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In-Office Nasal Airway Obstruction Surgery

Author Julia Casazza covers In-Office Nasal Airway Obstruction Surgery on BackTable ENT

Julia Casazza • Apr 24, 2024 • 35 hits

When medical management of nasal airway obstruction cannot relieve patient symptoms, in-office nasal airway obstruction surgery intervention is indicated. Radiofrequency ablation (RFA) of excess tissue using a device like Aerin Medical’s VivAer increases nasal airflow, providing patients with more “room to breathe.” Dr. Nora Perkins, an expert in nasal airway obstruction surgery, recently sat down with BackTable to share her insights.

This article features excerpts from the BackTable ENT Podcast. We’ve provided the highlight reel in this article, but you can listen to the full podcast below.

The BackTable ENT Brief

• Effective pain management underlies any successful office nasal airway obstruction surgery. A combination of systemic and topical analgesia helps patients stay comfortable during interventions such as radiofrequency ablation of nasal tissue.

• Anxiolytics (including triazolam and promethazine) are indicated for patients whose nervousness might make it difficult to tolerate an in-office surgery.

• Radiofrequency ablation (RFA) is an application of infrared to excess tissue. VivAer is a wand-like system that enables RFA of nasal tissue.

• Outfracturing (breaking) the nasal turbinates while performing RFA of nasal structures further increases nasal airflow.

• Otolaryngologists interested in expanding their repertoire of in-office procedures should reach out to sales representatives, who can connect them with peers performing the procedure of interest.

In-Office Nasal Airway Obstruction Surgery

Table of Contents

(1) Nasal Airway Obstruction Surgery Anesthesia

(2) Nasal Airway Obstruction Surgery: VivAer Device

(3) Developing an In-Office Procedural Skill Set

Nasal Airway Obstruction Surgery Anesthesia

Effective anesthesia is a prerequisite for any successful in-office nasal airway obstruction surgery. One hour before their arrival to the office, Dr. Perkins’ patients decongest using intranasal 0.05% oxymetazoline. They also take 50mg of tramadol for analgesia, and (if desired) 0.125 mg of triazolam and/or 25 mg of promethazine for anxiolysis.

When the patient arrives in the room, Dr. Perkins places pledgets containing 0.05% oxymetazoline + 4% lidocaine in their nasal cavities. Using cotton swabs, she applies cetacaine to the canine fossa to reduce the pain of associated injections. She then performs a modified infraorbital block and applies intranasal pledgets with 4% lidocaine and 1:1000 epinephrine. Finally, she injects the target area with 1 or 2% lidocaine plus 1:200,000 epinephrine.

[Dr. Nora Perkins]
I have patients ahead of time use Afrin at home, typically starting about an hour or so before they're supposed to come into the office. They apply Afrin a few times. They're already very decongested when they come to the office. I generally will have patients use an oral anxiolytic regimen. I would say 70% of my patients use this. I think VivAer is one of the procedures where it is the least necessary.

If patients have any hesitation about taking it, they want to drive themselves, I'm fine with them not taking the pre-medications or oral anxiolytics. For more posterior treatments, if you're doing the treatment of the posterior nasal nerve, if you're doing a Eustachian tube balloon, if you're doing sphenoid balloons, in those situations, I push the pre-medications more because then I get a very consistent patient. I know how they're going to be. I know we're going to be able to successfully do this.

An hour before the procedure, I will typically have patients take 50 milligrams of Tramadol, 0.125 milligrams of triazolam, and then 25 milligrams of Phenergan or promethazine. They take that little combo ahead of time. They do have to have a driver. Their consents and everything are done ahead of that time. They're done really when they sign up for the procedure. In the office, if somebody is still just incredibly anxious, which again is not real common for the VivAer procedures, but if somebody has-- they're just tapping their toes, feeling anxious, then I will give them more triazolam in the office. They bring their meds with them in case they need more.

Then I move to topical medications. I like to do just Afrin, regular Afrin with 4% lidocaine pledgets to start with. Then I put a little bit of cetacaine underneath the lips in the canine fossa because I do an infraorbital injection for any anterior nasal, like lateral nasal wall procedure. I call it “walrus-ing.” I take those long Q-tips, the wooden Q-tips, put a little cetacaine on it. Yes, exactly. They look like a walrus for a few minutes.

Those stay in for typically about seven minutes or so. I take those out. I will then do the infraorbital injection and it's not really a true infraorbital block. I'm just going into the canine fossa and fanning out about half of a milliliter of lidocaine. With supply issues, it's either 1% or 2%. I do use with epinephrine, but I use 1:200,000 epinephrine. Patients don't typically notice any kind of tachycardia. If they do, I will mention that they might, you may notice a little bit of an increase in your heart rate. I just want you to know you're not getting anxious. It's just the medication. It goes right away.

I should mention that we also do routinely put a pulse ox on the patients. We're monitoring heart rate. We're monitoring oxygen. Nothing I'm really giving them besides the epinephrine is going to affect that. I think it's probably more for my comfort and well-being. Even just being able to see, "Hey, your heart rate went from 65 to 85. Fine. Oh, it's already coming back down," just giving the patient feedback so that they know what to expect and also know that you're aware of it and you're monitoring it, I think just reassures people quite a bit.

After the infra-orbital injection, I will usually place another pledget inside the nose with 4% lidocaine and then typically epi, 1:1,000. Again, they're so decongested by that time that really there's no change in their heart rate with that topical administration. I'll let those sit for a few more minutes and then I'll come back and do injections with 1% or 2% lidocaine, 1:200,000 along the area of treatment in the nasal valve, the turbinate, the septum, so whatever areas I'm going to treat.

I think the alar injections or that valve injection can be incredibly painful. We were actually involved in one of the initial studies for the lateral nasal wall implant. We were doing some of those injections without doing the infra-orbital block. It was very, very painful. When we reduced, we started doing the infra-orbital blocks, that pain and discomfort reduced dramatically. I make it a pretty routine part of my anesthetic protocol. The injection there is minimally uncomfortable or has minimal discomfort, but the injection of the ala can be very uncomfortable. The infra-orbital injection makes it a zero, a one, so really minimally uncomfortable.

Listen to the Full Podcast

Nasal Airway Management: Evolving Practices in Diagnosis and Treatment with Dr. Nora Perkins on the BackTable ENT Podcast)
Ep 158 Nasal Airway Management: Evolving Practices in Diagnosis and Treatment with Dr. Nora Perkins
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Nasal Airway Obstruction Surgery: VivAer Device

The VivAer wand uses infrared energy to ablate the cause of nasal airway obstruction – excess nasal tissue. After local anesthesia sets in, Dr. Perkins begins the ablation. She starts at the anterior-inferior portion of the inferior turbinate, then moves posterior-superiorly to treat the entire turbinate. Outfracturing the turbinate can provide additional breathing room within the nose. She then moves on to the septal swell bodies, which can be difficult to identify following decongestion. For this reason, she advises identifying this treatment area before decongestion. Finally, she treats the internal nasal valve, starting at the middle, and then moving superiorly and inferiorly. While VivAer is a safe procedure whose only reported complication is nosebleed, Dr. Perkins recommends narrating your actions of the nasal airway obstruction surgery in real-time to reduce patient anxiety.

[Dr. Nora Perkins]
Yes, for the procedure itself, typically I'll start with the turbinate. I start anteriorly on the turbinate. I will progressively work myself, maybe the superior aspect of the anterior inferior turbinate, and then go right below that, and then stepwise work more posteriorly. Like I said, I will often treat the entire turbinate. I will often take a freer and out-fracture the turbinate as well because that is giving everyone a little bit more space, and with the local anesthetic, patients tolerate that really, really well.

Then I will treat the septal swell, and that definitely with the amount of decongestion can be a little challenge. You want to have your treatment area in mind at the beginning before you really get started. After it's been anesthetized, that area is very easy to treat and you do see some pretty immediate treatment response in that area.

You see it on the turbinates as well, but I think the septal swell is even more pronounced where you can see that tissue really retract. Then I go to the nasal valve last and typically I'm treating three sites. I usually start in the middle of the nasal valves and I'll treat that area and then I'll move more superiorly toward the apex and then I'll move more inferiorly. If somebody still has some collapse or if they just have a larger space, I may do a fourth treatment site. Trying not to overlap.

Developing an In-Office Procedural Skill Set

While often underemphasized in academic settings, in-office procedures are an important part of the job for many private practice otolaryngologists. Dr. Perkins advises that graduating residents (and anyone looking to expand a procedural skill set) communicate with sales representatives from medical device companies. These individuals can share extensive knowledge of their product(s) and can connect surgeons willing to share skills. Administering surveys such as the Nasal Obstruction and Septoplasty Effectiveness Scale (NOSE) before and after intervention provides an idea of efficacy.

[Dr. Nora Perkins]
Yes, I think the first thing that I would recommend, especially if you're a practicing physician already or a resident who's a recent graduate, is reaching out to your rep because they have a wealth of resources and information to help you. They can set you up with docs who do a lot of these. They can invite you to courses where you can learn the techniques and learn the anesthetic protocols and speak to other physicians so that, again, you don't necessarily have to listen to the rep about how you should do it, but you can talk to other physicians.

I would encourage everyone to work with their rep. They have seen hundreds of cases. They are trained in this device and this procedure, in the pathology, and although they are not surgeons, I am happy to take any advice from somebody who's seen tens, hundreds, however many other physicians do this procedure and may be able to offer things that I didn't even think about, but that somebody else has done and they've seen success with. I think reaching out to the rep and working with the industry people is very important.

The other thing I would say is if you're thinking about doing these type of procedures, adding the NOSE score routinely is very, very helpful because you're going to identify patients. There was that fairly recent study. We're looking at 3,500 patients. 37% of them had severe, extreme nasal airway symptoms, even if they weren't coming to the office for nasal airway. You're going to pick up patients in your practice. You do not have to necessarily market for this. These people are already in your practice and do the modified Cottle because if you're not making that part of your physical exam, then you're missing patients. If you stick a speculum in somebody's nose and ask them how they're breathing, they're going to feel amazing, but you've already gone past the nasal valve.

I think that's an important thing. The last thing I would say is if you want to start doing office procedures, set aside a block in your schedule to do them because if you're trying to squeeze it in at your lunchtime, if you're trying to squeeze it into a regular appointment slot, you're going to have a lot of difficulty. You're going to feel rushed. If you give yourself an afternoon and you put on two in-office procedures, if you give yourself time and your staff time and the patients time, it's going to be a wonderful experience.

Podcast Contributors

Dr. Nora Perkins discusses Nasal Airway Management: Evolving Practices in Diagnosis and Treatment on the BackTable 158 Podcast

Dr. Nora Perkins

Dr. Nora Perkins is an otolaryngologyst with Albany ENT & Allergy Services in New York.

Dr. Ashley Agan discusses Nasal Airway Management: Evolving Practices in Diagnosis and Treatment on the BackTable 158 Podcast

Dr. Ashley Agan

Dr. Ashley Agan is an otolaryngologist in Dallas, TX.

Dr. Gopi Shah discusses Nasal Airway Management: Evolving Practices in Diagnosis and Treatment on the BackTable 158 Podcast

Dr. Gopi Shah

Dr. Gopi Shah is a pediatric otolaryngologist and the co-host of BackTable ENT.

Cite This Podcast

BackTable, LLC (Producer). (2024, February 13). Ep. 158 – Nasal Airway Management: Evolving Practices in Diagnosis and Treatment [Audio podcast]. Retrieved from

Disclaimer: The Materials available on are for informational and educational purposes only and are not a substitute for the professional judgment of a healthcare professional in diagnosing and treating patients. The opinions expressed by participants of the BackTable Podcast belong solely to the participants, and do not necessarily reflect the views of BackTable.



Nasal Airway Management: Evolving Practices in Diagnosis and Treatment with Dr. Nora Perkins on the BackTable ENT Podcast)


Nasal Airway Obstruction Treatment & Symptoms

Nasal Airway Obstruction Treatment & Symptoms


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