimbursement and rising consumer demand, healthcare delivery is shifting more from in-hospital settings to outpatient facilities and physicians’ offices. Over the past decade, the number of procedures carried out in office-based settings by a range of clinicians—including but not limited to surgeons, gastroenterologists, ophthalmologists, dermatologists and radiologists—has steadily grown. In some situations, ear, nose and throat (ENT) physicians will perform minor surgery in an office setting using only local anesthesia and/or an oral sedative, in which case an anesthesia provider is not necessary. Using this approach can reduce costs for patients, however, such cases need to be carefully considered and thoughtfully approached from a safety and comfort perspective. 

As surgical technique, medical technology, and analgesic strategies improve, it is more and more possible for patients to undergo procedures with less anesthesia than before, whether that means avoiding general anesthesia but still needing management by an anesthesia provider, or needing only the most basic pain relief or sedation. There are a number of benefits to this trend. However, safety remains the highest priority.  

More and more surgeons who are performing office-based procedures enumerate a number of reasons for which these are preferable. Since they often require very minimal sedation (in some cases simply a little bit of Valium) 1 and do not require patients to be wheeled in and out, patients tend to experience less anxiety going into surgeries than they would in an outpatient surgery center or hospital environment. Many patients clearly state that they prefer them. 

Furthermore, in-office procedures without an anesthesia provider are less expensive. For example, an in-office procedure room designed only for ophthalmological procedures can improve outcomes and safety standards relative to other centers, allowing surgeons to maximize efficiencies in terms of scheduling, staffing, and supplies. This benefits patients, surgeons and payers alike. 

However, a number of physicians remain skeptical of performing procedures without an anesthesia provider. If a patient experiences issues such as pain or anxiety, or if the sublingual anxiolytic or Valium that was administered to a patient fails to work properly, there will be no anesthesiologist to call on to administer an intravenous solution. It would be extremely challenging, if not impossible to pause the surgery and take the patient to the nearest hospital to finish up the procedure there without poorer outcomes. A certain element of safety may thus be compromised 1.  

ENT surgery is one area where the question of whether and when an anesthesia provider is not needed is highly relevant. A number of common ENT procedures in modern medicine are relatively fast, minimally invasive, and low risk. For example, balloon sinuplasty, turbinoplasty, polypectomy, septoplasty, and rhinoplasty are all commonly performed in-office. Conscious sedation can facilitate a smoother procedure and a more comfortable experience for the patient, but some ENT surgery may also be performed under local anesthesia without an anesthesia provider. Endoscopic sinus surgery is also becoming more common in the office-based setting. A recent retrospective chart review was carried out that was focused on adult patients who underwent in-clinic sinonasal procedures and surgery 2. Patient procedures spanned 166 turbinoplasties, 118 ESS, 35 septoplasties, 34 rhinoplasties, and 4 septorhinoplasties. Data revealed that complication rates and tolerability measures of ESS were similar to those of other reported in-office sinonasal procedures carried out under local anesthetic. In addition, the need for a revision endoscopic sinus surgery was minimal when considering the extent of surgery that was performed. Ostensibly, an in-clinic procedure may avoid a general anesthetic in the operating room for appropriately selected patients, as office-based rhinologic surgery can be safe and well tolerated. 

In general, procedures carried out with minimal sedation do not require accreditation 3. For more involved sedation, what a surgeon rather than an anesthesiologist may provide varies a bit by state, but an anesthesia provider is needed if administering general anesthesia or conscious sedation.  

Retaining a high degree of safety remains a key consideration for office-based ENT surgery without an anesthesia provider 4. The lack of uniform government oversight and the medley of credentialing requirements result in a lack of standardized safety and quality metrics for medical offices. Training, an appropriate operating environment, strict selection of patients, and contigency plans are necessary for the safety of ENT surgery without an anesthesia provider. 

References  

1. Office-Based Surgery: The Pros and Cons. Available at: https://www.reviewofophthalmology.com/article/officebased-surgery-the-pros-and-cons. (Accessed: 28th June 2023)
2. Scott, J. R., Sowerby, L. J. & Rotenberg, B. W. Office-based Rhinologic Surgery: A Modern Experience with Operative Techniques under Local Anesthetic. https://doi.org/10.2500/ajra.2017.31.4414 31, 135–138 (2017).
3. Office-Based Surgery (OBS) Frequently Asked Questions (FAQ’s) for Practitioners. Available at: https://www.health.ny.gov/professionals/office-based_surgery/obs_faq.htm. (Accessed: 28th June 2023)
4. Urman, R. D., Punwani, N., Shapiro, F. E. & à, D. Office-Based Surgical and Medical Procedures: Educational Gaps. Ochsner J. 12, 383 (2012).