Nasal airway procedures can be vital for treating obstructive sleep apnea, but patients are often reluctant to undergo a trip to the operating room. Moving these procedures to the office can make patients feel more comfortable while saving time and money.
By Lisa Rapaport
There are many reasons why patients and sleep specialists may want to avoid the operating room (OR). Chief among them include scheduling challenges, high costs, the risks of general anesthesia, and post-op recovery time.
Fortunately, new technology and revamped treatments increasingly make it possible to perform nasal airway procedures like septoplasty, turbinate reduction, and nasal valve treatments without stepping into an OR.
“Sinonasal surgeries and procedures have been gradually transitioning from the OR towards the office over the past 10-plus years,” says Stanley McClurg, MD, FARS, of ENT Associates in Kansas City, Mo.
Some of the main drivers of this change have been patient convenience, recovery time, and cost, says McClurg, who serves as a consultant for Aerin Medical, makers of the in-office radiofrequency VivAer and RhinAer styluses. If a procedure can be conducted under local anesthesia instead of general anesthesia, the patient’s recovery period is dramatically reduced. Patient costs can also go down as coinsurance and copays for office procedures tend to be significantly lower than for OR procedures done under general anesthesia. Avoiding the OR also makes it easier for physicians to manage their time and accommodate more patients.
Certainly, the lack of available ORs during the COVID-19 pandemic has also forced many providers to reconsider what procedures might be possible in the office, McClurg says.
“The most significant recent driver of the move to the office has been the COVID-19 pandemic, which has shown us how effectively we can treat patients with sleep-disturbed breathing in the office setting, while also avoiding potentially dangerous aerosolizing procedures typically conducted in the operating room,” McClurg says.
While factors such as convenience and cost may be fueling the desire to move more procedures from the operating room to the clinic, advances in technology have helped make it possible. Options for less invasive procedures that can be done without general anesthesia are expanding the list of surgical treatments that no longer require a team of people in a traditional OR, says Ofer Jacobowitz, MD, PhD, FAASM, FAAOA, co-director of sleep at ENT and Allergy Associates in New York City and an associate professor of otolaryngology at Zucker School of Medicine at Hofstra/Northwell.
Balloon sinuplasty, for example, was once only done in an OR under general anesthesia but now can be done in the clinic using local anesthesia, Jacobowitz says. Smaller, more flexible catheters can open blocked passages and aid mucus drainage before the sinus balloon is inflated to help widen and reshape the sinus passage without the need for cutting or removing any bone or tissue.
Medical devices have also evolved to enable nasal valve treatments to be done outside of the OR. With VivAer, for example, ear-nose-throat (ENT) surgeons can numb the inside of the nose with a local anesthetic, then insert a small wand into the nasal passage to target a blockage that’s causing nasal airway obstruction. Another option to address nasal airway obstruction, Latera (by Stryker), is an absorbable nasal implant that can be implanted in an office setting and used to support the upper and lower cartilage inside the lateral wall of the nose.
Clinicians can also treat chronic rhinitis in the clinic. One option is the RhinAer stylus, which uses temperature-controlled radiofrequency technology to target the posterior nasal nerves. The device can also treat the inferior turbinate to reduce congestion. Another option is ClariFix Cryotherapy (by Arrinex Inc), a cooling probe that also targets the posterior nasal nerves.
“In the correct patient, allowing adequate time for local anesthesia, a well-trained surgeon can perform procedures using some of these newer tools, or perform procedures using conventional tools such as microdebriders and standard septoplasty surgery,” Jacobowitz says.
Even when patients experience significantly reduced quality of life that might be improved by nasal surgery, they often balk at the prospect of OR procedures that require general anesthesia. Sometimes, this will be a nonstarter that leads them to refuse treatment.
Anesthesia can have a profound impact on whether it’s possible for some patients to consider treatment at all. For some, the lack of transportation makes it challenging to sort out how to get to and from the hospital. For others, particularly the uninsured and those with high deductible health plans, steep copays or coinsurance costs make surgery too expensive to consider. Even those who can pay these fees still may not be able to afford time off of work, the child care needed during surgery, and the longer recovery period.
Options that require only a trip to the doctor’s office and local anesthesia may help persuade patients to get help, says Joseph Han, MD, chief of the Division of Allergy and the Division of Rhinology and Endoscopic Sinus-Skull Base Surgery at Eastern Virginia Medical School.
“It is less cost to the patient, less time off from work, and less time to recover from procedures,” Han says.
Other patients may have a significant fear of pain that makes them reluctant to undergo surgery. They, too, may be more open to intervention when it’s possible to do without a trip to the hospital, says Scott McCusker, MD, with Dignity Health Mercy Medical Group in Sacramento, Calif.
“Many patients prefer avoiding general anesthesia and find it more convenient and less time consuming to do things in the clinic,” McCusker says. “Having some minimally invasive options, even if they don’t fix everything, will at least help get some people some degree of relief.”
There’s an inherent inefficiency in relying exclusively on an OR that can be alleviated to a large degree by moving more procedures to the clinic, Jacobowitz says. Booking OR time is one challenge, and then dealing with unanticipated delays and last-minute shifts to the schedule is another.
With OR procedures, the otolaryngologist can’t control the way the schedule gets carried out. Delays are common due to challenges with staffing or other procedures running over their allotted times.
Surgeons also have to build out time in their schedules to get back and forth between the hospital and the clinic. Performing procedures in the office enables the surgeon to see other patients in consultations on the same day, Jacobowitz says.
Additionally, improved efficiency and easier schedule management are good for the bottom line. “Overall, reimbursement for my practice is usually about the same as, or frequently even better than, OR-based procedures, due to reductions in overhead and staffing for cases,” McClurg says.
Preparation is key, however. Staff will need training regarding the set-up for procedures, expectations, and roles, Jacobowitz says. Surgeons also need to have equipment and supplies available to handle emergencies such as bleeding, and clinics need to have personnel and space dedicated to post-procedure recovery.
In the future, workflow could be greatly improved if it becomes possible to also move drug-induced sleep endoscopy to the clinic. Right now, this needs to be done in an OR with an anesthesiologist to titrate the sedation. Because this is so often required prior to sleep interventions, it would further streamline scheduling and reduce costs and recovery time for patients if this could be done in the clinic.
“The general trend of ENT procedures over the past decade has been to adapt the surgeries that we have done in the operating room to allow them to be conducted in the office setting,” McClurg says. “I can foresee that many procedures, such as palate surgeries, drug-induced sleep evaluations, and tongue reduction/advancement procedures, will be more frequently conducted in the office setting.”
Lisa Rapaport is a freelance journalist with experience writing and editing news about health, medicine, wellness, and science.