An Overview of Innovations in Office-Based Rhinology

Martin J. Citardi, MD, Pete S. Batra, MD, and R. Peter Manes, MD

The following article provides highlights from the Panel Presentation “Innovations in Office-Based Therapy for the Rhinology Patient,” presented by the authors at the AAO-HNSF 2024 Annual Meeting & OTO EXPO. If you missed last year’s presentation, be sure to attend this year’s panel on the same topic on Tuesday, October 14, at the upcoming meeting in Indianapolis, Indiana.

Office-based rhinology procedures have emerged as effective alternatives to traditional operating room surgeries for select nasal and sinus conditions. They provide a lower-cost setting, high patient acceptance, and streamlined coordination, reserving the operating room for the most challenging cases. Advances in technology and technique now allow some treatments to migrate from the hospital to the clinic. Here, we review some of these procedures along with considerations for incorporating them into your practice—from anesthesia needs to billing codes and recovery care.

Anesthesia

Conducting rhinologic procedures in the office hinges on effective local anesthesia to ensure patient comfort. Commonly, a combination of topical and infiltrative anesthetics is used to numb the nasal cavity. Lidocaine has a rapid onset and moderate duration (~one to two hours, extended to three to four hours with epinephrine), while tetracaine has a slower onset but can last much longer (several hours, significantly prolonged with epinephrine). It is important to stay within safe dosage limits (e.g., lidocaine up to ~7 mg/kg with epinephrine) to avoid systemic toxicity. Techniques often involve 4% topical lidocaine (spray or soaked pledgets) to anesthetize the mucosa, followed by targeted injections (e.g., 1% lidocaine with epinephrine) at specific targets such as the sphenopalatine foramen area and the turbinates.

True allergic reactions to local anesthetics are rare. Side effects of local anesthesia, when they occur, are typically due to high systemic absorption. Patients may experience lightheadedness or central nervous system effects (in extreme cases, seizures or drowsiness) and cardiovascular effects (low blood pressure or arrhythmia) if too much anesthetic enters the bloodstream. Including epinephrine constricts blood vessels and reduces absorption, though it may cause transient heart palpitations or jitteriness.

Overall, with skilled application of topical and local anesthesia, most patients tolerate office procedures well, often reporting only mild pressure or moments of discomfort rather than pain. The ability to achieve profound local anesthesia is what makes complex office procedures feasible in awake patients. Some practitioners also offer a mild sedative (such as a low-dose benzodiazepine) for anxious patients. Ensuring the patient is adequately numb and at ease is critical; this not only improves the patient experience but also allows the surgeon to work meticulously without time pressure.

Mometasone Implants

Chronic rhinosinusitis, especially with nasal polyps (CRSwNP), often requires prolonged anti-inflammatory treatment. Mometasone-eluting sinus implants are a novel therapy that enables targeted steroid delivery in the sinuses over a period of weeks to months. These bioabsorbable implants (e.g., Propel® and SINUVA®) slowly release mometasone furoate, a corticosteroid, to reduce inflammation and polyp regrowth. They are placed endoscopically into the sinus cavities—often the ethmoid sinus—either during an office visit or at the end of sinus surgery.

Propel implants come in assorted sizes (standard, Mini, Contour), but each carries 370 µg of mometasone. They expand to prop open sinus passageways while delivering the drug locally. Propel is typically used after surgical sinus opening (e.g., post-ethmoidectomy) to improve healing and keep the sinus open. SINUVA, by contrast, contains a larger steroid dose (1350 µg) and is specifically indicated for patients with recurrent polyps after prior surgery; it is inserted in the office into an existing ethmoid cavity and releases steroid over approximately 90 days.

Clinical outcomes are encouraging. In a key randomized trial (RESOLVE II), the SINUVA implant significantly improved nasal congestion and reduced polyp size compared to a sham procedure. Many patients experience noticeable improvement in nasal breathing and a reduction in the need for oral steroids or revision surgery for polyps in the months following implant placement.

The advantage of these implants is targeted therapy: delivering a high concentration of steroid exactly where it is needed (in the sinuses) while minimizing systemic exposure (and thus reducing side effects like those from oral steroids). They effectively turn a surgical cavity into a drug reservoir. Being able to place them in the office is another advantage—a quick endoscopic procedure can postpone or obviate the need for another full surgery.

However, not all patients are candidates. These tools are intended for those who have already had sinus surgery and who are experiencing polyp recurrence or inflammation that is not controlled by sprays or medication alone. In unoperated sinuses, the natural openings are too small for these implants. Also, while the implants relieve inflammation, they do not physically remove polyps or debris. So, if a patient has large polyps or osteitic bone, they might still need surgical debridement in addition to steroid therapy.

Balloon Sinus Ostial Dilation

Balloon sinus ostial dilation is a minimally invasive technique to widen the drainage pathways of the paranasal sinuses without traditional cutting instruments. Instead of removing tissue, a small balloon catheter is inserted into the natural sinus opening and inflated to gently fracture thin bone and stretch the opening wider. This procedure can be performed in-office under local anesthesia, offering symptomatic relief for selected patients with chronic sinusitis.

The appeal of balloon dilation lies in its simplicity and safety. Because it preserves the mucosa and just remodels the existing anatomy, there is usually minimal bleeding and a faster recovery compared to endoscopic sinus surgery. Many patients return to normal activity within 24–48 hours.

Balloon sinuplasty is most effective for patients with mild to moderate chronic sinusitis confined to specific sinuses, as well as for cases of sinus outflow tract scarring or recurrent blockage where a touch-up procedure can delay more invasive surgery. It spares healthy tissue and can be repeated if necessary. However, it is not appropriate for severe polyposis or pan-sinusitis where extensive disease needs removal; in those cases, traditional endoscopic sinus surgery is required. It also cannot address problems like large nasal polyps, significant septal deviation, or tumors. Patient selection is crucial: A careful CT scan evaluation ensures that the disease is of the type that a balloon can adequately treat (e.g., narrowed sinus ostia without diffuse mucosal disease).

Importantly, if a balloon procedure does not achieve the desired outcome, it does not “burn any bridges”—that is, the patient can still go on to have conventional sinus surgery. Thus, many surgeons consider it as an initial option for appropriate cases.

Posterior Nasal Nerve Ablation

Chronic rhinitis, particularly non-allergic rhinitis, is characterized by chronic nasal congestion and a runny nose due to neurogenic hyperactivity rather than allergens. Patients often have an imbalance in autonomic input: excessive parasympathetic stimulation leads to over-secretion by nasal glands and swollen nasal tissues. While intranasal steroid sprays, antihistamines, and anticholinergic sprays are first-line treatments, a considerable subset (estimates of 10%–20%) remains symptomatic despite maximal medical therapy. For these patients, a more definitive solution has emerged with ablation of the posterior nasal nerve (PNN).

The PNN carries parasympathetic signals from the pterygopalatine ganglion to the nasal mucosa. Ablating this nerve—either by cryotherapy or radiofrequency (RF)—can significantly reduce rhinorrhea and congestion by cutting off the neural drive for mucus production and vasodilation. Both techniques are typically done in the office under endoscopic guidance and local anesthesia, targeting the area in the posterior lateral nasal wall (just behind the middle turbinate) where these nerves branch into the nasal cavity.

Using a cryotherapy device (e.g., ClariFix®), the probe is placed in the posterior nasal passage and cooled to extremely low temperatures, ablating the nearby nerve fibers. Early studies demonstrated safety and efficacy (Hwang et al. 2017) treating patients with chronic rhinorrhea (allergic and non-allergic) with cryoablation and saw a dramatic drop in symptom scores by one month and sustained relief through one year.¹ Patients reported only mild discomfort, such as headache or some nose pain, in the first few days. A larger 98-patient trial (Chang 2020) also showed significant improvement in total nasal symptom scores, noting that 42% of patients were able to discontinue using intranasal steroids after the procedure.² To identify ideal candidates, one retrospective insight is that when a patient responds well to a trial of ipratropium spray (which also targets parasympathetic activity), they are likely to respond well to PNN ablation.

Devices like RhinAer® and (later) Neuromark® use controlled heat (~60°C) to target the PNN region. A multicenter randomized trial (Stolovitzky 2021) showed that RF neurolysis significantly outperformed sham at three months in reducing symptoms.³ Impressively, a two-year follow-up revealed an 87% responder rate (defined as ≥30% improvement in symptom scores) following a single treatment. Patients also reduced their need for ongoing nasal medications, with half stopping or decreasing some of their meds. The Neuromark device, with its multipoint electrode array, has demonstrated that around 80% of patients still meet response criteria at 12 months.⁴ These outcomes underscore that RF is highly effective and durable for many patients.

No direct head-to-head trials have been completed, but meta-analyses suggest both cryo- and RF-ablation are effective and equivalent in overall outcome. One review (Gorelik 2023) found no significant difference in symptom improvement between cryotherapy and RF when comparing the results of separate studies.⁵ Another analysis (Kang 2023) noted that both modalities improved all rhinitis symptoms and quality of life measures, although RF might have a slight edge in reducing certain symptoms, such as rhinorrhea, in purely non-allergic patients.⁶ In practical terms, both treatments are viable, and the choice may depend on the surgeon’s familiarity or the patient’s preference; some patients might opt for one over the other if, for instance, they’ve heard about it or want to avoid the sensation of extreme cold (in cryotherapy) or heat (in RF).

Both treatments are safe with few adverse events. The most common side effects are temporary (e.g., mild nosebleeds, transient nasal dryness or crusting, headache, or a sensation of dryness in the throat or eyes shortly after treatment). These typically resolve within days to a couple of weeks. Serious complications are rare; a small percentage (~2%) of patients may experience a significant nosebleed a few weeks post-procedure that may require medical attention, but such cases are uncommon. There is no evidence of harmful long-term effects like permanent numbness or excessive nasal dryness (atrophic rhinitis) in published studies.

One consideration is that nerve fibers can regenerate over time. Some patients might experience a gradual return of symptoms many months or years after the procedure.

Reimbursement

As these new office procedures have gained popularity, proper coding and reimbursement frameworks have been catching up. Recent updates include several new CPT codes that specifically describe these interventions:

• 30469—RF ablation of nasal valve area (effective 2023): covers treatments for nasal valve collapse, valued at 2.70 work RVUs.
• 31242—Nasal/sinus endoscopy with RF ablation of the posterior nasal nerve (new for 2024): describes in-office endoscopic PNN ablation using RF (2.70 wRVUs, similar to 30469).
• 31243—Nasal/sinus endoscopy with cryoablation of the posterior nasal nerve (new for 2024): analogous to 31242 but for cryotherapy of the PNN (also 2.70 wRVUs).

These Category I CPT codes help provide specific coding guidance for these new procedures. Prior to 2024, PNN ablations were billed under unlisted or Category III codes (e.g., 0404T), which often led to reimbursement challenges since many payers view Category III (temporary) codes as investigational. Now, with specific codes, providers can more reliably bill these services. It is noteworthy that you cannot bill both 31242 and 31243 on the same date, and any PNN ablation code is typically reported only once per session (even if you treat both sides, it’s considered a bilateral service inherently). Also, it is important to keep in mind that the existence of a code does not guarantee coverage. Physicians should be sure an individual’s insurance company covers the specific procedure.

For RF of septal swell bodies, guidance from the CPT editorial panel suggests using 30117 (excision/destruction of intranasal lesion) for this purpose. Surgeons must be careful not to overlap this with a septoplasty code (30520) in the same session, as these would be bundled. Turbinate reduction codes (30801, 30802) can be billed separately if performed, but a -50 modifier (bilateral) is not applicable to 30117 in this context.

When it comes to mometasone sinus implants, coding and payment can be complex. There is no dedicated CPT procedure code for “sinus steroid implant placement” in the office, so the act of placing it is usually captured by an existing endoscopy code. The implant itself is a supply, and payers differ on whether they reimburse it separately:

• In a facility (hospital outpatient or ASC) setting, many private payers use S1091 for Propel implant supply. Medicare/Medicaid, which do not use S-codes, may accept C2625 (non-coronary stent) on facility claims.
• In an office (physician clinic) setting, one might also bill S1091 for commercial plans. For others (including Medicare), the implant can be reported with a J-code for unclassified drugs, J3490, along with a notation of the specific product (using its NDC number).

Despite these codes, a major issue is that some payers bundle the implant cost into the procedure and do not provide separate reimbursement for the implant device. Medicare often considers the steroid implant part of the overall endoscopy service, meaning the practitioner bears the cost of the device. Given that these implants are expensive, a lack of reimbursement can disincentivize their use. Ongoing advocacy is necessary to demonstrate the value of steroid implants in reducing downstream healthcare costs, thereby encouraging more insurers to cover them appropriately.

In summary, the reimbursement environment is gradually improving for office rhinology. It is crucial for providers to use the correct codes and to check payer policies. Patient documentation should clearly justify the clinical reason for the procedure. By staying informed on coding changes, such as the new 31242/31243 codes, otolaryngologists can ensure they are fairly compensated for these procedures, which ultimately benefit patients by making these services more accessible.

Conclusion

Office-based procedures in rhinology are transforming the management of sinus and nasal disorders. Innovations such as balloon sinus dilation, steroid-eluting implants, and posterior nasal nerve ablation have proven efficacy and safety for appropriately selected patients. These interventions fill an important middle ground between medical therapy and OR surgery, allowing many patients to find relief with less invasive means.

The office setting is becoming an extension of the OR, with many equipped with innovative tools and techniques, and is poised to play a significant role in rhinologic patient care moving forward.

References

1. Hwang PH, Lin B, Weiss R, Atkins J, Johnson J. "Cryosurgical posterior nasal tissue ablation for the treatment of rhinitis." International Forum of Allergy & Rhinology 7 (2017): 952–956.
2. Chang MT, Song S, Hwang PH. "Cryosurgical ablation for treatment of rhinitis: a prospective multicenter study." Laryngoscope 130, no. 8 (2020): 1877–1884.
3. Stolovitzky JP, Ow RA, Silvers SL, Bikhazi NB, Johnson CD, Takashima M. "Effect of radiofrequency neurolysis on the symptoms of chronic rhinitis: a randomized controlled trial." OTO Open 5, no. 3 (2021): 2473974X211041124.
4. Reh DD, Lay K, Davis G, Dubin MG, Yen DM, O'Malley EM, Sillers M. "Long-term outcomes following impedance-controlled radiofrequency ablation for the treatment of chronic rhinitis." Laryngoscope Investigative Otolaryngology 9, no. 3 (2024): e1286. doi: 10.1002/lio2.1286.
5. Gorelik D, Dhanda AK, Choi A, Takashima M, Khan NS, Rowan NR, Jafari A, Syed T, Ahmed O. "Modified technique improves efficacy for in-office posterior nasal nerve ablation." Laryngoscope Investigative Otolaryngology 9, no. 2 (2024): e1238.
6. Kang YJ, Stybayeva G, Hwang SH. "Comparative Effectiveness of Cryotherapy and Radiofrequency Ablation for Chronic Rhinitis: A Systematic Review and Meta-analysis." Clinical and Experimental Otorhinolaryngology 16, no. 4 (2023): 369–379.